Cicatricial Stenosis Research Articles

Urinary Tuberculosis: From Demolition to Reconstruction

Tuberculosis is increasing in Italy and even today is still a progressive fatal illness if not treated quickly. Drug therapy still plays an important role, while endoscopy and surgery offer further therapeutic possibilities compared to the past, with excellent results regarding the most feared complication - cicatricial stenosis. Simple ureteral endoscopic dilation with catheters has given way to the insertion of modern well-tolerated in-dwelling stents that can be used even with upper calyceal stenoses. Reconstructive bladder surgery, making new orthotopic-bladders, is a valid method for treating retracted bladders. The authors report their experience in treating TBC complications in 45 patients and in particular one paradigmatic case of urinary tuberculosis with serious stenosis involving the complete urinary system between the pelvis and the distal urethra. Urethroplasty and new orthotopic ileal bladder allowed the patient, who previously had an external deviation, to micturate naturally again.

Mucosal wound and cicatricial stricture formation in the dog trachea: an experimental study

Complete healing of full-thickness tracheal mucosal wounds of different sizes was studied in three groups of dogs. No stricture was observed when the mucosal wounds were less than 20 x 15 mm. Obvious stricture, however, occurred when the wounds were 20 x 25 mm. Normal epithelium regenerated on the wounded areas in all of the three groups within seven weeks.

Photodetection and photodynamic therapy of ‘early’ squamous cell carcinomas of the pharynx, oesophagus and tracheo-bronchial tree

The efficacy of photodynamic therapy (PDT) alone was evaluated on 41 ‘early’ squamous cell carcinomas of the pharynx (10), oesophagus (15) and tracheo-bronchial tree (16). All lesions but two were synchronous second primaries in ENT-patients suffering from a more extensive cancer, governing the overall oncological prognosis. Photofrin I (3 mg/kg) or Photofrin II (2 mg/kg) were injected 72 h prior to the red light irradiation, supplied by an argon pumped dye laser. A diffusing cylinder was used to obtain a homogeneous light distribution at the tumour site (60 J to 150 J/cm2). In the oesophagus and bronchi, the results are good for cancers staged in situ or microinvasive at endoscopy (two recurrencies for 23 lesions treated). For more advanced cancers (submucosal in the oesophagus or invading the bronchial cartilage), the results are less satisfactory (three recurrencies for eight lesions treated). In the pharynx where light dosimetry is more difficult, the rate of recurrencies is higher (3/10 lesions treated). In the bronchi (one case) and oesophagus (one case), the longest disease-free survival is now 5 years. The irradiation of a non-cancerous zone of normal buccal mucosa on 25 patients having received HPD showed necrosis in all cases with light doses as low as 50mW/cm2 for 20 min (60 J cm−2), even with Photofrin II. We encountered six complications (three cicatricial stenosis, two fistulae, one severe sunburn), most of them resulting from the lack of selectivity of HPD. According to these experiments, PDT is efficient at destroying early squamous cell carcinomas in the pharynx, oesophagus and bronchi, but the tumour selectivity of HPD is poor in the digestive tract lined with squamous cell epithelium. The only hope for the future lies in the synthesis of a more selective and more stable photosensitizer. This discussion reviews possible directions of research for the development of new dyes (cationic dyes, dyes attached to monoclonal antibodies, etc), for PDT and hyperthermia, for photodetection of early cancers using a fluoro-endoscope, and finally, for tumour depth profiling in hollow organs using lasers of different wavelengths.

A CASE OF ESOPHAGEAL METASTASIS OF BREAST CANCER

Distant metastases of breast cancer rarely appear in the gastrointestinal tract paticularly in the esophagus. We report an esophageal metastasis of breast cancer in a 63-year-old woman who underwent modified radical mastectomy for breast carcinoma 8 years ago. The patient complained of passage disturbace and dysphasia. Esophagogram revealed a narrowing of cervical esophagus, and esophagoscopy showed a smooth identation usually covered with normal mucosa. Esophageal biopsy resulted in negative for carcinoma. Histologically a resected speciman showed adenocarcinoma and it was determined a metastasis of breast cancer. It was important to differenciate the metastasis from cicatricial stenosis, benign or malignant subumucosal tumor, because the metastatic lesion is usually covered with normal mucosa. Recurrent breast cancer should be considered for a patient presenting with esophageal narrowing who have a past history of breast cancer.

A New Retrograde Dilation Method for Esophageal Cicatricial Stenosis: Gulp and Pull Dilator with Cushion

This article presents the use of a new retrograde dilation method without gastrostomy in the treatment of 22 cases of esophageal cicatricial stenosis. We believe that this technique is more effective

外傷性喉頭下咽頭狭窄症の治療経験

A case of 56-year-old woman who was strangled by an agricultural machine, was reported. She had been complaining of dysphagia and dyspnea since one month after the accident. Clinical examinations revealed that there had been laryngopharyngeal stenosis and fractures of both the hyoid bone and the thyroid cartilage. Reconstruction of the lumen had been performed. However, the tendency of cicatricial stenosis was observed for two years. The scar tissue was vapolized with CO2 laser irradiation finally.

Postendoscopic Sphincterotomy Stenosis

We report on two patients. The first patient is a 62-year-old female patient who had cholecystectomy in 1970, and in whom two small bile duct stones were removed after endoscopic sphincterotomy in 1987. Within two months of this procedure, she developed three episodes of documented acute pancreatitis. The other patient, a 58-year-old female, developed acute pancreatitis three months after an endoscopic sphincterotomy for stones in the common bile duct. In both patients, ERCP revealed a cicatricial stenosis of the common bile duct and the pancreatic duct. The condition was resolved by repeat sphincterotomy. The first patient needed repeated endoscopic insertion of bilioduodenal endoprostheses and an endoprosthesis in the pancreatic duct. It is interesting to note that, in contrast to surgical reports, very few postpapillotomy stenoses are reported by endoscopists.

Esophagocoloplasty for cicatricial stenosis after chemical injury

Our experience with esophageal replacement by transposition of the right colon with a segment of ileum in patients with cicatricial esophageal strictures caused by the ingestion of caustic agents has been discussed. We demonstrated, by means of the D-xylose test, that the length of ileal segment did not adversely affect the absorptive ability of the intestine, which returned to the preoperative level shortly after the operation and even exceeded that level 12 months thereafter.

Endoscopic treatment of scar stenosis in the upper GI tract.

Short cicatricial stenoses following surgery of the upper gastrointestinal tract are difficult to treat and have a high recurrence rate. A method of eliminating stenoses endoscopically with the aid of diathermy is described. This method has, to date, been employed in 51 patients, and only a single serious complication has been observed. The procedure can thus be recommended, since reoperation with resection of the anastomosis is associated with a very high rate of complications. A new method of treating scar stenosis in the upper GI tract, which develops in particular after surgical anastomosis of the esophagus, is described, in 51 patients this method helped replace bougienage. This method obviates the need for life-long, unpleasant dilatation with the bougie in the mostly elderly patients.

Pharyngoesophageal stricture and fistula. Treatment by free jejunal graft.

Fifty-five patients with disorders of the pharynx or cervical esophagus requiring extensive ablative therapy were reconstructed by heterotopic autotransplantation of a segment of jejunum. Of these 55 patients, the overwhelming majority were treated for squamous cell carcinoma or the complications of combined radiation and operative therapy. There were six graft failures in the entire group of 55 patients for a transfer reliability of 90%. Three patients died in the perioperative period (5%). The purpose of this paper is to report on the treatment of a subset of these patients in whom fixed cicatricial stenosis of the gullet was the problem or in whom a radionecrotic cutaneous fistula existed. Fourteen such patients were treated, ten with stricture and four with fistula. Both patch grafts of on-lay segments and more routine circumferentially intact tubed segments of jejunum were used depending upon the nature of the defect. The youngest patient in this group was a 3-year-old juvenile diabetic with caustic stricture and the oldest was a 75-year-old man with fixed stricture following operation and radiation for cancer. Nine of ten and four of four anatomic reconstructions were successful in the stricture and fistula patients, respectively. All of these 13 patients with a neo- gullet of jejunum were able to handle secretions and liquids satisfactorily. Eleven patients were on a regular diet and had no discernible physiological impairment in alimentation. One patient had mild dysphagia and used a blenderized diet. One patient was able to swallow liquids only. In this patient the resection for tumor was so high and so extensive that the physiologic act of deglutition itself was impaired. There were no perioperative deaths, although one patient has succumbed to recurrent and metastatic carcinoma. When conventional treatment for stricture or fistula in the cervical alimentary tract has failed, reconstruction can be accomplished safely by free revascularized jejunal graft. Successful alimentation can be anticipated in all patients in whom the physiologic mechanism of deglutition itself is not drastically impaired.

Canine model of subglottic stenosis secondary to prolonged endotracheal intubation.

Acquired subglottic stenosis is usually a consequence of prolonged endotracheal intubation. The present study describes a canine model of subglottis stenosis which is congruent with the known and suspected pathogenesis of the disease in man. Eighteen young pups (Canis familiaris) were used. A modified cuffed endotracheal tube was placed within the subglottis and secured by inflating the cuff. The capillary tube supplying the cuff was sealed and cut so as to lie below the epiglottis. Three animals died of tracheal rupture or collapse prior to or on the thirteen day following intubation. In the remaining animals, the cuffed tube was removed and the subglottis was examined. All exhibited ulcerations and exuberant polyploid granulations at the level of the subglottis and trachea. A 4 mm uncuffed endotracheal tube was introduced and secured within the subglottis and trachea of a number of the pups to provide an airway. After a 3-week period, the tube was removed and the dogs were sacrificed. Examination of the specimens showed various degrees of "hard" cicatricial stenosis of the subglottis and trachea. Histologic studies showed destruction of the cartilage with replacement by scar tissue and partial epithelialization. This model may be useful to investigations of the prevention and treatment of the disease.

Penetrating Injuries of the Ureter

We reviewed 18 cases of penetrating ureteral injury encountered during a 10-year interval. Low velocity gunshot injuries occurred in 16 patients. All levels of the ureter were represented with near equal incidence. Stented ureteroureterostomy was the primary mode of management and had satisfactory results, with temporary urine leaks resolving spontaneously in 4 patients, responding to temporary catheter diversion in 1 and requiring reoperation in 2. Plastic stents were inferior to silicone or rubber materials. Colon and/or bowel injury was universal and was not found to justify alteration in the choice of surgical timing or technique, or to influence over-all results. Adequately drained urine poses no threat of cicatricial stenosis. Excretory urography is reliable and retrograde studies are dependable when urography is equivocal.

Penetrating injuries of the ureter.

Eighteen cases of penetrating ureteral injury encountered over 10 years are reviewed. Low-velocity gunshot was the mode of injury in 16. All levels of the ureter were represented with near-equal incidence. Stented uretero-ureterostomy was the primary mode of management, offering satisfactory results, with temporary urine leaks resolving spontaneously in four, responding to temporary catheter diversion in one, and requiring reoperation in two. Plastic stenting was inferior to silastic or rubber materials. Colon and/or bowel injury was universal and was not found to justify alteration in choice of surgical timing or technique, or to influence overall results. Adequately drained urine poses no threat to cicatricial stenosis. Urography is reliable; retrograde studies are dependable when urography is equivocal.

Surgical management of cicatricial post-scleromatous sub-glottic stenosis.

In Egypt, sub-glottic stenosis is commonly caused by scleromatous affection. The countries in which scleroma is endemic have been reviewed. The incidence of scleroma, laryngeal scleroma, and sub-glottic affection, and their sex ratios have been discussed. Radiological study of the sub-glottic extension has been done. The operative procedures are detailed and the results are presented. The use of the Montgomery T-tube is an essential part of all these operations. The excision of scar tissue from the sub-glottic region was done in children, and this accords with recent trends. Twenty cases have been operated upon, with airway improvement in all of them.

レーザーブロンコスコープの臨床応用

Two cases of tracheal stenosis were successfully treated with the use of a specially designed laser bronchoscope.Case 1. A 32-year-old male.The patient met with a traffic accident in October, 1978. Tracheotomy was performed for lung complication. The tracheostoma was closed two months after the operation.In April, 1980, he was admitted to our hospital as an emergency patient because of severe dyspnea. Cicatricial stenosis of the trachea was observed at the distance of 3cm from the carina. The inside diameter was only 3mm at the stenosis. No traditional procedures were thought to be useful to obtain a good air way. Therefore, we vaporized the cicatricious tissue with the use of the laser bronchoscope.After the vaporization, the lumen of the stenotic area became 6.5cm in diameter, resulting in a normalrange of respiratory function. He has been free from the symtome for 6 months since the operation.Case 2. An 84-year-old female.The patient was a case of recurrent papillary adenocarcinoma of the thyroid gland. She first developed a mass of the thyroid gland in 1957. She had a hemithyroidectomy in 1969. Since then, she had had local recurrence twice and neck metastasis twice, each being surgically treated. In 1980, a recurrent tumor was developed from the anterior wall of the trachea. It occupied a half of the lumen. The tumor was located 3cm below the vocal folds extending 1.3 cm downward.Because of the advanced age and the very slow proliferation of the tumor vaporization of the intra-tracheal mass was performed under the laser broncho-scope as a palliative treatment. Since the operation, she has been free from recurrence for 6 months.On the bases of the clinical experiences described above, we can conclude that laser vaporization under the specially designed bronchoscope is the choice of treatment for some stenotic lesion of the trachea.

Surgical Treatment of Chronic Laryngotracheal Stenosis

The author presented 28 patients with chronic stenosis of the larynx and cervical trachea, which were treated over a period of 13 years.Successful decannulation was achieved in 26 of the 28 patients. In 24 cases, laryngeal and tracheal reconstruction were performed and in 2 cases, silicon T-tubes were used for stenting following repair of stenosis in the thoracical trachea region. Two cases have not as yet been decannulated.The techniques which have successfully repaired chronic laryngeal and cervical tracheal stenosis are presented:1. Surgical treatment is necessary only when cicatrical stricture in the larynx and trachea becomes apparent due to invasion of the cartilageneous framework. Appropriate resection of its scar tissue and necrotic cartilage was done in order to keep the sufficient lumen and this was followed by muco-cutaneous suture to keep the wound open. One month after the operation, the scar around the fistula had become firm enough to become the framework to maintain the lumen. If the tracheal mucosa degenerates to fibrous tissue, the trachea is opened and after removal of scar tissue the raw area is covered with nasal septal grafts.2. In stenosis with median fixation of the vocal cord, the author applied a new technique for widening of the anterior glottal space instead of the lateralization method. The median portion of the thyroid cartilage is resected 10 to 15mm wide bilaterally. The mucosa of the anterior commissure of the cord is separated at the midline. The edge of each side of the mucosa is sutured to the perichondrium and to the skin of the same side. The anterior part of the glottic space is widened to become 4mm apart to ensure an adequate airway.3. The wound is left open to prevent the reproduction of the cicatricial stricture and the skin flap is closed secondarily 1 or 2 months after surgery.

A Case of Cicatricial Stenosis of the Esophagus Successfully Treated by Bouginage under Fiberscopy

A case of cicatricial stenosis of the esophagus following the transection of the esophagus for varices in a 20 year old female was reported. The patient developed dysphagia five months after the surgery. The fiberoptic esophagoscopy and barium swallowing showed marked stenosis at 33cm. from the upper incisors. After inserting a piece of thread into the stenotic region under fiberoptic esophagoscopy, the stenosis was successfully dilatated with bouginage. We emphasized that the fiberoptic esophagoscopy could be utilized as a therapeutic measure in a case of cicatricial stenosis of the esophagus.

Mesentsery and colon injuries secondary to blunt trauma.

Three cases of colon lesions following blunt trauma are presented to illustrate their varied manifestations. Although these injuries are not as common as those to the small bowel and solid viscera, the radiologist's awareness of them and of their various presentations may be helpful in suggesting the correct diagnosis. The major types of colon injury include mesenteric laceration with blood loss, vascular injury with or without bowel ischemia, intramural hematoma, bowel wall laceration, and delayed cicatricial stenosis.

Tucker Retrograde Esophageal Dilatation 1924–1974

Emphasis has been placed on a historical review of corrosive ingestion in the last 175 years with particular reference to etiology, diagnostic technique, therapy and sociologic factors. A complete reversal of the medical approach, i.e., from therapy of cicatricial stenosis to prevention of the formation of esophageal stenosis, has occurred. The reasons for and methods of this change have been presented. Tucker retrograde bougienage as a valued technique in the therapy of severe esophageal obstruction has withstood the “test of time.” Its minimal application has to date included many thousands of patients. Current figures from the manufacturer indicate a steady distribution rate of 10 sets/month. Its indication and application has broadened from caustic ingestion to include congenital, acquired, severe esophageal, hypopharyngeal and even cases of laryngeal stenosis. The necessity for the use of Tucker retrograde bougienage has, thankfully, greatly diminished.

Tucker Retrograde Esophageal Dilatation 1924–1974

Emphasis has been placed on a historical review of corrosive ingestion in the last 175 years with particular reference to etiology, diagnostic technique, therapy and sociologic factors. A complete reversal of the medical approach, i.e., from therapy of cicatricial stenosis to prevention of the formation of esophageal stenosis, has occurred. The reasons for and methods of this change have been presented. Tucker retrograde bougienage as a valued technique in the therapy of severe esophageal obstruction has withstood the “test of time.” Its minimal application has to date included many thousands of patients. Current figures from the manufacturer indicate a steady distribution rate of 10 sets/month. Its indication and application has broadened from caustic ingestion to include congenital, acquired, severe esophageal, hypopharyngeal and even cases of laryngeal stenosis. The necessity for the use of Tucker retrograde bougienage has, thankfully, greatly diminished.