Long-term Relief Of Dysphagia Research Articles

Cap-Assisted Endoscopic Septotomy of Zenker's Diverticulum: Early and Long-Term Outcomes.

Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting. From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon. Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures. FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia.

Cricopharyngeal myotomy for delayed Cricopharyngeal dysfunction after head and neck surgery \u2013 case report

BackgroundHead and neck surgeries can perturb normal structures of neck muscles and nerve innervations, which are supposed to function in harmony to allow complicated process like swallowing. It is still likely that cricopharyngal dysfunction emerges years after the head and neck surgeries.Case presentationWe report a case with history of left unilateral vocal cord immobility and development of dysphagia and aspiration 2 years after radical thyroidectomy with neck lymph nodes dissection and medialization thyroplasty. Cricopharyngeal dysfunction was impressed and was confirmed with visualization of cricopharyngeal narrowing segment in radiographic contrast swallow examination. The patient was treated successfully by cricopharyngeal myotomy, achieving long-term relief in our 4 years of follow up.ConclusionsOur case of delayed cricopharyngal dysfunction after radical thyroidectomy and medialization thyroplasty shows that it is important to follow up swallowing functions after patients with UVCI undergo medialization thyroplasty. In the event of delayed manifestation of cricopharyngeal function, it can still be treated successfully by cricoharyngeal myotomy, achieving long term relief of dysphagia.

A Comparison of Temporary Self-Expanding Plastic and Biodegradable Stents for Refractory Benign Esophageal Strictures

It is a challenge to manage refractory benign esophageal strictures (RBES). We compared the efficacy and safety of self-expanding plastic stents (SEPSs) with placement of biodegradable stents for the treatment of RBES. We studied 2 groups of consecutive patients with RBES who received temporary placement (6 weeks) of SEPSs (n = 20) or biodegradable stents (n = 18). Data were collected with respect to clinical outcome, complications, recurrent dysphagia, and reinterventions. SEPSs were removed in 16 (80%) patients. Stent placement was not successful in 1 patient, while stent removal was not performed in another 3 patients. Six (30%) patients with an SEPS were dysphagia-free after a median follow-up of 385 days (range, 77-924 days). Ten (50%) developed recurrent dysphagia. Major complications occurred in 2 patients (10%; 1 with hemorrhage and 1 with perforation). Six patients (33%) with a biodegradable stent were dysphagia-free after a median follow-up of 166 days (range 21-559 days) (P = .83 compared with SEPS). Twelve patients (67%) had recurrent dysphagia. Major complications occurred in 4 patients (22%; 2 with hemorrhage, 2 with severe retrosternal pain) with a biodegradable stent (P = .30 compared with SEPS). Reinterventions were less frequently indicated after biodegradeble stent than after SEPS placement (15 [mean, 0.8 ± 0.6 per stent placed] vs 21 [mean, 1.3 ± 0.4 per stent placed], respectively; P = .03). Placement of SEPSs or biodegradable stents provides long-term relief of dysphagia in 30% and 33%, respectively, of patients with RBES. Biodegradable stents require fewer procedures than SEPSs, offering an advantage. Although stent placement is a viable strategy in patients with RBES, the ideal strategy still needs to be defined.

Tuberculosis presenting as an endobronchial mass

patients. In this study, we have shown that inkwelling significantly increases the incidence of benign anastomotic stricture after Ivor Lewis esophagogastrectomy without affecting that rate of anastomotic dehiscence. Of note is that our study shows a high rate of benign anastomotic stricture. A similar incidence of benign anastomotic stricture has been reported in other series. 4 The incidence of stricture is influenced considerably by its definition and the quality of follow-up. In our center, patients are followed up every 6 months for life, and this may explain our high stricture detection rate. Our study is limited by the fact that it is a retrospective nonrandomized study; therefore, we were not able to control for other factors that may have influenced stricture formation, for example, staple size. 5 In conclusion, life expectancy is limited in most patients after Ivor Lewis esophagogastrectomy; 5-year survival in our unit is 22%, 2 and so for the majority of patients the benefit of the procedure is excellent palliation with rapid and long-term relief of dysphagia. The development of anastomotic stricture therefore reduces the benefit of the operation and casts doubts on the utility

Traitements palliatifs endoscopiques des cancers de l’œsophage

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.

Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial

Both single-dose brachytherapy and self-expanding metal stent placement are commonly used for palliation of oesophageal obstruction due to inoperable cancer, but their relative merits are unknown. We undertook a randomised trial to compare the outcomes of brachytherapy and stent placement in patients with oesophageal cancer. Nine hospitals in the Netherlands participated in our study. Between December, 1999, and June, 2002, 209 patients with dysphagia from inoperable carcinoma of the oesophagus or oesophagogastric junction were randomly assigned to stent placement (n=108) or single-dose (12 Gy) brachytherapy (n=101), and were followed up after treatment. Primary outcome was relief of dysphagia during follow-up, and secondary outcomes were complications, treatment for persistent or recurrent dysphagia, health-related quality of life, and costs. Analysis was by intention to treat. Nine patients (six [brachytherapy] vs three [stent placement]) did not receive their allocated treatments. None was lost to follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. Stent placement had more complications than brachytherapy (36 [33%] of 108 vs 21 [21%] of 101; p=0.02), which was mainly due to an increased incidence of late haemorrhage (14 [13%] of 108 vs five [5%] of 101; p=0.05). Groups did not differ for persistent or recurrent dysphagia (p=0.81), or for median survival (p=0.23). Quality-of-life scores were in favour of brachytherapy compared with stent placement. Total medical costs were also much the same for stent placement (8215) and brachytherapy (8135). Despite slow improvement, single-dose brachytherapy gave better long-term relief of dysphagia than metal stent placement. Since brachytherapy was also associated with fewer complications than stent placement, we recommend it as the primary treatment for palliation of dysphagia from oesophageal cancer.

Quality of life after palliative treatment for oesophageal carcinoma – a prospective comparison between stent placement and single dose brachytherapy

Metal stent placement and single dose brachytherapy are commonly used treatment modalities for the palliation of inoperable oesophageal carcinoma. We investigated generic and disease-specific health-related quality of life (HRQoL) after these palliative treatments. Patients with dysphagia from inoperable oesophageal carcinoma were randomised to placement of a covered Ultraflex stent ( n=108) or single dose (12 Gy) brachytherapy ( n=101). We obtained longitudinal data on disease-specific (dysphagia score, European Organisation for Reasearch and Treament of Cancer (EORTC) OES-23, visual analogue pain scale) and generic (EORTC Quality of Life-Core 30 Questionnarie (QLQ-C30), Euroqol (EQ)-5D) HRQoL at monthly home visits by a specially-trained research nurse. We compared HRQoL between the two treatments and analysed changes in HRQoL during follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. For generic HRQoL, there was an overall significant difference in favour of brachytherapy on four out of five functional scales of the EORTC QLQ-C30 (role, emotional, cognitive and social) ( P<0.05). Generic HRQoL deteriorated over time on all functional scales of the EORTC QLQ C-30 and EQ-5D, in particular physical and role functioning (on average −23 and −24 on a 100 points scale during 0.5 years of follow-up). This decline was more pronounced in the stent group. Major improvements were seen on the dysphagia and eating scales of the EORTC OES-23, in contrast to other scales of this disease-specific measure, which remained almost stable during follow-up. Reported levels of chest or abdominal pain remained stable during follow-up in both treatment groups, general pain levels increased to a minor extent. The effects of single dose brachytherapy on HRQoL compared favourably to those of stent placement for the palliation of oesophageal cancer. Future studies on palliative care for oesophageal cancer should at least include generic HRQoL scales, since these were more responsive in measuring patients' functioning and well-being during follow-up than disease-specific HRQoL scales.

Quality of Life After Palliative Treatment for Esophageal Carcinoma: A Longitudinal Prospective Comparison Between Stent Placement and Single Dose Brachytherapy

Background: Metal stent placement and single dose brachytherapy are commonly used treatment modalities for the palliation of inoperable esophageal carcinoma. We investigated generic and disease-specific health-related quality of life (HRQoL) after these palliative treatments. Methods: Patients with dysphagia from inoperable esophageal carcinoma were randomized to placement of a covered Ultraflex stent (n=108) or single dose (12 Gy) brachytherapy (n=101). We obtained longitudinal data on disease-specific (dysphagia score, EORTC OES-23, visual analogue pain scale) and generic (EORTC QLQ-C30, EuroQol scales) HRQoL at monthly home visits by a specially-trained research nurse. We compared HRQoL between the two treatments and analyzed changes in HRQoL during follow-up. Results: Dysphagia improved more rapidly after stent placement than after brachytherapy, but long term relief of dysphagia was better after brachytherapy. For generic HRQoL, there was an overall significant difference in favor of brachytherapy on several functional scales of the EORTC QLQ-C30 (role, emotional, cognitive and social) (p<0.05). Generic HRQol deteriorated over time on all functional scales of the EORTC QLQ C-30 and Euroqol scales, in particular physical and role functioning (-23 and -24 on a 100 points scale during 0.5 years of follow-up) in both treatment groups. This decline was more pronounced in the stent group. In contrast, except for the dysphagia and eating scales, no major changes during follow-up were seen for disease-specific HRQoL. Self-reported pain levels remained stable during follow-up in both treatment groups. Conclusions: Treatment with single dose brachytherapy gave better overall scores on HRQoL scales compared to stent placement for the palliation of esophageal cancer. Generic HRQol scales were more responsive in measuring patients' functioning and well-being during follow-up. Pain management was adequate during follow-up.

Effectiveness of endoscopic dilation for dysphagia from cricopharyngeal bars

The cricopharyngeal (CP) bar is a common radiographic finding that can cause oropharyngeal dysphagia (OPD). Treatment options include CP myotomy, which is problematic given that CP bars primarily affect elderly patients with comorbidities who are at higher risk for peri-operative complications. The aim of this study was to examine the effectiveness of endoscopic dilation in the management of dysphagia attributed to a CP bar. Review of upper endoscopic (EGD) and videofluoroscopic swallowing studies from 1999–2002 identified 32 patients with CP bars. CP bar was defined by radiology as a distinct posterior impression in the cervical esophagus inferior to the vocal cords. Six of these patients had dysphagia without any other identifiable cause aside from the CP bar. Each of these six patients underwent EGD with Savary (5) or balloon dilation (1) of the upper esophageal sphincter to a diameter of 51–60 Fr. Short- and long-term follow-up was conducted post-dilation at 1–4 weeks and 10–27 months, respectively. The median age of the 32 patients with CP bars was 63 yrs. The 6 symptomatic patients who underwent endoscopic therapy were women with median age of 62 yrs. Each of the 6 patients experienced immediate improvement in dysphagia. None of the patients developed complications of post-dilation pain, bleeding or perforation. Five patients had continued improvement of their OPD at short-term follow-up. One patient who was dilated to 51 Fr using a Savary dilator experienced return of globus sensation after 48 hours, although dysphagia and regurgitation had resolved. A second Savary dilation, one month after the initial procedure, resulted in complete elimination of symptoms at subsequent short-term follow-up. Four patients had continued complete resolution of OPD at long-term follow-up. The remaining two patients reported the recurrence of significant dysphagia after 6 and 8 months, which they stated was less severe than at initial presentation. None of the patients required surgical or endoscopic myotomy for residual or refractory dysphagia. Every patient was satisfied with the results and stated they would recommend endoscopic dilation to others with the same problem.(1) CP bar is an important cause of dysphagia that affects elderly patients. (2) Endoscopic dilation of symptomatic CP bars can produce long-term relief of dysphagia. (3) Further controlled studies are warranted to better define the efficacy and safety of endoscopic CP bar dilation as an alternative to surgical myotomy in symptomatic patients.

7145 Endoscopic changes following esophageal dilation in patients with peptic stricture, non-obstructive dysphagia or achalasia.

Esophageal bougie dilation is a technique that is used as an effective strategy to relieve symptomatic peptic strictures and non-obstructive dysphagia. Pneumatic dilation is a primary mode of therapy for patients with achalasia. The goals of this study were as follows: First, to assess the endoscopic changes that occur in the esophageal mucosa following dilation; and second to correlate these changes with clinical efficacy and long-term relief of dysphagia in patients with peptic stricture, non-obstructive dysphagia and achalasia. Methods: Included in the study were patients who received bougie dilation for peptic stricture and non-obstructive dysphagia; and pneumatic dilation for achalasia. Upper endoscopy was initially performed to assess the esophagus and for placement of a Savary guide wire. The bougie esophageal dilations were performed over a Savary guide wire with American dilators. The pneumatic dilations were performed over a Savary guide wire with Microvasive balloons. Following the dilations the esophagogastroduodenoscope was reinserted and advanced to the site of dilation for photodocumentation. Patients were then followed by telephone consultation at two weeks, four weeks and six weeks with the frequency of symptoms recorded. Results: Thirty-one subjects were included in the study during the period of 7/98 to 11/99. There were fourteen women and seventeen men with a mean age of 55.5 (range 19 to 89). The diagnoses were as follows: 11 with peptic stricture, 7 with B-ring, 6 with achalasia, 4 with nonobstructive dysphagia, 1 with mid esophageal web, 1 with anastomotic stricture and 1 was post-Nissen. The mucosal changes following dilation included the following: 8 with increased diameter, 17 with tear, 7 with submucosal hemorrhage, and 12 with blood observed on the dilator. At two, four and six weeks following esophageal dilation, there was improvement in dysphagia (p

Transthoracic Oesophagomyotomy in the Treatment of Achalasia: A 15-year Experience

Oesophageal achalasia was treated with modified Heller's oesophagomyotomy in 51 patients (19 males, 32 females) via thoracotomy in 47 cases and thoracoscopy in 4 cases. A Belsey Mark IV antireflux procedure was added to transthoracic oesophagomyotomy in two cases, because of extended cardiomyotomy. There were no hospital deaths. The overall improvement rate was 93.5%, with excellent results in 80.6%. Postoperative follow-up averaged 7.4 years. In all four cases of thoracoscopic oesophagomyotomy, simultaneous oesophagoscopy was performed to facilitate the procedure. One patient required repeat surgery 2 months later because of inadequate myotomy. Thirty-one patients, including three with severe gastro-oesophageal reflux, received long-term medication. Barrett's oesophagus developed in two of the 31 patients (6.5%) 4.7 and 7.6 years, respectively, after myotomy and squamous cell carcinoma was diagnosed in a 44-year-old woman 2.2 years postoperatively. The study suggests that transthoracic oesophagomyotomy without antireflux procedure can provide excellent long-term relief of dysphagia in oesophageal achalasia and carries a low risk of serious postoperative complications.

Long term results of endoscopic dilatation for corrosive oesophageal strictures.

Although dilatation is the treatment of choice for most patients with benign oesophageal strictures, there is little information on its efficacy and safety in corrosive oesophageal strictures. Of 123 adults with benign oesophageal strictures treated by endoscopic dilatation, 52 (42.3%) had strictures after corrosive ingestion and 39 (31.7%) had peptic strictures. Treatment was considered adequate if the oesophageal lumen could be dilated to 15 mm and there was complete relief of dysphagia. If dysphagia recurred after adequate initial dilatation, the stricture was dilated again up to 15 mm. Initial dilatation was adequate in 93.6% of patients with corrosive strictures and this success rate was comparable with that of the peptic stricture group (100%, p > 0.05). Long term success after adequate initial dilatation was studied in 36 patients with corrosive strictures (mean follow up 32.36 (17.12) months, range 6-60) and 33 patients with peptic strictures (mean follow up 36.32 (17.9) months, range 6-60). The mean (SEM) number of symptomatic recurrences per patient month during the total follow up period in the corrosive group was significantly higher than that in the peptic group (0.27 (0.04) v 0.07 (0.02), p < 0.001). The recurrence rate in the corrosive group, however, decreased over time, and after 12 months it was significantly (p < 0.001) lower than the recurrence rate in the first six months. After 36 months, the difference in the recurrence rate in the two groups was not significant (p > 0.05). Only nine oesophageal perforations occurred during a total of 1373 dilatation treatments (procedure related incidence 0.66%), and eight of these were in the corrosive stricture group. These patients were managed conservatively and subsequently strictures were dilated adequately in all. Endoscopic dilatation is safe and effective for short and long term relief of dysphagia in patients with corrosive oesophageal strictures.

Cutting the defiant lower esophageal ring

A symptomatic lower esophageal ring generally responds to standard bougienage therapy. However, a subset of patients with a lower esophageal ring defy dilation therapy. We have evaluated the efficacy of electrocautery incision of "defiant" lower esophageal rings, the data of which forms the basis of this report. Seven of 75 patients with a lower esophageal ring failed to respond to conventional esophageal dilation. All seven patients underwent electrocautery incision of a "defiant" lower esophageal ring with alleviation of dysphagia. One patient had recurrence of dysphagia that occurred 6 months after initial electrocautery incision. No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months. Electrocautery incision of "defiant" lower esophageal ring is efficacious, safe, and results in long-term relief of dysphagia.