Endoscopic Dilation Research Articles

Endoscopic Balloon Dilatation of Ileal Pouch-Anal Anastomosis Strictures in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for medically refractory inflammatory bowel disease (IBD). In this systematic review and meta-analysis, we assess outcomes and safety of endoscopic balloon dilatation (EBD) for IPAA strictures. A systematic search of numerous databases was performed through June 2023 to identify studies reporting on the outcomes of EBD in pouch-related strictures. Outcomes included technical success, clinical success at index dilation and in pouch retention, recurrence of symptoms post-EBD, and adverse events of EBD. Meta-analysis was performed using a random-effects model, and results were expressed in terms of pooled rates along with relevant 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran Q statistical test with I2 statistics. Seven studies with 504 patients were included. The pooled rate of technical success and clinical success of index dilatation was 98.9% (95% CI, 94.8-99.8%; I20%) and 30.2% (95% CI, 7.1-71%; I20%), respectively. The pooled rate of clinical success in pouch retention without the need for additional surgery was 81.4% (95% CI, 69.6-89.3%; I272%). The pooled failure rate of EBD was 18.6% (95% CI, 10.7-30.4%, I272%). The pooled rate of recurrence of symptoms after index dilatation was 58.9% (95% CI, 33.3-80.5%; I213%). The pooled rate of serious adverse events was 1.8% (95% CI, 1-3.5%, I20%). No deaths related to EBD were reported. Endoscopic balloon dilatation is safe and highly effective for management of IPAA strictures. Additional studies are needed to compare its efficacy with surgical interventions.

Subglottic Stenosis in a 3-Year-Old Child Following Prolonged Intubation - A Case Report

Subglottic stenosis is a serious complication of prolonged intubation in pediatric patients and Over 90% of acquired cases are iatrogenically caused and result from endotracheal intubation. Subglottic stenosis is an unanticipated problem that needs to be diagnosed and treated immediately. The majority of pediatric subglottic stenosis occurrences are mild to moderate. This case highlights the challenges and outcomes associated with this condition. Here, we present a 3-year-old child presented with high fever and scrotal pain with swelling, diagnosed as scrotal cellulitis. Laboratory results showed anemia, leukocytosis, and metabolic acidosis, and the child's condition deteriorated due to respiratory distress, requiring intubation and PICU admission. Following a scrotal abscess drainage, the child was discharged but returned with severe respiratory distress, cyanosis, and subglottic stenosis, confirmed by laryngobronchoscopy and imaging. After failed extubation attempts and further complications, a tracheostomy and endoscopic subglottic dilation were performed. The child was successfully decannulated after eight days, with near-complete recovery except for a slight change in voice tone. The case highlights the challenges in managing complex respiratory complications in pediatric patients. This case underscores the importance of monitoring for subglottic stenosis in children who have undergone prolonged intubation and demonstrates the efficacy of endoscopic dilatation in managing this complication.

Identification of gaps in the delivery of high-quality care of patients with eosinophilic esophagitis.

Quality indicators (QIs) are standardized metrics that can be used to quantify health care delivery and identify important areas for practice improvement. Nine QIs pertaining to the diagnosis and management of eosinophilic esophagitis (EoE) were recently established. We therefore aimed to identify existing gaps in care using these QIs. This is a retrospective, multicenter study utilizing recently established EoE QIs to evaluate practice patterns among adult gastroenterologists in the diagnosis and management of EoE. Three patient cohorts of 30 patients each presenting with dysphagia, food impaction, and new diagnosis of EoE, respectively, were obtained, yielding 120 patients per site to assess for every QI. Summary statistics were reported across two main themes: diagnosis and management. Subsequent analysis of gaps in care was then performed. The domain of diagnosis of EoE (QI 1 and 2) had the most notable gap in care with only 55% of the presenting patients undergoing appropriate evaluation for EoE. The domain of management of EoE had overall higher QI fulfillment-however it also contained significant intra-category variation in care. Notably, while 79% of patients had clinical follow-up within 1year from remission, only 54% underwent surveillance endoscopy within 2years of remission. In contrast, 100% of patients with symptomatic strictures independent of histologic response underwent endoscopic dilation (QI 4). Management approaches for EoE are evolving and variation in care delivery exists. We identified significant gaps in both diagnosis of EoE especially amongst patients presenting with index food impaction and long term management of EoE, when retrospectively evaluating care patterns using newly established QIs. This is the first study of its kind to utilize these previously established QIs to objectively identify care gaps that exist in EoE amongst several institutions. These findings also highlight the importance of QIs and standardization of management of complex chronic diseases like EoE to help bridge these gaps and provide a framework to measure adherence to these best practices.

Role of endoscopy in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease involving inflammation of the esophagus. Endoscopy is essential in the diagnosis and treatment of EoE and shows typical findings, including esophageal edema, rings, exudates, furrows, and stenosis. However, studies involving pediatric and adult patients with EoE suggest that even a normally appearing esophagus can be diagnosed as EoE by endoscopic biopsy. Therefore, in patients with suspected EoE, biopsy samples should be obtained from the esophagus regardless of endoscopic appearance. Moreover, follow-up endoscopies with biopsy after therapy initiation are usually recommended to assess response. Although previous reports of endoscopic ultrasonography findings in patients with EoE have shown diffuse thickening of the esophageal wall, including lamina propria, submucosa, and muscularis propria, its role in EoE remains uncertain and requires further investigation. Endoscopic dilation or bougienage is a safe and effective procedure that can be used in combination with medical and/or dietary elimination therapy in patients with esophageal stricture for the management of dysphagia and to prevent its recurrence.

Advancements in Surgical Management of Megaureters.

To review and describe the recent evolution of surgery for the various types of pediatric megaureter. Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.

Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis.

Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length. The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD. All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity). There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]). The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study.

The incidence of cholelithiasis has been on the rise in recent years, but the choice of procedure is controversial. To investigate the efficacy of laparoscopic cholecystectomy (LC) combined with endoscopic papillary balloon dilation (EPBD) in patients with gallbladder stones (GS) with common bile duct stones (CBDS). The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC + EPBD group (n = 50) or an LC + endoscopic sphincterotomy (EST) group (n = 52) according to surgical methods. Surgery-related indexes, postoperative recovery, postoperative complications, and expression levels of inflammatory response indexes were compared between the two groups. Total surgical time, stone free rate, rate of conversion to laparotomy, and successful stone extraction rate did not differ significantly between the LC + EPBD group and LC + EST group. Intraoperative hemorrhage, time to ambulation, and length of hospitalization in the LC + EPBD group were lower than those of the LC + EST group (P < 0.05). The rate of total complications of the two groups was 9.80% and 17.65%, respectively, and the difference was not statistically significant. No serious complications occurred in either group. At 48 h postoperatively, the expression levels of interleukin-6, tumor necrosis factor-α, high-sensitivity C-reactive protein, and procalcitonin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). At 3 d postoperatively, the expression levels of aspartate transaminase, alanine transaminase, and total bilirubin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS, in which LC combined with EPBD is beneficial to shorten the patient's hospitalization time, reduce the magnitude of elevated inflammatory response indexes, and promote postoperative recovery.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi.

Endoscopic retrograde cholangiopancreatography (ERCP), with its clinical ad-vantages of less trauma and faster recovery, has become the primary treatment for choledocholithiasis. To investigate the effects of different ERCP procedures on the sphincter of Oddi. The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively. The patients were divided into endoscopic sphincterotomy (EST, n = 24) and endoscopic papillary balloon dilation (EPBD, n = 67) groups. The duration of operation, pancreatic development, pancreatic sphincterotomy, intubation difficulties, stone recurrence, and incidence of reflux cholangitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction in the EST and EPBD groups. Differences in hypertension, diabetes, increased bilirubin, small diameter of the common bile duct, or ampullary diverticulum between the two groups were not significant. Statistically significant differences were observed between the two groups concerning sex and age (< 60 years). Patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group. The number of cases of pancreatic development, pancreatic duct sphincterotomy, and difficult intubation were higher in the EST group than in the EPBD group. The number of Oddi's sphincter manometries, ERCP surgical outcomes, and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group. The numbers of stone recurrences, reflux cholangitis, and cholecystitis were higher in the EST group than in the EPBD group. In summary, common bile duct stones, pancreatitis history, and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD. Based on this evidence, this study can provide actionable insights for clinicians and researchers.

Effectiveness of direct needle puncture for complete hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy (with video)

AbstractA 79‐year‐old Japanese woman, who had undergone pancreaticoduodenectomy 6 months prior to presentation owing to pancreatic cancer, complained of jaundice with high fever. Computed tomography revealed proximal bile duct dilatation with complete hepaticojejunostomy anastomotic stricture (HJAS). We performed a single‐balloon endoscopy for biliary drainage. The presence of a scar‐like feature surrounding the anastomosis was identified as the HJAS. White‐light imaging during single‐balloon endoscopy revealed that the HJAS contained a milky whitish area (MWA), suggesting that a membranous and fibrosis layer affected continuous inflammation around the center of the anastomosis (within a scar‐like feature). Endoscopic dilatation was performed using an endoscopic injection needle, with the MWA used as an indicator. A 23‐gauge endoscopic injection needle was used to penetrate the center of the blind lumen within the MWA, and a pinhole was created in the stricture. After confirming the position of the proximal bile duct using a contrast medium with the needle, an endoscopic guidewire with a cannula was inserted into the pinhole. A through‐the‐scope sequential balloon dilator was used to dilate the stricture, and a plastic stent was inserted into the proximal bile duct. This endoscopic intervention led to positive outcomes. In cases of complete HJAS occlusion, an endoscopic approach to the bile duct is difficult because the anastomotic opening of the HJAS is not visible. Thus, puncturing within the MWA, which can be used as a scar‐like landmark within a complete membranous HJAS, is considered a useful endoscopic strategy.

Efficacy and Safety of Endoscopic Stricturotomy in Inflammatory Bowel Disease-Related Strictures: A Systematic Review and Meta-Analysis.

Luminal strictures, common in inflammatory bowel disease (IBD), especially Crohn's disease (CD), are typically treated with endoscopic balloon dilatation (EBD). The newer endoscopic stricturotomy (ESt) approach shows promise, but data is limited. This systematic review and meta-analysis assess the effectiveness and safety of ESt in IBD-related strictures. A comprehensive literature search was conducted until November 2023 for studies assessing ESt efficacy and safety in IBD. Primary outcomes were clinical and technical success, with secondary endpoints covering adverse events, subsequent stricture surgery, additional endoscopic treatments (ESt or EBD), medication escalation, disease-related emergency department visits, and hospitalization post-ESt. Technical success was defined as passing the scope through the stricture, and clinical success was defined as symptom improvement. Single-arm meta-analysis (CMA version 3) calculated the event rate per patient with a 95% confidence interval (CI). Heterogeneity was evaluated using I2. Nine studies were included, involving 640 ESt procedures on 287 IBD patients (169 CD, 118 ulcerative colitis). Of these, 53.3% were men, with a mean age of 43.3 ± 14.3years and a mean stricture length of 1.68 ± 0.84cm. The technical success rate was 96.4% (95% CI 92.5-98.3, p-value < 0.0001), and the clinical success rate was 62% (95% CI 52.2-70.9, p-value = 0.017, I2 = 34.670). The bleeding rate was 10.5% per patient, and the perforation rate was 3.5%. After an average follow-up of 0.95 ± 1.1years, 16.4% required surgery for strictures post-ESt, while 44.2% needed additional endoscopic treatment. The medication escalation rate after ESt was 14.7%. The disease-related emergency department visit rate was 14.7%, and the disease-related hospitalization rate post-procedure was 21.3%. Our analysis shows that ESt is safe and effective for managing IBD-related strictures, making it a valuable addition to the armamentarium of endoscopists. Formal training efforts should focus on ensuring its widespread adoption.

Clinical outcomes of serial endoscopic balloon dilation for duodenal Crohn's disease-associated strictures.

Endoscopic balloon dilation (EBD) is a safe and effective treatment for Crohn's disease (CD)-associated strictures. However, serial EBDs have rarely been reported. This study aimed to evaluate the efficacy and safety of serial EBDs for treating CD-associated duodenal strictures compared with intermittent EBDs. Patients with CD-associated duodenal strictures who underwent EBD were recruited. The clinical data, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were divided into a serial dilation group and an intermittent dilation group to analyze the differences in safety and efficacy. Forty-five patients with duodenal CD-associated strictures underwent a total of 139 dilations. A total of 23 patients in the serial dilation group underwent 72 dilations, for a median of 3 (range 3 ~ 4) dilations per patient, and 22 patients in the intermittent dilation group underwent 67 dilations, for a median of 3 (range 1 ~ 6) dilations per patient. Technical success was achieved in 97.84% (136/139) of the patients. During the follow-up period, three patients in the intermittent dilation group underwent surgery, and the total clinical efficacy was 93.33% (42/45). No difference in safety or short-term efficacy was noted between the two groups, but serial EBDs exhibited significantly greater clinical efficacy between 6months and 2years. No significant difference in recurrence-free survival was observed, but the median longest recurrence-free survival and recurrence-free survival after the last EBD in the serial dilation group were 693days (range 298 ~ 1381) and 815days (range 502 ~ 1235), respectively, which were significantly longer than the 415days (range 35 ~ 1493) and 291days (range 34 ~ 1493) in the intermittent dilation group (p = 0.013 and p = 0.000, respectively). At the last follow-up, the mean diameter of the duodenal lumen was 1.17 ± 0.07cm in the serial dilation group, which was greater than the 1.11 ± 0.10cm in the intermittent dilation group (p = 0.018). We also found that the Simple Endoscopic Score for Crohn's Disease was associated with an increased risk of surgical intervention (HR 2.377, 95% CI 1.125-5.020; p = 0.023) and recurrence at 6months after the last EBD (HR 0.698, 95% CI 0.511-0.953; p = 0.024), as assessed by univariate analysis. Compared to the intermittent EBDs, serial EBDs for duodenal CD-associated strictures exhibit greater clinical efficacy within two years and could delay stricture recurrence. We suggest that serial EBDs can be a novel option for endoscopic treatment of duodenal CD-associated strictures.

Balloon dilation of congenital perforated duodenal web in newborns: Evaluation of short and long-term results.

Incomplete congenital duodenal obstruction (ICDO) is caused by a congenitally perforated duodenal web (CPDW). Currently, only six cases of balloon dilatation of the PDW in newborns have been described. To present our experience of balloon dilatation of a perforated duodenal membrane in newborns with ICDO. Five newborns who underwent balloon dilatation of the CPDW along a preinstalled guidewire between 2021 and 2023 were included. Nineteen newborns diagnosed with ICDO who underwent laparotomy were included in the control group. In all cases, good anatomical and clinical results were obtained. In three cases, a follow-up study was conducted after 1 year. The average time to start enteral feeding per os was significantly earlier in the study group (4.4 d) than in the laparotomic group (21.2 days; P < 0.0001). The time spent by patients in the intensive care unit and hospital after balloon dilatation was also significantly shorter. We determined the selection criteria for possible and effective CPDW balloon dilatation in newborns as follows: (1) Presence of dynamic radiographic signs of the passage of a radiopaque substance beyond the zone of narrowing or radiographic signs of pneumatisation of the duodenum and small bowel distal to the web; (2) presence of endoscopic signs of CPDW; (3) successful cannulation with a guidewire performed parallel to the endoscope, with holes in the congenital duodenal web; and (4) successful positioning of the balloon performed along a freestanding guidewire on the web. Strictly following selection criteria for newborns with ICDO caused by CPDW ensures that endoscopic balloon dilatation using a pre-installed guidewire is safe and effective and shows good 1-year follow-up results.

Early topical mitomycin-C prevents stricture formation in children with caustic ingestion.

Stricture formation is the most common remote complication of caustic ingestion. The aim of this study was evaluation of the efficacy of early topical endoscopic application of mitomycin C (MMC) in prevention of stricture formation after corrosive ingestion in children. We enrolled 78 children with a history of caustic ingestion within 48 h in a prospective, randomised-controlled study. Only 61 children completed the study and were classified into two groups: group A and B. After initial stabilisation, patients in group A (n = 30) received topical application of MMC within the initial 48 h while patients in group B (n = 31) only received conventional management. Follow-up endoscopic dilatation was done every 2 weeks to patients in either group until no need for further dilatation. The barium study, which was done on the third week, revealed that all the patients (100%) on conservative management (group B) had strictures while only nine patients (30%) in group A had strictures (P < 0.001). The median number of dilatations required for patients in group B was 26 (min. = 23 and max. = 32) while in group A, it was 0 (min. = 0 and max. = 7) (P < 0.001). The success of early MMC application was complete response in 26 patients (86.7%), partial response in 3 patients (10%) and no response in 1 patient (3.3%). On the other side, conventional therapy with endoscopic dilatation achieved complete response in 11 patients (35.5%). Early topical MMC application proved its efficacy and safety in prevention of scar and stricture formation in children following caustic ingestion.

Laparoscopic interventions in children with cystic bile duct dilations

Aim. To evaluate the efficacy of laparoscopic interventions and to carry out a comparative analysis of various options for biliodigestive anastomoses in children with cystic dilation of bile ducts. Materials and methods. The results of laparoscopic interventions were retrospectively analyzed in 110 children aged 2 months – 17 years with cystic bile duct dilation. Conversion was required in 3 observations (2.7 %). Laparoscopically assisted or total laparoscopic extirpation of dilated bile ducts with hepaticojejunostomosis was performed in 83 patients (75.5 %), laparoscopic surgery with hepaticoduodenostomosis – in 24 patients (21.8 %). Results. The duration of surgery was significantly shorter when hepaticoduodenoanastomosis was formed. After laparoscopic interventions, early complications were revealed in 10 observations (9.3 %), including 7 cases (6.5 %) of hepatico-duoduodenoanastomosis failure in which relaparotomy was performed with reconstruction of both interintestinal and biliodigestive anastomosis. Late postoperative complications (anastomotic stenosis and adhesive intestinal obstruction) developed in 11 patients (10.2 %). In 5 observations (4.6 %), percutaneous transhepatic cholangiostomy with staged balloon dilation of hepaticojejunostomosis (n = 3) and endoscopic balloon dilation of hepaticoduodenostomosis with stenting (n = 2) were performed with a positive effect. Conclusion. Resection of bile ducts with cystic dilations with the formation of biliodigestive anastomosis can be performed both via video-assisted surgery and completely laparoscopically. Laparoscopic interventions in children with different variants of cystic dilation of the bile ducts prove to be effective and safe.

Intensive triamcinolone acetonide injection regimen can highly prevent stricture after extensive esophageal endoscopic submucosal dissection

Background This study aimed to investigate the utility of intensive triamcinolone acetonide (TA) injections after extensive esophageal endoscopic submucosal dissection (ESD). Methods This retrospective study included 27 lesions in 27 consecutive patients who underwent ESD (ulcers encompassing ≥3/4 of the esophageal circumference) and received TA injections without oral steroid administration. Groups A and B included patients undergoing ESD with and without complete circumferential resection, respectively. All patients received TA injections (100 mg/session) immediately after ESD. In Group A, weekly based TA injections were performed until near-complete ulcer epithelialization. In Group B, patients did not receive additional injections or received weekly or biweekly TA injections. The primary outcome was stricture rate, and the secondary outcomes were the proportion of patients requiring endoscopic balloon dilation (EBD) and the number of TA injections. Results Group A included 7 lesions, and Group B included 20 lesions. The median (range) tumor lengths were 40 (30–90) and 45 (30–110) mm in Groups A and B, respectively. In Group A, the median circumferential resection diameter was 40 (20–80) mm. The stricture rate and the proportion of patients requiring EBD were 0 (0%) in Group A and 1 (5.0%) in Group B. The number of TA injection sessions was significantly higher in Group A than in Group B (8 [5–25] vs 1.5 [1–3]; p < 0.001). Conclusions Intensive weekly or biweekly based TA injections might aid in preventing post-ESD stricture and the need for EBD in patients undergoing extensive resection involving the entire esophageal circumference.

Manometric profile of patients presented with dysphagia – A hospital-based descriptive study

Objectives: The prevalence of dysphagia is 16–22%. Achalasia is characterised by impaired relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. Minimally invasive procedures, endoscopic pneumatic balloon dilatation (PD) and peroral endoscopic myotomy (POEM) are treatments of choice. We aimed to assess the manometric profile of patients presented with dysphagia and pre- and post-LES pressure and integrated relaxation pressure (IRP) of patients who underwent PD and POEM. Materials and Methods: One hundred and twenty-nine patients presented with dysphagia underwent high resolution oesophageal manometry (HREM). Manometric parameters: IRP, LES and pattern of motility were noted. According to Chicago classification 4.0, those who are diagnosed with achalasia underwent PD (17) and POEM (15). Statistical analysis was performed using the Statistical Package for the Social Sciences version 28. Pre- and post-procedure values (IRP and basal LES) were compared using the Wilcoxon signed-rank test. Results: Out of 129 patients with dysphagia, 57 had increased IRP and 75 had simultaneous motility. The mean LES pressure and IRP were found to be 28 ± 19.82 and 17 ± 14.04 mmHg, respectively. On analysis, of patients who underwent procedures PD (17) and POEM (15), a statistically significant decrease in IRP was observed in patients with post POEM compared to post PD status (P = 0.005 and 0.017, respectively). Reduced basal LES pressure was observed in patients with post-POEM status compared to post-PD status, which was not statistically significant. Conclusion: About 44% of patients presented with dysphagia were diagnosed with achalasia cardia. POEM procedure was found to be more effective compared to pneumatic dilatation.

Esophageal Self-Dilation in Benign Refractory Esophageal Strictures: Outcomes from a Randomized Controlled Trial and a Prospective Observational Study

BackgroundPatients with benign esophageal strictures may not maintain a response to endoscopic dilation, stenting, incisional or injectional therapies. For patients with these refractory esophageal strictures, esophageal self-dilation therapy (ESDT), performed to maintain luminal patency, may provide persistent symptomatic benefit while reducing patients’ reliance on healthcare services and the risk associated with repeated endoscopic procedures.AimsThe aim of this study was to evaluate the efficacy and safety of EDST in a randomized controlled trial and prospective observational study.MethodsTwenty-five patients with refractory benign esophageal strictures were recruited at two esophageal clinics between November 2018 and June 2021. Twelve patients participated in the randomized trial and 13 in the prospective observational study. The number of endoscopic dilations, impact of therapy on dysphagia, adverse events, and complications were recorded.ResultsIn the randomized study, 50% of patients performing ESDT and 100% of controls required endoscopic dilation during follow-up (P = 0.02). In the observational study, the median (IQR) number of endoscopic dilations fell from 7 [7–10] in the 6 months prior to commencing ESDT to 1 [0–2] in the 6 months after (P < 0.0001). Most patients (22/25) were able to learn self-dilation. Few serious adverse events were noted. Dysphagia severity remained unchanged or improved.ConclusionsESDT appears to be a safe effective therapy for benign esophageal strictures refractory to endoscopic treatment.Clinical Trial NumberNCT03738566.

Degrees of Inflammation in the Treatment of Subglottic Stenosis in a Rabbit Model: Histopathological Assessment of a Novel Bioabsorbable Ultra-high Ductility Magnesium Alloy Stent

ObjectiveUtilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent. MethodsSGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers. ResultsWe found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area. DiscussionRabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS.

Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors.

Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.

The Utility of Magnetic Resonance Enterography and Double Balloon Enteroscopy-Assisted Endoscopic Balloon Dilatation for Small Bowel Strictures in Crohn’s Disease: A Retrospective Observational Study

Introduction: Crohn’s disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures. Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up. Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2–3 months. Surgery was not needed during the follow-up period. Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients.