Esophageal Anastomotic Stricture Research Articles

The application of linear endoscopic ultrasound in the patients with esophageal anastomotic strictures.

Objectives:To evaluate the role of linear endoscopic ultrasound (EUS) in the diagnosis and treatment of the anastomotic stricture after esophagectomy for locally advanced esophageal cancer (EC).Materials and Methods:A retrospective analysis was performed in patients undergone EUS assessment and endoscopic treatment for anastomotic stricture after esophagectomy for locally advanced EC from January 2010 to December 2014 at Shengjing Hospital. The linear EUS was performed in all the patients to assess the thickness of the esophageal wall, the length and width of the lesion, and to evaluate the severity of anastomotic stricture. According to the EUS features of the lesion, different endoscopic therapy were performed.Results:There were 92 patients enrolled in this study. All the lesions of the patients were assessed by EUS. Eighty-six patients had cicatricial stricture of the esophagus confirmed by EUS, and were treated by endoscopic balloon dilation. Five patients were suspected to have tumor relapses, and the other one had lymphatic metastasis. All the six patients were undergone endoscopic metal stent implantation. The EUS diagnoses of all the patients were confirmed by pathological biopsy.Conclusion:Linear EUS is safe and effective for distinguishing the nature of the anastomotic stricture, and should be performed before endoscopic or surgical treatment.

The roles of connective tissue growth factor in the development of anastomotic esophageal strictures.

IntroductionThe aim of this study was to investigate the roles of connective tissue growth factor (CTGF) in the development of anastomotic strictures after surgical repair of the esophagus.Material and methodsTissues collected from the patients were divided into three groups based on the results of endoscopy and clinical grading. Patients without dysphagia after esophagectomy were used as the control population. The protein levels of CTGF, TGF-β1, Smad2, and Smad4 were determined by immunohistochemistry (IHC) and western blot analyses, while the mRNA levels of the two growth factors were evaluated by real-time polymerase chain reaction.ResultsCompared with the control group, significantly increased (p < 0.01) levels of CTGF and TGF-β1 protein were observed in the anastomotic stenosis (AS) group, and levels of the two proteins detected by the IHC and western blot analyses were also significantly increased with the increasing severity of stenosis (p < 0.05). The mRNA levels of CTGF and TGF-β1 in the tissues collected from the patients with stenosis were significantly up-regulated (p < 0.05) as compared with those from the control group. In addition, the levels of Smad2 and Smad4 protein were also significantly increased (p < 0.05) with the increasing severity of stenosis, and the protein levels were positively correlated with the levels of CTGF (r = 0.59, p < 0.05) and TGF-β1 (r = 0.63, p < 0.05).ConclusionsInhibition of CTGF protein or mRNA expression may be a distinctive and effective therapy for the treatment of postoperative anastomotic strictures.

The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia

BackgroundAnastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation. MethodsDigital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC). ResultsForty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87. ConclusionThe EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance.

Esophageal Anastomotic Strictures: Outcomes of Endoscopic Dilation, Risk of Recurrence and Refractory Stenosis, and Effect of Foreign Body Removal

Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness after dilation and factors associated with refractory stenosis. We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated during a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions during 10 weeks. Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median, 37 days; interquartile range [IQR], 20-82 days) or lengthen the dysphagia-free interval (37.4 days; IQR, 8-41 weeks), compared with patients who did not undergo removal (initial patency, median 55 days; IQR, 14-109 days; P= .66 and median dysphagia-free interval, 21.7 days; IQR, 9-64 weeks; P= .8). Use of fluoroscopy during dilation (odds ratio, 8.92; 95% confidence interval, 1.98-40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio, 0.28; 95% confidence interval, 0.07-0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis. Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.

Externally removable stents in the treatment of benign recalcitrant strictures and esophageal perforations in pediatric patients with esophageal atresia

We investigated whether removable stents, such as self-expandable plastic stents (SEPSs) and fully covered self-expandable metal stents (FCSEMSs) could provide an alternative treatment for recalcitrant strictures and esophageal perforations after esophageal atresia (EA) repair. The primary aim of our study was to evaluate technical feasibility. Secondary aims were to evaluate safety and procedural success. Retrospective study. Tertiary-care referral center. A total of 24 children with EA. Retrospective review of all children with EA who underwent dilation and esophageal stent placement from January 2010 to February 2013 at our institution. Healing of perforation and stricture resolution at 30 and 90 days. A total of 41 stents (SEPSs 14, FCSEMSs 27) were placed in 24 patients with EA during the study period, including 14 who had developed esophageal leaks. Procedural success of esophageal stent placement in the treatment of refractory strictures was 39% at 30 days and 26% at 90 days. The success rate was 80% for closure of esophageal perforations with stent therapy after dilation and 25% for perforations associated with surgical repair. Adverse events of stent placement included migration (21% of SEPSs and 7% of FCSEMSs), granulation tissue (37% of FCSEMSs), and deep ulcerations (22% of FCSEMSs). Retrospective study with small sample size. SEPSs and FCSEMSs can be placed successfully in small infants and children with a history of EA repair. The stents appear to be safe and beneficial in closing esophageal perforations, especially post-dilation. However, a high stricture recurrence rate after stent removal may limit their usefulness in treating recalcitrant esophageal anastomotic strictures.

Fluoroscopic Balloon Dilation of Esophageal Atresia Anastomotic Strictures in Children and Young Adults: Single-Center Study of 103 Consecutive Patients from 1999 to 2011

To determine whether fluoroscopic balloon dilation (FBD) is a safe and effective method of treating esophageal anastomotic stricture after surgical repair in an unselected patient population. With ethics committee approval, records for 103 consecutive patients who underwent FBD with our interventional radiology service (1999-2011) were reviewed retrospectively. Patients underwent diagnostic contrast material-enhanced study prior to the first dilation. Dilations were performed by using general anesthesia. Outcomes were number and/or frequency of dilations, clinical effectiveness and response to dilations, esophageal perforation, requirement for surgery, and mortality. Data were expressed as mean ± standard deviation (with range). Comparisons were conducted by using the Fisher exact test and log-rank test. The significance level was set at P < .05. One hundred three patients (61 male patients, 59%) underwent 378 FBD sessions (median, two dilations per patient; range, 1-40 dilations). The median age at first FBD was 2.2 years (range, 0.1-19.5 years). The balloon catheter diameters ranged from 4 to 20 mm. FBD was successful in 93 patients (90%): 44 (47%) after single dilation and 49 (53%) after multiple dilations. There was no difference in the proportion of patients who required one dilation and were younger than 1 year versus those who were 1 year of age and older (P > .99; odds ratio, 1.07 [range, 0.43-2.66]). Ten patients (10%) required further procedures: Three underwent stent placement, three underwent esophageal stricture resection, and four underwent esophageal reconstruction. Four esophageal perforations (1%) developed after FBD. Antireflux surgery was performed in 18 patients (17%). There were no deaths. FBD for anastomotic strictures after esophageal atresia repair is feasible and acceptably safe and provides relief of symptoms in most patients (90%); however, about half require more than one dilation, and surgery is best predicted if more than 10 dilations are required.

Membrane-covered self-expanding stents in the treatment of high-positioned esophageal stenosis or fistula

To investigate the efficacy and safety of membrane-covered self-expanding metal stent in the treatment of high-positioned esophageal diseases, including esophageal stenosis, esophagotracheal fistula and anastomotic stricture. Clinical data of 84 patients who underwent stenting in our center from May 2005 to July 2013 were retrospectively analyzed. Of 84 patients, 31 were diagnosed as esophageal malignant stenosis, 2 compression stenosis, 10 radiation stenosis, 4 recurrent malignant stenosis, 27 anastomotic stricture, 1 esophageal stenosis after endoscopic submucosal dissection (ESD), 7 esophageal-tracheal fistula, 1 esophageal-mediastinal fistula, and 1 remnant stomach fistula. Distance from stenosis or fistula to central incisor was 15-20 cm in 48 cases, and more than 20 cm in 36 cases. All the patients were treated by 16 mm membrane-covered self-expanding metal stents. Main clinical manifestations and complications were evaluated. A total of 100 stents were placed in 84 patients,with a success rate of 100%. There were no complications such as perforation and bleeding during operation. Dysphagia and cough were improved quickly with a success rate of 100%. After the placement of stents, the incidence of complication was 6.0% (5/84), of which 2 cases were severe retrosternal pain, 1 was tracheal collapse, and 2 were stent displacement. Seventy-six patients (90.5%) received complete follow-up of 1 to 36 months (mean 15 months). Re-stenosis occurred in 4 cases, new esophageal-tracheal fistula in 2 cases. Among these 6 cases, 5 cases underwent successfully stent placement once again, and another one case received Savary bougie and Argon-ion coagulation with good efficacy. Endoscopic membrane-covered self-expanding metal stent placement is effective and safe for the relieve of dysphagia symptoms and the sealing of esophagotracheal fistula.

Sa1459 Acceleration of Luminal Remediation by Removal of Suture Material and Staples in Anastomotic Esophageal Strictures

A common endoscopic finding in patients who have undergone esophagectomy or laryngectomy and present with dysphagia is the presence of suture material or staples from the surgical field protruding into the esophageal lumen. Presence of a foreign body may impair remediation following endoscopic dilation for esophageal stenosis.

Sa1460 Risk of Recurrence and Outcomes for Endoscopic Dilation of Anastomotic Esophageal Strictures

Sa1460 Risk of Recurrence and Outcomes for Endoscopic Dilation of Anastomotic Esophageal Strictures

226 Externally Removable Tracheal Stents to Treat Recalcitrant Esophageal Anastomotic Strictures in Pediatric Patients With Long Gap Esophageal Atresia

patients) and the ESBD groups (60 patients). There were no significant differences in background demographics. 39 patients had prior history of endoscopic sphincterotomy (P 0.825). The mean (S.D.) size of the largest common bile duct stone was 12.87 (7.11) and 12.53 (5.07) mm respectively (P 0.82). There were no differences in the rate of stone clearance during the index ERCP for all stones (90.9% vs 86.67%, P 0.435) and for stones that were 1.5cm (85% vs 80%, P 0.25). However, significantly more patients in the ES group required the use of the BML to complete stone extraction (45% vs 28.3%, P 0.047). Complications occurred in 18.2% and 20% of the patients respectively (P 0.795) and there were no differences in the rates of postsphincterotomy bleeding amongst the 2 groups (10.6% vs 8.35%, P 0.66). There were no procedure-related mortalities.Conclusions:Combined sphincterotomy and balloon dilation enables the retrieval of large common bile ducts stones with reduced need of the BML. The procedure can achieve high rates of complete stone clearance with comparable rates of morbidities to standard sphincterotomy.

The Findings Influencing Restenosis in Esophageal Anastomotic Stricture After Endoscopic Balloon Dilation: Restenosis in Esophageal Anastomotic Stricture

Between 1998 and 2007, eligible 24 of 72 patients undergoing endoscopic balloon dilation for esophageal anastomotic stricture were reviewed. The findings influencing the repeated balloon dilation for restenosis were evaluated during 12 months of follow-up. About 83.3% (10/12) of cases required repeated dilation within 4 months. A duration of <90 days from surgery to initial intervention and a diameter of the stricture of <13 mm after initial intervention were independent clinical findings for repeated dilation. The probability of remaining free of repeated balloon dilatation were higher with an interval of >or=90 days than with that of <90 days. The patients with a diameter of <13 mm were more likely to need repeated dilation than that of >or=13 mm. The patients undergoing the balloon dilation <90 days from surgery require careful observation for restenosis. Postdilator diameter beyond 13 mm would be needed to avoid restenosis.

Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture

Benign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation. Our study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture. A prospective outcome study. Tertiary-care academic medical centers. A total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy. Under direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip-knife. Efficacy, safety, and long-term patency after procedures were evaluated. During 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications. Our study included a small number of patients. Therefore, further prospective randomized controlled trials are needed. A modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture.

The Use of Self-Expanding Silicone Stents in Esophagectomy Strictures: Less Cost and More Efficiency

Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation. A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable silicone-covered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared. The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months' duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations. In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

Endoscopic Incisional Therapy with Iso-Tome and Transparent Hood in Patients with Benign Anastomotic Esophageal Stricture

Background: Benign anastomotic stricture of the esophagus following surgical resection has been reported to occur in 5% to 46% of patients. There is a significant recurrence rate in bougie, or balloon dilation, which requires repeated dilation sessions to maintain the patency. Electrocautery treatment was proposed to be a good alternative treatment in several studies. Aim: Our study evaluated the efficacy of endoscopic incisional therapy using an Iso-Tome and an end-viewing endoscope fitted with a transparent hood in patients with benign anastomotic esophageal strictures, prospectively.

The Use of Self-Expanding Silicone Stents in Esophageal Strictures: Less Cost and More Efficiency

Background. Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation. Methods. A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable siliconecovered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared. Results. The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months’ duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations. Conclusions. In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

Clinical usefulness of combination therapy with endoscopic incision with needle knife papillotome and local injection of steroid for the treatment of benign esophageal anastomotic stricture

Clinical usefulness of combination therapy with endoscopic incision with needle knife papillotome and local injection of steroid for the treatment of benign esophageal anastomotic stricture

Esophageal perforations, anastomotic leaks, and strictures: The role of prostheses

Misfortunes deriving from esophageal anastomotic leaks, perforations, and strictures are surgical problems of major magnitude, especially when a delay in treatment exceeds 12 hours. To this date, there is not unanimity in the approach to these problems. The costs in hospital expense, morbidity, and mortality are such that methods thought to improve outcome should be given careful consideration. The author presents personal experience with intraluminal stenting under various circumstances with Celestin and Hood prostheses that seems to support their use in esophageal surgery as others have found in colon surgery. Further study of this method is suggested.

Treatment of a Ruptured Anastomotic Esophageal Stricture Following Bougienage with a Dacron-Covered Nitinol Stent

Treatment of a Ruptured Anastomotic Esophageal Stricture Following Bougienage with a Dacron-Covered Nitinol Stent

胆管用同軸ダイレーターを利用して拡張した食道切除後の高度吻合部狭窄の2例

胆管用同軸ダイレーターを利用して拡張した食道切除後の高度吻合部狭窄の2例

食道吻合部狭窄に対する内視鏡的拡張術の適応と限界

1982年から1991年2月までに経験した91例の食道吻合部狭窄症例を対象とし, ブジーとバルーンダイレイターを併用した内視鏡的拡張術の適応と限界を検討した.良性狭窄84例での有効例は80例95%で, このうち長期に経過を観察できたものはいずれも拡張術から離脱し, それに要した拡張術の平均回数は3.7回であり, 食道切除で縫合不全のある症例では施行回数が多かった.拡張不能例は瘻孔形成例で瘻孔を拡大した1例のみであった.拡張困難例は3例でいずれも狭窄部の長いものであった.吻合部付近の癌再発による悪性狭窄7例では拡張不能2例, 拡張困難4例, 早期死亡1例で成績は不良であった.本法による合併症は輸血が必要な出血2例, 一過性の発熱2例, 頸部皮下膿瘍1例, 瘻孔拡大1例, の計6例6.6%で重篤なものは無く, 再手術を必要としたのは1例のみで, 死亡例はなかった.以上より食道吻合部良性狭窄に対し本法は安全で有効な方法と考えられた.