Long-segment Strictures Research Articles

Retrograde Submucosal Tunneling Technique for Management of Complete Esophageal Obstruction

Complete esophageal obstruction is a challenging problem that is not amendable to standard dilation techniques. Multiple endoscopic techniques as well as radical surgical procedures have been developed with the goal of restoring a patent esophageal lumen. In patients with complete esophageal obstruction, an antegrade-retrograde technique has been described, but this generally depends on the ability to transilluminate across the stricture. Successful transillumination allows for safe direct puncture across the stricture, followed by dilation. In long-segment strictures (greater than 2-3 cm), transillumination may not be possible. We report a case of a 63 year-old woman who developed a complete esophageal obstruction from radiation therapy (RT) for hypopharyngeal squamous cell carcinoma. She did have enteral access via a percutaneous endoscopic gastrostomy (PEG) tube which had been placed prior to beginning RT. A combined antegrade (through the mouth) and retrograde (through PEG site) approach was done, but transillumination across the stricture failed. Fluoroscopy demonstrated a 4 cm long stricture. The creation of a submucosal tunnel from the retrograde direction decreased the stricture length to 15 mm and transillumination was achieved. This allowed safe puncture of the stricture, placement of a guidewire, then successful dilation. The patient can now tolerate soft foods and maintain her weight. Submucosal tunneling can be used to achieve transillumination for the combined antegrade-retrograde approach to complete esophageal obstruction.

Renal Autotransplantation for Iatrogenic High-Grade Ureteric Stricture

A 47-year-old Hispanic woman developed a chronically obstructed left kidney, due to a long-segment ureteric stricture deemed not amenable to reimplantation, following left ovarian cyst excision in 2004. Therefore, a ureteral stent requiring exchange every 3 months was necessary, due to hydronephrosis, recurrent urosepsis, chronic pain, and a poor quality of life. Her medical history was complicated by hypertension, poorly controlled diabetes mellitus, and microalbuminuria, suggesting early diabetic nephropathy. A left nephrectomy was recommended. This was deferred, due to concern for progressive kidney failure associated with her comorbidities. A radionuclide Tc-99m MAG3 renal scan revealed differential perfusion as follows: 44% left kidney and 56% right kidney, with symmetrical uptake on the renogram phase and delayed excretion on the left, which were correctted following furosemide administration. A left ureteronephrectomy with autotransplantation of the left kidney and ureteroneocystostomy was performed in 2009. Since then, the patient has experienced no further complications or need for invasive procedures, with excellent diabetic control and stable renal function (eGFR > 60 mL/min/1.73 m2). This technique is seldom employed in the surgical management of complex ureteral injuries, but may be an alternative for appropriate cases.

Endoscopic Treatment of Benign Colorectal Striture. A Retrospective Study

Purpose: Endoscopic balloon dilation and electroincision have proven to be an alternative to surgery in the treatment of symptomatic colorectal strictures. The aim of this study was to analyze its efficacy and safety at our Institution. Methods: This study is to retrospectively investigate the results of endoscopic balloon dilation and electroincision for symptomatic stenotic benign colorectal lesions, whether they be anastomotic or not. All patients underwent dilation by using through-the-scope balloon dilation(TTS) or needle knife electrosurgery stenotomy. Student t test was applied in order to analyze means and chi-square was used to compare frequency. P value <0.05 was considered significant. Colonoscopies were performed under light sedation. Results: Forty-four patients from 2001 to 2010 with benign colorectal strictures were enrolled in this study. Sixteen were male and 28 female, the youngest being 32 and the oldest 84. Mean age was 60+/-13for the whole group. No difference between ages of male and female, 64+/-10 and 58+/-14 P>0.05 was observed. Twenty-eight (71%)out of 39 patients with anastomotic stricture and 4 (80%) out of 5 without bowel resection were successfully treated P>0.05. Failure was mostly related to long-segment stricture, being 2 (16%) for short and 10 (83%) for long P<0.01. Twelve were submitted to radiation therapy before the endoscopic procedure, 7 of them (58%) had successful outcome P>0.05. There were two (4%) perforations treated through surgery. No casualties. Five (11%) and 39 (88%) were submitted to electroincision and TTS dilatation, respectively. Conclusion: Endoscopic treatment is an alternative to surgery when we are dealing with a benign stricture of the colon. Besides, no statistical difference was obtained, it seems that previous radiation therapy had made the procedure more difficult. In our study, long segment stricture was the worst problem to be solved.

The response of Crohn’s strictures to endoscopic balloon dilation

Endoscopic balloon dilation has been shown to be an alternative to surgery in the treatment of Crohn's symptomatic strictures. To analyse the impact of the type of the strictures -de novo or anastomotic - their location and their length on the outcome of endoscopic balloon dilation. Between December 1999 and June 2008, 55 patients underwent 93 balloon dilations for 74 symptomatic strictures. One stricture was located in the duodenum, 39 strictures were in the terminal ileum, 17 at the ileocoecal anastomosis after a preceding resection and 17 in the colon. Endoscopic treatment was successful in 76% of the patients during an observation period of 44 (1-103) months. Of the patients, 24% required surgery. All patients who underwent surgery had de novo strictures in the terminal ileum. These strictures were significantly longer compared with the ileal strictures that responded to endoscopic treatment [7.5 (1-25) cm vs. 2.5 (1-25) cm; P = 0.006]. The long-term success of endoscopic balloon dilation depends on the type of the strictures, their location and their length. Failure of endoscopic treatment was observed only in long-segment strictures in the terminal ileum.

MR Imaging and CT of the Biliary Tract

Magnetic resonance (MR) imaging and computed tomography (CT) can be useful in the diagnosis of biliary disease, with both modalities allowing detailed evaluation of the biliary tract. Careful interrogation of the images is critical, regardless of modality. The identification of dilated bile ducts necessitates evaluation for strictures or filling defects, which is best performed with thin-section imaging. Smooth, concentric short-segment strictures favor a benign cause, whereas abrupt, eccentric long-segment strictures favor a malignancy. At MR imaging, extrabiliary entities such as crossing vessels or metallic clip artifact may mimic strictures and should not be mistaken for disease. A stone is the most common biliary filling defect and may occur in the absence of dilated ducts. Stones commonly have a lamellated, geometric shape and are found in a dependent portion of the duct. Identification of bile duct wall thickening raises concern for cholangitis or malignancy. Improved diagnosis of biliary disease can be achieved with a knowledge of the benefits and limitations of modern MR and CT cholangiographic techniques, including the use of biliary-excreted contrast material and of various postprocessing techniques. Familiarity with the radiologic appearances of the duct lumen, wall, and surrounding structures is also important for accurate image interpretation. The rapidly evolving technology for both MR imaging and CT of the biliary tract will continue to present radiologists with opportunities as well as challenges.

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.

Airway stenoses after lung transplantation: Incidence, management, and outcome

Airway stenoses have been a significant cause of morbidity and mortality after lung transplantation. We reviewed our 11-year experience with dilatation and silicone stent treatment of airway strictures after lung transplantation. We adopted this approach after managing the complications of nitinol/wire mesh stents, including stent fracture, granulation tissue overgrowth, and difficulty with removal. Between January of 1996 and December of 2007, 240 patients underwent lung transplantation (132 single lung, 108 double lung; 121 male, 119 female; mean age 49.4 +/- 12.9 years). Twenty patients (8.3%) developed >50% stenosis in 22 airways over 35 to 135 days following surgery. Short and long-segment strictures were managed with rigid bronchoscopy, mechanical/laser debridement, balloon dilatation, and silicone stent placement. Mean follow-up was 4.9 +/- 3.5 years after stent removal. The mean time to diagnosis of airway stenosis was 81.5 +/- 26.9 days. Pulmonary aspergillosis and pseudomonal infection, age less than 45 years, and early rejection correlated with airway stenosis; however, ischemic time, side of transplant, and preoperative disease did not. Airway patency and symptom improvement were achieved in 18 of 20 patients. Sixteen patients were able to have their stents removed at a mean of 362.3 +/- 126.4 days with permanent resolution of airway stenosis. Overall survival was similar for patients with and without airway stenosis. Airway stenosis after lung transplantation can be successfully managed with bronchoscopic dilatation and temporary silicone stent placement. With time, most short and long airway stenoses resolve with atraumatic stenting of the affected areas. Removal of stents with permanent airway patency is achievable in most lung transplant recipients with airway stenosis.

Leiomyomatosis of the Esophagus: Experience over a Decade

PurposeTo assess the clinical, radiological findings, and treatment strategies in patients with esophageal leiomyomatosis. BackgroundEsophageal leiomyomatosis is a rare hamartomatous disorder with varied presentation. It is described mostly in children and is associated with Alport’s syndrome. MethodsA retrospective analysis of three cases managed in the Department of General Surgery at Chandigarh over a period of 10 years. ResultsThe study involves three female patients of different generations within the same family with age range of 10–58 years. All presented with dysphagia of 2–7 years duration. Barium swallow revealed a long-segment stricture in two patients. Computed tomography (CT) demonstrated a circumferential mass lesion in the lower esophagus in all the patients. Esophageal resection was carried out in all the patients. All patients made an uneventful recovery. ConclusionsEsophageal leiomyomatosis should be suspected in patients with long-standing dysphagia. Barium findings are suggestive but can mimic achalasia. CT scan shows a circumferential esophageal wall thickening. Surgical resection and reconstruction of the digestive passage is the optimal treatment.

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Bile duct stents in the management of hepatolithiasis with long-segment intrahepatic biliary strictures.

Biliary stricture represents a challenging problem in the treatment of hepatolithiasis because of its association with treatment failure and stone recurrence. The long-segment type of stricture is difficult to manage and is likely to recur. To investigate the necessity for biliary stenting after balloon dilatation therapy, 20 consecutive patients with long-segment strictures who had 22 stents (group 1) were compared with ten patients who refused stenting (group 2). The long-segment strictures in group 1 were located on the right side in 80 per cent of patients, on the left side in 10 per cent, and were bilateral in 10 per cent. The stents, varying from 8 to 12 Fr, were retained for at least 6 months. They were inserted through the routes of a matured T tube track (five cases), percutaneous transhepatic track (14 cases), a jejunal limb (two cases) and a fistula (one case). Complications of stenting consisted of dislodgement (one case), haemobilia (two cases), cholangitis (two cases) and intrahepatic abscess (one case). The cumulative probability of stricture recurrence in group 1 was 10 per cent, 15 per cent and 21 per cent at 2, 3 and 4 years, respectively, whereas in group 2 it was 80 per cent at 2 years (P less than 0.003). The results suggest that intrahepatic biliary stenting after balloon dilatation appears necessary and helpful in the management of hepatolithiasis with long-segment biliary strictures.

Home dilatation of long-segment oesophageal stricture using a pneumatic indwelling balloon catheter

After a long-gap oesophageal atresia was bridged by a fullthickness, tubularised, postero-superiorly-based flap of proximal oesophagus, home-based pneumatic dilatation was employed twice daily to treat the subsequent narrowed segment.

Dilatation of intrahepatic biliary strictures in patients with hepatolithiasis

To investigate the role of balloon dilatation in the management of complicated hepatolithiasis with intrahepatic biliary stricture, 57 consecutive patients who received 208 sessions of dilatation in addition to the usual treatment were analyzed. The strictures were located in the right intrahepatic ducts (84.2%), left intrahepatic ducts (12.3%), or both (3.5%). Dilatation began 3-4 weeks after surgery. The routes of dilatation included the matured T-tube tract (3 cases), percutaneous transhepatic biliary drainage tracts (42 cases), and both (12 cases). The immediate overall success rate of complete stone clearance increased significantly from 0% predilatation to 94.7% postdilatation. The main complications of dilatation therapy consisted of septicemia (10.5%), hemobilia (10.5%), and mild diarrhea (80%). Eight patients (14%) with long-segment strictures received 11 postdilatation biliary stentings. Complications were 1 patient with occlusion and 2 patients with "spontaneous" hemobilia. Severe multiple strictures and coexistent secondary biliary cirrhosis were the contributing factors to complications. During the follow-up of 3.4 +/- 1.2 years, recurrence of strictures was found in 4 patients. Two of them belonged to the stenting group. The cumulative probability of restricture was low: 4% at 2 years, 6% at 2.5 years, and 8% at 3 years. We conclude that in complicated cases of hepatolithiasis with intrahepatic biliary stricture, dilatation and stenting are good adjuvant therapies.