Cervical Esophageal Strictures Research Articles

Surgical management of upper cervical esophagus stricture caused by ingestion of corrosive substances – a single-center experience

Introduction and aim. Corrosive strictures of the upper cervical esophagus and hypopharynx are hard to treat in the operating room because there is a high chance of aspiration during swallowing after a high-up or proximal esophageal anastomosis. In this cases, we aimed to evaluate the role of intraoperative dilatation of the proximal hypopharyngeal and cervical esophageal stumps during surgery. Material and methods. Patients who underwent surgery and had upper cervical esophageal and hypopharyngeal strictures from corrosive substance ingestion were included. Results. Out of total 27 patients, 10 had a cricopharyngeal or proximal cervical esophageal stricture with a long segment tho racic esophageal stricture that was treated with intra-operative dilatation (IOD) of the proximal hypopharyngeal stump. IOD was done in two cases with Hegar’s dilator and in three cases with wire-guided Savary Gillard dilators. In 74% (20/27) of the cases, the colon was frequently used as an esophageal substitute, while the stomach was only used in 10 cases. On follow-up, none of them developed repeated aspirations or required a tracheotomy. Conclusion. IOD of the proximal hypopharyngeal and cervical esophageal stumps during surgery for corrosive upper cervi cal esophageal or cricopharyngeal strictures helps to save the proximal stump and avoid frequent hospital stays and multiple surgeries.

Lichen Planus

HomeRadioGraphicsVol. 43, No. 4 PreviousNext Cases from the Cooky JarFree AccessLichen PlanusEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriAuthor AffiliationsFrom the Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin D07 R2WY, Ireland (E.M.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (N.S.); Department of Education, Wright State University Boonshoft School of Medicine, Dayton, Ohio (A.M.S.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institution, Baltimore, Md (P.K.).Address correspondence to E.M. (email: [email protected], @edwardmcd).Edward McDermott Nadia SolomonAnnelise M. SilvaParisa KhoshpouriPublished Online:Mar 16 2023https://doi.org/10.1148/rg.220200MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Lichen planus is a chronic condition that predominantly affects middle-aged and older women and represents an autoimmune T-cell–mediated inflammatory disorder (Fig 1) that affects the skin, oral and genital mucosa, esophagus, hair, and nails (1). Cutaneous involvement manifests with flat violaceous papules, and mucosal manifestations typically manifest with white lacelike lesions, papules, erythematous lesions, and erosions (Fig 2) (2). Esophageal lichen planus has been reported in more than 50% of patients with mucocutaneous lichen planus and is underrecognized and underreported (2).Figure 1. Esophageal lichen planus. There are limited studies of the pathogenesis of esophageal lichen planus, but it appears to be mediated by cytotoxic CD8-positive T cells. Biopsy of affected esophageal tissue shows keratinization with inflammatory cell infiltration of the epithelium with activated T lymphocytes (6).Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. Mucosal manifestations of lichen planus in a 73-year-old woman who presented with solid food dysphagia. (A) Photograph shows white plaquelike lesions on the tongue. (B) Endoscopic image demonstrates erythema and white papules (arrows).Figure 2.Download as PowerPointOpen in Image Viewer Barium esophagography is the most relevant imaging study to evaluate esophageal lichen planus. Imaging features include a smooth small-caliber esophagus with cervical esophageal webs, strictures, and pseudodiverticula (Fig 3) (3,4). Strictures most commonly occur in the proximal esophagus, and their presence correlates with a longer duration of disease (5). Squamous cell carcinoma of the esophagus has been rarely reported in patients with esophageal lichen planus; for this reason, early diagnosis is key.Figure 3. Esophageal lichen planus in a 73-year-old woman (same patient as in Fig 2). Barium esophograms show smooth long stricturing of the entire course of the esophagus with tapered margins (white arrow in A) and esophageal webs (black arrows in A). There are focal weblike strictures in an overall small-caliber lumen of the cervical esophagus (black arrow in B). Overall thin smooth luminal narrowing of the entire course of the esophagus is seen in C.Figure 3.Download as PowerPointOpen in Image Viewer Patients with esophageal lichen planus often present with dysphagia related to the strictures, with reflux-type symptoms, and weight loss. Strictures can be treated with balloon dilation, although this often requires regular repeat treatments (5). Endoscopic findings include superficial white papules, pseudomembranes, webs, and strictures.Disclosures of conflicts of interest.—All authors have disclosed no relevant relationships.AcknowledgmentWe thank Ciléin Kearns, MD, MBChB, for feedback and advice on the medical illustration in Figure 1.All authors have disclosed no relevant relationships.

A New “Ice Globe” Method for Dilating Leaking Cervical Esophageal Strictures

An esophageal stricture may develop during healing of a large esophageal perforation. When such a stricture occurs, mechanical dilatation is the treatment of choice. As in our case, if a cervical esophageal stricture and leakage are present together, the treatment becomes even more challenging. As a new treatment method, we made spherical ice globes of various sizes using molds created with a 3D printer to treat the esophageal stricture and prevent its progression. This method can be used to safely treat leaking cervical esophageal strictures. A step-by-step of how to do it has been described.

Esophageal stenosis in head and neck cancer patients: Imaging's accuracy to predict dilation response.

ObjectivesThe primary goal of this study was to examine how well findings of cervical esophageal stenosis on modified barium swallow (MBS) and esophagram correlate with clinical improvement following dilation in patients with a history of head and neck (H&N) cancer.MethodsA retrospective review was performed at an academic hospital. The study population included H&N cancer patients with a history of neck dissection surgery who underwent esophageal dilation from 2010 to2018. Pre and postdilation swallowing function was assessed. The Functional Outcomes Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) were used as outcome measures.ResultsThe 95 patients were included. All patients had imaging prior to dilation. Post‐dilation FOSS and FOIS scores were significantly improved (P < .001). In identifying the patients that would have improvement from dilation, esophagram and MBS had average sensitivities of 81% and 82%, respectively. The negative predictive value (ie, the ability of a normal esophagram or normal MBS to exclude patients that would not improve with dilation) was only 46% and 38%, respectively. When the specific finding of aspiration on MBS was considered, the positive predictive value (PPV) (ie, the ability of an MBS positive for aspiration to predict that a patient would benefit from dilation) was 87% (P = .03). When only the specific finding of stenosis on esophagram was considered, the PPV of improvement post‐dilation was 58% (P = .97). The delay in time from imaging to dilation was significantly longer in those who had an unidentified stenosis (false negative) on imaging when compared to those who did not (46.8 ± 35.2 days vs 312.6 ± 244.1 days, P < .001).ConclusionIn high risk patients for cervical esophageal stenosis, such as those with a history of H&N cancer and open neck surgery with or without radiation, MBS and esophagram appear to have mixed reliability as predictors of response to esophageal dilation. In these patients, a “negative” result on MBS and esophagram may not be diagnostically accurate enough to exclude patients from consideration of dilation.Level of EvidenceIIb

A new designed self-expandable metal stent for the management of benign radiotherapy-induced hypopharyngeal or cervical esophageal strictures.

The management of patients with hypopharyngeal or cervical esophageal refractory benign strictures (RBS) after surgery and radiotherapy ± chemotherapy for laryngeal cancer is challenging. We aimed to assess the long-term efficacy and safety of a new designed fully covered SEMS in these patients. We reviewed the results of a prospectively collected database of 40 consecutive patients with dysphagia due to RBS of the cervical esophagus or hypopharynx after surgery and radiotherapy with or without chemotherapy for laryngeal cancer, unfit for surgery, referred in two tertiary-care endoscopic centers from June 2005 to December 2018. All of them were treated with placement of a Niti-S Conio cervical stent. After placement of the first stent, dysphagia improved in all patients. The total number of adverse events was 35 out of a total of 299 procedures (11.7%): 25 (8.4%) stent migrations, 6 (2%) tumor overgrowth, 3 severe pain and 1 pharyngo-cutaneous fistula. Stents were periodically changed. In only one patient with a cervical esophageal stricture the stent was definitively removed after 7 sessions of stent placement because of stricture resolution. Patients were followed-up for a median of 11.6months and a significant improvement in dysphagia was reported in all patients (p < 0.001). The use of this conformable, small caliber new designed Niti-S stent, exchanged periodically, appeared safe and permitted durable oral intake in patients with difficult-to-treat hypopharyngeal or cervical esophagus strictures, avoiding the need for periodic dilations.

S1937 Development of Eosinophilic Esophagitis in a Patient With Radiation-Induced Esophageal Strictures: A Case Report

INTRODUCTION: Radiation therapy for head, neck, and esophageal cancer often results in difficult to manage esophageal strictures. These strictures often require repeat dilation to improve dysphagia symptoms. Eosinophilic esophagitis (EOE) can present with similar symptoms of malnutrition and dysphagia and can lead to strictures. We present the unique case of a female with suspected radiation strictures found to have associated eosinophilic esophagitis with improvement in dysphagia with anti-reflux therapy. CASE DESCRIPTION/METHODS: A 49 year old female with history of tongue cancer status post hemiglossectomy and multiple radiation treatments developed worsening chronic oropharyngeal dysphagia and regurgitation. Patient underwent a barium esophagram which showed esophageal narrowing. She then had an upper endoscopy which revealed a cervical esophageal stricture and underwent bougie dilation. Patient was diagnosed with a post-radiation stricture. On repeat endoscopy one month later, patient was found to have a similar esophageal stricture but noted to have associated linear furrows with upper esophageal biopsies showing 110 eosinophils per high power field. She was dilated at that time and also started on anti-reflux therapy daily. On repeat endoscopy, patient was noted to have significant improvement in her symptoms with no subsequent dilations required and improved nutritional performance. DISCUSSION: Upper esophageal strictures can be challenging to treat. Strictures in patients with EOE can often escape detection during endoscopy. Our patient demonstrates a unique case with simultaneous radiation and eosinophilic stricture causing dysphagia. Her symptoms responded significantly better after initiation of proton pump therapy, highlighting the importance of considering dual etiology for esophageal strictures. In patients who do not respond to multiple dilations for radiation strictures, co-existing pathology such as EOE should be considered. Patients with refractory radiation esophagitis warrant careful endoscopic evaluation for associated EOE. Treatment for patients with radiation strictures and dysphagia often requires dilation, which may place patients at higher risks for complications with underlying EOE. Patients with radiation esophagitis with suspicion for EOE should undergo cautious dilation. This case propagates the role for empiric anti-reflux therapy in patients with a high pre-test probability of EOE complicating radiation and other benign esophageal strictures.Figure 1.: Proximal Esophagus Stricture.Figure 2.: Linear Furrows in Upper Esophagus.

Retrograde percutaneous transgastric esophageal endoscopic submucosal dissection: a peculiar endoscopic submucosal dissection technique for therapy of esophageal cancer with esophageal stenosis after chemoradiation therapy.

The patient was a 69-year-old man who had received chemoradiotherapy for T3N2M0, stage III cervical esophageal cancer 10 years earlier and exhibited complete response. He developed cervical esophageal stenosis caused by fibrosis as a result of treatment and experienced dysphagia within 1 year after treatment.

What is the Best Choice for Esophageal Replacement in Children?

Esophageal replacement surgery is performed in children with either congenital long gap esophageal atresia or acquired esophageal damages such as caustic injury of the esophagus. although the left colon because of less variation in blood supply and suitable diameter in comparison with right colon is the better choice. A secured pedicled colon is mandatory for reducing the sever complications, such as leak and necrosis. Ileocolic conduit is an alternative method of colon interposition which has anti reflux effect and therefore with less complications related to gastroesophageal reflux. When we have a short segment esophageal stricture due to corrosive esophagitis or other causes of esophageal strictures which is refractory to repeated dilatations, it is advisable to perform colon patch esophagoplasty. Gastric transposition can produce a good way for gastrointestinal continuity with a perfect weight gain and oral feeding, therefor it can be a safe choice for esophageal replacement in children. Partial gastric pull-up is an alternative operation for esophageal replacement in children and infants with long gap esophageal atresia. Gastric conduit replacement is another alternative technique for esophageal replacement, in which a gastric tube is created in the abdomen and it is pulled to via thoracic cavity to the neck and is committed by cervical anastomosis. Antral patch esophagoplasty is used for benign and limited esophageal stricture due to gastroesophageal reflux. Usefulness of pedicled jejunum was under optimal results because of technical problems and high rate of necrosis and mortality for decades. Sternocleidomastoid myocutaneous esophagoplasty is a scarce method which is reported by some surgeons for limited cervical esophageal stricture repair. Free microvascular transfer of the reverse ileo-colon flap with ileocaecal valve valvuloplasty is used for reconstruction of a pharyngoesophageal defect, and Patch esophagoplasty by using of degradable bioscaffolds of extracellular matrix have shown good results in preclinical and clinical outcomes to prevent stenosis after endoscopic mucosectomy. We will explain the advantages and disadvantages of these different surgical methods in this review article.

Clinical Efficacy of Stent in Patients with Cervical Esophageal and/or Hypopharyngeal Stenosis after Total Laryngectomy.

We retrospectively analyzed 17 patients with esophageal stent who underwent cervical esophageal and/or hypopharyngeal stenosis after total laryngectomy (TL) from January 2014 to January 2018. The success rate of stent implantation was 100%. Dysphagia in 16 patients improved to class 0 or 1 (16/17, 94.12%) after stent implantation and in 1 patient was improved to class 2 (1/17, 5.88%). Two patients died of tumor progression at 7 months and 11 months after stent implantation, respectively, but both could eat semi-solid/solid food before death. Dysphagia was resolved in the remaining 15 patients, and there was no recurrence of dysphagia including feeding obstruction during follow-up. Therefore, this case series concludes that the esophageal stent position after TL can be much higher than that of patients with normal pharyngeal structures. Esophageal stent implantation is a feasible and effective treatment for patients with laryngopharyngeal/esophageal stenosis following TL.

1836 The Bougie Cap: A Novel Device for Treatment of Esophageal Strictures

INTRODUCTION: Treatment of high cervical esophageal strictures can be technically challenging. Placement of endoscopic balloons across the stricture may not be feasible due to their proximal location. Serial dilation with the use of Savary-Gilliard dilators is a well-established method for treatment of these strictures. However, this technique does not allow for direct optical feedback during dilation. We present a case of benign cervical esophageal stricture treated with a novel method utilizing the BougieCap (Ovesco Endoscopy AG). CASE DESCRIPTION/METHODS: A 62-year-old male presented with dysphagia. He had a prior history of peptic stricture at the gastroesophageal junction, treated with multiple balloon dilations that was complicated by an esophageal perforation. Patient underwent an emergent thoracotomy, esophagectomy, and gastric pull-up with placement of a feeding jejunostomy. Four months after surgery, he noted recurrence of dysphagia, with food getting lodged in the area below his throat and upper chest. Barium swallow revealed a tight stricture at the anastomosis that narrowed the lumen down to 5 mm in size. Upper endoscopy confirmed a stricture located 18 cm from the incisors. Using an endoscopic BougieCap the stricture was dilated serially from 7 to 12 mm in size with good results. Expected mucosal disruption was identified at the end of the procedure. On follow up, patient reported significant improvement in his symptoms without any complications. DISCUSSION: Use of Savary-Gilliard Dilators for stricture dilation provides only haptic control and often requires the use of fluoroscopic guidance. Our case highlights the use of a novel device - the BougieCap - for treatment of esophageal strictures which allows for direct visual control and optical feedback during the procedure. Ability to visualize the tension on the tissue while passing the stricture with the cap avoids overstretching and may help reduce the risk of complications, allowing for a more effective procedure. Moreover, by eliminating the need to switch instruments, the use of BougieCap can reduce procedure times. Additional prospective studies with a larger number of patients and long-term follow-up are necessary to determine its safety and long-term efficacy.

2151 Size Matters: A Case of Recurrent Proximal Esophageal Stenosis Treated With a Biliary Self Expanding Metal Stent (SEMS)

INTRODUCTION: Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution. CASE DESCRIPTION/METHODS: Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration. DISCUSSION: Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.

A Rare Case of Chilaiditiʼs Sign Associated with Cervical Neuropathy

Chilaiditi's sign, the colonic interposition between the liver and diaphragm, is an uncommon radiographic finding.1 While it has been previously observed in the setting of cirrhosis, chronic obstructive pulmonary disease, obesity, near-term pregnancy, mental disorder, and primary lung cancers, its etiology is unknown.2 We describe a case of a man with cervical neuropathy and esophageal strictures as a consequence of radiation therapy and a total laryngectomy for head and neck carcinomas, who was found to have Chilaiditi's sign following an endoscopic esophageal dilation. A 70-year-old man was referred to our clinic for endoscopic dilation of known esophageal strictures in the setting of progressive dysarthria, dysphagia, and weight loss. He was initially treated with radiation therapy for nasopharyngeal carcinoma at age 47, and at age 55, he underwent a total laryngectomy and additional radiation for supraglottic laryngeal carcinoma. During the next fifteen years, he developed progressive dysarthria and weakness of the neck, shoulder, and rotator-cuff muscles secondary to nerve impingement from extensive fibrosis, lymphedema, and neck scarring. He developed dysphagia due to recurrent esophageal strictures, responsive to periodic endoscopic dilations. A repeat, uneventful endoscopic esophageal dilation was performed, after which he returned to clinic three days later with complaints of subjective fevers and heartburn. He denied abdominal pain, nausea, vomiting, or melena. His examination was notable for vitals within normal range and decreased breath sounds in the right lung base. A CT with oral contrast revealed an increase in the elevation of the right hemi-diaphragm with interposition of the colon between the liver and right hemi-diaphragm, consistent with Chilaiditi's sign (Figures 1-3). He was managed conservatively given lack of dyspnea and resolution of his fevers and heartburn. The etiology of Chilaiditi's sign is unknown and rarely discussed in the literature. Our case highlights a potential association between Chilaiditi's sign and cervical nerve damage as a result of post-laryngectomy and radiation-induced fibrosis. Fibers from the C3, C4, and C5 nerve roots innervate the muscles of the upper extremity and neck and also compose the phrenic nerve. Our patient's cervical neuropathy and its potential effects on diaphragmatic function may serve as a causative link between the two findings.1498_A Figure 1. Coronal CT slice of the colonic interposition between liver and diaphragm1498_B Figure 2. Second coronal CT slice of Chilaiditi's sign1498_C Figure 3. Axial CT slice demonstrating Chilaiditi's sign

Esophagram findings in cervical esophageal stenosis: A case-controlled quantitative analysis.

Cervical esophageal stenosis is often diagnosed with a qualitative evaluation of a barium esophagram. Although the esophagram is frequently the initial screening exam for dysphagia, a clear objective standard for stenosis has not been defined. In this study, we measured esophagram diameters in order to establish a quantitative standard for defining cervical esophageal stenosis that requires surgical intervention. Single institution case-control study. Patients with clinically significant cervical esophageal stenosis defined by moderate symptoms of dysphagia (Functional Outcome Swallowing Scale > 2 and Functional Oral Intake Scale < 6) persisting for 6 months and responding to dilation treatment were matched with age, sex, and height controls. Both qualitative and quantitative barium esophagram measurements for the upper, mid-, and lower vertebral bodies of C5 through T1 were analyzed in lateral, oblique, and anterior-posterior views. Stenotic patients versus nonstenotic controls showed no significant differences in age, sex, height, body mass index, or ethnicity. Stenosis was most commonly at the sixth cervical vertebra (C 6) lower border and C7 upper border. The mean intraesophageal minimum/maximum ratios of controls and stenotic groups in the lateral view were 0.63 ± 0.08 and 0.36 ± 0.12, respectively (P < 0.0001). Receiver operating characteristic analysis of the minimum/maximum ratios, with a <0.50 ratio delineating stenosis, demonstrated that lateral view measurements had the best diagnostic ability. The sensitivity of the radiologists' qualitative interpretation was 56%. With application of lateral intraesophageal minimum/maximum ratios, we observed improved sensitivity to 94% of the esophagram, detecting clinically significant stenosis. Applying quantitative determinants in esophagram analysis may improve the sensitivity of detecting cervical esophageal stenosis in dysphagic patients who may benefit from surgical therapy. IIIb. Laryngoscope, 128:2022-2028, 2018.

Quantification of Dose-Volume and Dose-Length Parameters for Cervical Esophageal Stricture in Head and Neck Irradiation with the 3DCRT and IMRT Technique

PurposeTo quantify and compare dose-volume and dose-length parameters of cervical esophagus between three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiation therapy (IMRT) and to correlate with incidence of cervical strictures in head and neck cancer irradiation with radical intent. Materials and MethodsForty consecutive head and neck cancer patients who received radical radiation therapy, either with 3DCRT (n = 20) or IMRT (n = 20), between December 2011 and August 2012 were retrospectively analyzed and followed up for at least 4 years post-treatment completion. ResultsThe volumes of cervical esophagus receiving ≥54 Gy (V54) and ≥60 Gy (V60) and lengths receiving circumferential dose of ≥50 Gy (L50) and ≥54 Gy (L54) were significantly higher in patients treated with IMRT as compared to 3DCRT (P ≤ .05). At the end of minimum 4 years' post-treatment, nine patients had documented symptomatic strictures; three patients were treated with 3DCRT and six patients with IMRT technique. ConclusionIMRT technique in entire-neck irradiation is associated with increased spillage dose to the cervical esophagus, and thereby increased risk for late sequelae. The cervical esophagus has to be considered as an organ at risk and constraints need to be given in IMRT planning, particularly for lower-neck irradiation.

Endoscopically placed stents: a useful alternative for the management of refractory benign cervical esophageal stenosis.

Benign esophageal strictures are relatively frequent and can severely affect the quality of life of a patient. Stenting has been proposed for the treatment of refractory cases. Lesions affecting the cervical esophagus are more difficult to treat, and the placement of stents in this location has traditionally been restricted due to potential adverse events. The aim of this study was to describe the efficacy and safety of endoscopic stenting in the management of refractory benign cervical esophageal strictures (RBCES) in a single-center cohort study. We analyzed 12 patients with RBCES (Kochman's criteria) and severe dysphagia. We recorded previous endoscopic treatments, stricture characteristics and demographic data. The two types of stents used were fully covered self-expandable metallic stents (FCSEMS) and uncovered biodegradable stents (BDS). FCSEMS were removed eight weeks after placement, and BDS were followed-up until degradation. We assessed technical and clinical success, rate of stricture recurrence and adverse events. The mean age of participants was 64 years (range 30-85). A total of 23 stents (13 FCSEMS and 10 BDS) were placed in 12 patients (median 1.92, range 1-4). The technical success rate was 96% (22/23 stents). Eight patients (66.6%) maintained adequate oral intake at the end of follow-up (median 33.3 months, range 3-84 months). Migration was recorded in 7/23 stents (30.4%) and epithelial hyperplasia in 4/23 stents (17.4%). No severe adverse events were noted. All patients complained of minor cervical pain after placement that was well controlled with mild analgesia. Endoscopic stent therapy seems to be effective and safe in the management of RBCES.

The Clinical Outcome in Patients Treated With a Newly Designed SEMS in Cervical Esophageal Strictures and Fistulas.

Using a self-expandable metallic stent (SEMS) in the cervical esophagus is controversial due to an increased risk of complications. Here we assessed a new type of SEMS purpose-designed for the cervical esophagus area. Patients with malignant or benign stenosis within 4 cm distance of the upper esophageal sphincter who underwent placement of a SEMS with a shorter proximal head (Niti-S Esophageal Covered Stent-Cervical-type, NSECSC), were included. Main outcome measures were the functional outcome, tolerance, complications, recurrent dysphagia, and survival. About 37 patients had an NSECSC placed between April 2008 and June 2013 for esophageal stenosis (malignant=20, benign=17), 5 with associated tracheoesophageal fistula. The mean stenosis-upper esophageal sphincter distance was 1.86±1.27 cm. The median follow-up was 150 days. Dysphagia improved in 27/37 cases (73%). Short-term and long-term tolerance without needing stent removal was 92% and 82%, respectively. The complication rate was 59% (22/37): 32% (n=14) major complications [fistula (3), perforation (3), aspiration pneumonia (5), laryngeal dyspnea (2), and bleeding (1)], and 27% (n=10) minor complications [pain (7) or dysphonia (3)]. A multivariate analysis confirmed a higher risk of major complications in cases of benign stenosis (odds ratio=5.2; 95% confidence interval, 1.05-25.90; P=0.04). Recurrent dysphagia occurred in 15 patients (obstruction=7, migration=8). The NSECSC does not appear less morbid than standard SEMS in the cervical esophageal area, but could be useful in malignant indications as it is well-tolerated and offers effective palliation of the dysphagia. However, this device should not be used in benign cervical esophageal strictures or fistulas.

Successful Surgical Management of Cervical Esophageal Membranous Obstruction and Stricture in a Cattle Calf

Copyright: © 2016 Ali MM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. *Corresponding author: Ahmed Ibrahim, Faculty of Veterinary Medicine, Assiut University, Assiut, Postal Code: 70155, Egypt, Tel: +201062204009; Fax: 088-208050; E-mail: elgrah38@gmail.com

Closure of a Persistent Non-healing Gastrocutaneous Fistula (GCF) With a Porcine Biodegradable Fistula Plug (FP) and an Over-The-Scope Clipping Device

Introduction: A 50yo M with a history of tonsillar cancer s/p chemoradiation and subsequent complications related to osteoradionecrosis of the left mandible required long-term placement of a PEG tube (24Fr). After removal the patient developed a persistent GCF. Attempts to close the site with endoclips were unsuccessful due to large size and difficulty opposing the edges of the internal defect. A large 14mm diameter over-the-scope clip was tried but could not be passed across a cervical esophageal radiation stricture. Due to extensive induration of the peristomal area, abdominal wall suture was not feasible. After disrupting the lining of the fistula tract with a cytology brush, a FP (7mm diameter) was placed in antegrade fashion percutaneously through the abdominal wall defect under direct endoscopic guidance. The distal tip of the trimmed fistula plug was secured internally with a 11mm over-the-scope clip. No sutures were required. Immediate closure of the GCF was achieved. Three weeks later, the fistula plug remains in place and is dissolving without leakage. Discussion: PEG tube tracts usually close spontaneously within a few days after removal. Infrequently, a GCF develops. Before attempts at endoscopic closure, disrupting the lining within the fistula tract with a brush or silver nitrate may be enough to facilitate closure if the tract is small. Potential endoscopic management options for refractory GCF usually include through-the-scope endoclips, over-the-scope clipping devices or endoscopic suturing devices. Percutaneous trans-abdominal suture placement or the use of tissue adhesives such as the fibrin sealant may also be considered when feasible. The use of a FP for GCF closure using a technique similar to PEG tube placement has been described in which the FP is pulled through the GCF by a percutaneously placed snare with base of plug located internally within stomach. This method requires sutures to be placed between either the internal and / or external buttons to secure the FP, which can be technically difficult. To our knowledge, this report is the first to describe this variation of technique in which a FP was used to close a large GCF secured internally with an over-the-scope clip. Conclusion: FP can be feasible alternative to consider for refractory GCF. They can be secured internally with an over-the-scope clipping device without the need for sutures.Figure 1

Endoscopic Balloon Dilation of Esophageal Strictures in 9 Horses.

BackgroundMedical treatment of esophageal strictures in horses is limited and the use of balloon dilatation is described in few cases. Long‐term follow up after balloon dilatation and the use of intralesional corticosteroids has not been evaluated.ObjectivesTo describe the use of endoscopic guided, esophageal balloon dilatation in horses for cervical and thoracic esophageal strictures and administration of intralesional corticosteroids at the time of dilatation.AnimalsNine horses from the hospital population with benign esophageal strictures.MethodsRetrospective study: Medical records were reviewed from horses presented to the William R. Pritchard, Veterinary Medical Teaching Hospital at UC Davis from 2002 to 2013. Records were searched using the key words: equine, horse, balloon dilatation, bougienage, and esophageal stricture.ResultsNine horses with esophageal strictures were treated with esophageal balloon dilatation. Five horses survived (survival at writing ranged from 2 to 11 years after discharge) and all nonsurvivors were <1 year of age and presented with concurrent problems or developed complications including megaesophagus, unresolved esophageal obstruction requiring esophagostomy, or severe aspiration pneumonia. Four horses were treated with intralesional corticosteroids with no adverse effects noted in the survivors (n = 3). Four horses available for long‐term follow up were alive at 2, 5, 6, and 11 years after presentation and 3 of these horses were being fed a hay‐based diet.ConclusionsResolution of esophageal strictures in the horse can be performed successfully, safely, and under standing sedation using balloon dilatation. Intralesional corticosteroids might reduce the incidence of recurrent strictures.

Feasibility, efficacy and safety of stent insertion as a palliative treatment for malignant strictures in the cervical segment of the esophagus and the hypopharynx.

50% of esophageal cancers are inoperable at the time of diagnosis, and around 15% involve the cervical esophagus. The hypopharynx is often involved by these malignancies as well. Palliation of cervical esophageal malignancies through stent insertion is considered limited due to technical challenges, poor patient tolerance and high complication rate. The aim of this study is to review our experience with stent insertion in the cervical segment of the esophagus and to evaluate outcome differences between stent insertions involving or sparing the hypopharynx. We retrospectively reviewed data on 69 consecutive patients that underwent stent insertion for malignant strictures in the cervical esophagus at our Department. Patients were divided according to involvement or sparing of the lower hypopharynx. Dysphagia severity was measured with the Mellow-Pinkas scale before the procedure and on monthly follow-ups. Any complication and its management were recorded. The main outcome parameters were as follows: dysphagia improvement, rate of successful dysphagia palliation (i.e., a reduction of the score to 0 or 1 after stent insertion) and complication rate. Multivariable analysis was carried out to assess the influence of patient- and procedure-related factors on the outcome of the procedure. Stent insertion was achieved in 100% patients. At 4 weeks, dysphagia score improved from a median of 3-0 (p < 0.001), and a successful palliation was achieved in 76.8% patients. The 30-day mortality rate was 14.5%. Successful palliation throughout the follow-up was achieved in 72.9% of the surviving patients. Complications occurred in 31.9% patients. Dilation before stent insertion was associated with a less efficient short-term dysphagia palliation (OR 6.77, 95% CI 1.46-31.29, p = 0.02). Stent insertion is a safe and effective palliative treatment for malignant cervical esophageal strictures. Results are consistent even in patients with hypopharyngeal lesions. Dilation should be avoided before stent insertion.