Management Of Esophageal Strictures Research Articles

328. ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUPERFICIAL ESOPHAGEAL CARCINOMA INVOLVING THE ENTIRE ESOPHAGUS: SHORT-TERM RESULTS

Abstract Background The treatment of superficial esophageal carcinoma involving the entire esophagus remains challenging due to the difficulty in accurate preoperative diagnosis and the complexity of the Endoscopic Submucosal Dissection (ESD) technique. The management of esophageal stricture following ESD also remains controversial. In this study, we analyzed the advantages and disadvantages of ESD for superficial whole circumferential esophageal carcinoma in our hospital, based on short-term results. Methods We retrospectively analyzed 10 patients diagnosed with superficial esophageal carcinoma involving the entire circumference and treated with ESD from January 2021 to the present. We evaluated the accuracy of preoperative diagnosis, treatment-related complications of ESD, post-ESD stenosis, and adverse events associated with stenosis prophylaxis. Treatment Course: The primary treatment consisted of circumferential resection under general anesthesia followed by local injection of 120–320 mg of steroids into the ulcer after resection. Patients were started on a diet 2–3 days after surgery and initiated oral steroid therapy starting with 30 mg with PPI and Sulfamethoxazole Trimethoprim. The dose of steroids was gradually reduced by 5 mg every 3 weeks for a total of 18 weeks. Results The study included 7 males and 3 females with a mean age of 72.9 years. The lesions were located in Upper 1, Middle 5, and Lower 4. The average dissection time was 89.1 minutes, the mean length of endoscopic longitudinal mucosal defects was 70 mm, and the en bloc resection rate was 100%. The histological depth was EP/LPM 5, MM/SM 13, and SM2 or deeper 2. The accuracy of preoperative diagnosis was 80%, but all SM2 lesions were underdiagnosed as SM1. No ESD-related adverse events were observed in any case. Two patients with SM2 after ESD underwent additional surgery. Stenosis occurred in 25% of cases. Steroid-related events included drug-induced liver dysfunction in 4 cases, esophageal candida in 2 cases, pulmonary tuberculosis in 1 case, and delayed perforation in 1 case. Conclusion ESD for superficial esophageal carcinoma involving the entire esophagus can be safely and effectively performed. Steroid administration may be useful for preventing post-ESD stenosis, but its management requires attention as it may cause adverse events.

Infigratinib, a Selective Fibroblast Growth Factor Receptor Inhibitor, Suppresses Stent-Induced Tissue Hyperplasia in a Rat Esophageal Model.

Stent-induced tissue hyperplasia remains a challenge for the application of self-expanding metal stents in the management of esophageal stricture. This study aimed to evaluate the efficacy of infigratinib, which is a selective fibroblast growth factor receptor inhibitor, in the prevention of stent-induced tissue hyperplasia in a rat esophageal model. Twenty-four male Sprague-Dawley rats underwent esophageal stent placement and were randomized to receive 1ml of vehicle, 5mg/kg infigratinib in 1ml of vehicle, or 10mg/kg infigratinib in 1ml of vehicle via naso-gastric tube once daily for 28days. Follow-up fluoroscopy was performed on postoperative day 28, and the stented esophageal tissues were harvested for histological and immunofluorescence examinations. All rats survived until euthanasia on postoperative day 28 without procedure-related adverse events. The incidence of stent migration was 12.5%, 12.5% and 25% in the control group, the 5mg/kg infigratinib group and, the 10mg/kg infigratinib group, respectively. The percentage of granulation tissue area, the submucosal fibrosis thickness, the number of epithelial layers, the degree of inflammatory cell infiltration, the degree of collagen deposition, the number of fibroblast growth factor receptor 1 (FGFR1)-expressing myofibroblasts, and the number of proliferating myofibroblasts were all significantly lower in both infigratinib groups than in the control group (P < 0.05) but were not significantly different between the two infigratinib groups (P > 0.05). Infigratinib significantly suppresses stent-induced tissue hyperplasia by inhibiting FGFR1-mediated myofibroblast proliferation and profibrotic activities in a rat esophageal model.

Prevention and management of esophageal stricture after esophageal ESD: 10 years of experience in a single medical center

Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic procedure to deal with local early esophageal neoplasm, although post-ESD esophageal stricture is a major delayed complication of esophageal ESD greatly influencing the patient's quality of life. This retrospective study was conducted to analyze the esophageal stricture after esophageal ESD while determining further treatment and outcome of stricture management. From 2009 to 2021, we reviewed all patients who underwent ESD for esophageal squamous cell neoplasia in Kaohsiung Medical University Hospital. Totally, 133 patients with esophageal squamous cell neoplasm were enrolled. Among these 133 patients, 108 patients had lesions less than three-fourths in circumferential and 25 patients had lesions in excess of three-fourths circumferentially. Totally, 18 patients (13.5%) had symptomatic esophageal stricture and 17 patients (94.4%) had stricture existing over the upper or middle esophagus. The most important risk factor of esophageal stricture was the extent of resection of esophageal circumference, especially whole circumferential resection. Although oral steroid prevention medication was prescribed for high-risk patients with lesions more than three-fourth circumferential ESD, the stricture rate was still up to 40% (10/25). Endoscopic/luminal management with balloon dilation, radial incision and self-bougination achieved 83% (15/18) symptom remission. Three patients received surgical intervention with esophagectomy or jejunostomy. Esophageal stricture is frequently encountered in esophageal ESD. Aggressive preventative strategy is warranted for the high-risk group. Endoscopy/luminal management has high efficacy for post-ESD esophageal stricture.

New therapies for esophageal strictures in children.

The present review aims at describing recent advances in therapeutic strategies for the treatment of benign esophageal strictures in children. We discuss current knowledge and practice on esophageal dilations, which are still the mainstream of treatment. We present new evidence about adjuvant treatments for recurrent and refractory strictures, including endoscopic incisional therapy, esophageal stenting, intralesional or topical mytomicin C and intralesional, systemic or topical steroids. Current evidence on esophageal dilations is not sufficient to establish superiority of one of the available techniques, especially the use of balloon or bougie dilators, but a prospective international cohort study on anastomotic stricture in esophageal atresia is underway to address this issue. Recurrent and refractory strictures still represent a challenge, since none of the adjuvant pharmacological and mechanical interventions has shown to be enough feasible, effective and safe to revolutionize clinical practice. In the last couple of years, several encouraging results have been published on management of esophageal strictures in children. Further research is needed, hopefully directed toward secure, easily reproducible and minimally invasive measures.

The management of esophageal strictures by using self-expanding metallic stents

Esophageal stents are an important tool for palliative treatment of inoperable or recurrent esophageal cancer; and broncho-esophageal fistula; to bypass refractory benign stenosis. Our work aims are to study the indication of self-expanding metallic stents for esophageal strictures, as well as the challenges, and complications of their placement. Between May 2016 and November 2019, 10 esophageal stents placement procedures were performed on 9 patients. The placement of the esophageal stent was performed by using a guidewire. Radioscopic control has been systematically carried out, and all patients were monitored 24 hours after the procedure. Nine patients were included in this study, 77.7% (n=7) were male and 22.3% (n=2), were female, the average age was 54 years (18-67 years). All stents have been successfully placed. The average follow-up for the procedures was 24 weeks. 33.33% (n=3) of the patients had a stent migration treated by the placement of another stent in 11.1% (n=1). No stent occlusion and no complications were noted. The food recovery was again possible in all cases. The evolution was marked by the death in 33.3 % (n=3), fistula closure in 22.2% (n= 2) and persistent of stricture in 11.1% (n=1). Esophageal stents remain an important tool for the management of malignant esophageal diseases and refractory benign esophageal stricture. The simplicity and the functional success of the majority of cases, make them highly recommended as palliative treatment, as the success rate in our study was 66.7% (n=7).

Recurrent Esophageal Stricture Secondary to Pemphigus Vulgaris: A Rare Diagnostic and Therapeutic Challenge.

ABSTRACTPemphigus vulgaris (PV) is an autoimmune blistering disorder of skin and mucous membranes, characterized by acantholysis, can be life threatening, and carries significant morbidity. Esophageal involvement is uncommon, and the diagnosis can often be delayed. Esophageal stricture secondary to PV is extremely rare, and there are no guidelines on the management of this complication. We present a case of recalcitrant esophageal stricture, secondary to PV, successfully treated with topical and intralesional steroids. Moreover, we review the literature pertaining to esophageal PV and the management of esophageal strictures.

Efficacy and safety of endoscopic dilatation in the management of esophageal strictures in children.

Objectives:To determine the outcomes of endoscopic dilatation of esophageal strictures in children.Methods:Children younger than 18 years of age diagnosed with esophageal strictures over a period of 7 years (June 2010 to June 2017) were reviewed and analyzed retrospectively. The study took place at King Khalid University Hospital, Riyadh, Saudi Arabia. The patients’ clinical characteristics, endoscopic findings, and details of the strictures, treatment, and outcomes were documented.Results:Forty-three children with esophageal strictures were identified (median age, 8.1 years; range, 2-17 years; 23 [53.5%] boys). The median age at presentation was 2 years (range, 1-16 years), and the median follow-up period was 3 years (range, one month-17 years). Tracheoesophageal fistula (n=14, 32.6%), gastroesophageal reflux disease (n=10, 23.3%) and eosinophilic esophagitis (n=8, 18.6%) were the leading causes of esophageal strictures. Forty-three patients underwent 180 dilatation sessions; the median number of dilatation sessions per patient was 3 (range, 1-48), and the median interval between sessions was 8 weeks (range, 1-24 weeks). Among 180 dilatation sessions, 3 events (1.7%) of esophageal perforation were observed. The outcomes varied depending on the primary cause of the stricture; complete response was achieved the best in eosinophilic esophagitis-related strictures (87.5%), followed by anastomotic strictures post tracheoesophageal fistula repair (71.4%) and gastroesophageal reflux disease-related strictures (70%).Conclusion:Endoscopic dilatation is a safe and effective intervention in the management of esophageal strictures in children, with minimal complications when conducted by experts.

Tracheoesophageal fistula in adults due to corrosive ingestion: challenges in management.

Esophagorespiratory fistula in adults as a result of corrosive ingestion is a rare occurrence and is a difficult problem to manage. Three young (15-19 years) patients (2F, 1M) out of 115 (incidence 2.6%) of corrosive ingestion who had tracheoesophageal fistula (TEF) were reviewed retrospectively. After initial management, enteral route of nutrition was established. Based on the extent of concomitant esophageal stricture, the fistulae were classified as: type I (short) and type II (long segment). Fistula was repaired through thoracotomy and formation of a neomembranous trachea. Esophageal stricture could be managed either short-segment resection (type I) or resection and replacement (type II). The etiology was aluminum phosphide in two and caustic soda in one. All the patients were operated beyond 9 weeks of ingestion. Tracheal defect was 5, 9 and 30 mm. Fistula could be repaired by neomembranous trachea in all the patients and defect reinforced with pleural flap in two and intercostal muscle flap in one patient. Two patients required colon interposition, while one could be managed with short-segment resection. All the patients are well at follow-up. TEF due to corrosive ingestion is a rare entity in adults. Formation of a neomembranous trachea is feasible in all patients. Management of esophageal stricture depends upon the pattern of involvement of the esophagus.

Caustic injury of the oesophagus.

Caustic ingestion continues to be a significant problem world-wide especially in developing countries and particularly in the under 6years age group. The presence or absence of symptoms or oral lesions does not reliably predict the existence or severity of oesophageal lesions. Upper endoscopy remains the mainstay diagnostic modality for evaluation to define the extent and severity of the injury. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Early management strategies for caustic ingestion are well defined. Controversy still surrounds the use of steroids, antibiotics, antacid therapy in the acute phase, and the use of oesophageal stents and the frequency, timing and method of dilatation in the prevention and management of oesophageal strictures. There is a pressing need for non-invasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion. Indications for definitive surgery or bypass and the type of procedure to use are also subject to ongoing debate.

Topical Mitomycin C application for esophageal stricture: Safe, precise, and novel endoscopic technique

PurposeThe first line of management of benign esophageal stricture is endoscopic dilatation; however, multiple sessions are usually indicated especially in resistant cases. Topical Mitomycin C (MCC) application is a new adjuvant treatment in the management of esophageal stricture with promising results in different case series. Several techniques have been reported for application; nevertheless, the ideal technique has not been described yet. Material and MethodsIn this series we have devised a new technique using both the flexible and the rigid endoscope and a specially designed Nelaton catheter. ResultsThis technique was applied in 38 sessions for 16 caustic esophageal strictures with technical success in all cases. No procedure-related complications were observed in this series. ConclusionThis novel technique is feasible and effective and can be considered as standard for topical MMC application on esophageal stricture.

Efficacy and Safety of Endoscopic Management of Esophageal Strictures in Children

Efficacy and Safety of Endoscopic Management of Esophageal Strictures in Children

Achieving Success with Endoscopic Lumen Restoration for Aphagia

Standard endoscopic management of esophageal strictures is sometimes impossible, particularly when a guidewire cannot be positioned via an antegrade

Through-the-scope Polyethylene Balloon Dilations in Benign Corrosive Esophageal Stricture Complicated with Temporomandibular Joint Dislocation

Esophageal dilation is a non-surgical management for anatomic and functional abnormalities causing both benign and malignant esophageal stricture. The basic goals of stricture dilation include safe and efficacious lumenal enlargement plus prevention of restenosis. These could be achieved using through- the-scope (TTS) balloon dilations, ranged in diameter of 4 to 40 mm, they will allow dilation of previously inaccessible strictures in the esophagus, stomach, small bowel, and colon. There are 5,000–15,000 cases of stricture due to ingestion of corrosive substances in United States every year. The following case would demonstrate a 28-year-old male with depressive disorder who attempted a suicide by ingesting corrosive substances two months before admission. Subsequently he started having difficulty in swallowing even soft foods. The complaint was gradually increasing until a month before admission he went through endoscopic examination and a corrosive esophageal stricture found. Hence after, he underwent dilation using Savary bouginage with fluoroscopy and through-the-scope (TTS) balloon dilations. The patient underwent a series of dilation treatment and demonstrated vigorous improvement. Problems raised as the patient was complicated with temporomandibular joint (TMJ) dislocation due to traumatic injury after ingesting corrosive substances. The consideration in management of esophageal stricture with complications will be discussed further in this article. Keywords: esophageal stricture, corrosive substances, dysphagia, temporomandibular joint dislocation, through-the-scope polyethylene balloon dilation

Esophageal Stenting Following Perforation After Balloon Dilatation of Caustic Induced Esophageal Stricture in a 3-year-old Child

Purpose: Caustic ingestion in children is relatively common, causing variable injury to aerodigestive tissues. Esophageal strictures (ES) may occur in 20% of these patients. Treatment of ES involves dilatation with balloons, Savary or Eder-Puestow dilators. Such treatment may be complicated by esophageal perforation (EP). In children EP occurs most commonly during the first dilatation. Morbidity and mortality may be high following EP. Treatment of EP includes surgical repair or in selected patients medical treatment. Prognosis is better when EP is recognized early. Placement of esophageal stents has been used in the management of caustic esophagitis and ES both, in children and adults. In adults, placement of expandable, flexible stents has also emerged as effective treatment for EP. However, in North America the use of esophageal stents in pediatrics is a relatively uncommon practice (Curr Gastroenterol Rep 2010,12:203-210. Use of esophageal stents to treat EP in pediatrics is also rare (Endoscopy 2009,41:E325-326). A 3-year-old girl had accidental ingestion of oven cleaner (pH 14.0). Initial endoscopy showed severe, generalized, concentric esophagitis. She was treated with IV antibiotics, steroids, antacids and parenteral nutrition. She was discharged after 3 weeks on oral feedings, prednisone and lanzoprazole. Six weeks later, she reported progressive dysphagia for solids. Barium swallow showed dilatation of the esophagus proximal to the level of T3-T4, with distal esophageal narrowing. Repeat endoscopy revealed a severe stricture at ˜14 cm from dental line. Wire-guided balloon dilatations (6, 7 and 8 mm) were performed. Following the procedure, esophageal contrast injection showed extravasation associated with a pneumothorax. A 10-80 mm Wallflex Rx fully covered biliary stent (Boston Scientific) and chest tubes were immediately placed. She recovered well having occasional episodes of vomiting and was discharged on PO feedings, lanzoprazole and metoclopramide. At endoscopy one month later, she had significant granulation tissue with cobblestone aspect at the proximal and distal ends of the stent. The stent was removed without complications. The esophageal mucosa was still greyish, edematous and friable. Over the next eight months, recurrent dysphagia prompted monthly balloon dilatation of 2 ES at ˜14 and 18 cm. Her esophagitis and dysphagia have progressively improved. She eats solid food but the ES are still present. In our patient, other than formation of granulation tissue, we observed no complications after esophageal stent placement for 4 weeks. The biliary stent treated the EP and improved the segmental ES, but after 8 months, the child still needs esophageal dilatations.

Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

BackgroundEndoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but is associated with esophageal stenosis, particularly when ESD involves the entire circumference of the esophageal lumen. We examined the effectiveness of systemic steroid administration for control of postprocedural esophageal stricture after complete circular ESD.MethodsSeven patients who underwent wholly circumferential ESD for superficially extended esophageal squamous cell carcinoma were enrolled in this study. In 3 patients, prophylactic endoscopic balloon dilatation (EBD) was started on the third post-ESD day and was performed twice a week for 8 weeks. In 4 patients, oral prednisolone was started with 30 mg daily on the third post-ESD day, tapered gradually (daily 30, 30, 25, 25, 20, 15, 10, 5 mg for 7 days each), and then discontinued at 8 weeks. EBD was used as needed whenever patients complained of dysphagia.ResultsEn bloc ESD with tumor-free margins was safely achieved in all cases. Patients in the prophylactic EBD group required a mean of 32.7 EBD sessions; the postprocedural stricture was dilated up to 18 mm in diameter in these patients. On the other hand, systemic steroid administration substantially reduced or eliminated the need for EBD. Corticosteroid therapy was not associated with any adverse events. Post-ESD esophageal stricture after complete circular ESD was persistent, requiring multiple EBD sessions.ConclusionsUse of oral prednisolone administration may be an effective treatment strategy for reducing post-ESD esophageal stricture after complete circular ESD.

Epidermolysis Bullosa: Management of Esophageal Strictures and Enteric Access by Gastrostomy

Epidermolysis bullosa (EB) is a spectrum of rare, inherited, blistering skin disorders, primarily affecting the skin and pharyngoesophageal mucosa. EB affects approximately 2 to 4 per 100,000 children each year. Blistering and scarring occur in response to even the most minor trauma. In this article, the authors outline the potential management options for patients with EB complicated by feeding difficulties secondary to esophageal strictures as well as those with nutritional deficiencies requiring a gastrostomy tube for supplemental feeding.

Novel technique for management of esophageal strictures: double “J” stents and the use of urologic dilators

Current management of esophageal strictures using multiple dilations is the standard of care for symptomatic relief and cure. Diverse arrays of techniques have been developed with similar success rates. In this study we suggest the use of urologic dilator as a safe, alternative method for the management of esophageal strictures. We report a case of a patient with a history of severe, recurrent esophageal stricture secondary to tracheo-esophageal fistula repair, treated using Amplatz urologic dilators and double J stent as a mechanical temporizer for an esophageal stricture at risk for complete stenosis. Under general anesthesia, a flexible endoscope was passed into the proximal esophagus to visualize the stricture. A glide wire was passed through the stricture and its placement was confirmed by fluoroscopy. The endoscope was then removed and a series of urologic dilators sizing from 12Fr to 32Fr were passed through the stricture under fluoroscopic vision. Following this, a double "J" stent was left in place for further dilation sessions and to prevent complete stenosis. In conclusion, urologic dilators demonstrate a novel and simple technique for the treatment of esophageal strictures. This patient had no reported complications, and patient was able to tolerate the double "J" stent during dilation sessions.

Practice patterns in the management of patients with esophageal strictures and rings

Only few data exist on the epidemiology and management of esophageal strictures and rings. To study the epidemiology and management of esophageal strictures and rings. Case-control study. Endoscopic data repository of U.S. gastroenterology practices from 1998 to 2003 (Clinical Outcomes Research Initiative). Case subjects included 7287 patients with strictures and 4993 patients with rings. The control group consisted of 124,120 patients without endoscopic evidence of esophageal stenosis. Esophageal dilation. Patient demographics, types and diameters of esophageal dilators, frequency of repeat dilations. Strictures displayed a male predominance, and rings displayed a small female predominance. Compared with the control population, strictures and rings both occurred most frequently in elderly white patients. Dysphagia and reflux were the most common indications for dilation in both conditions. Compared with strictures, rings were treated more often with larger dilators and rubber bougies. One-year rates of repeat dilation for strictures and rings were 13% and 4%, respectively. The mean interval length between repeat dilations was 82 days for strictures and 184 days for rings. Only a limited amount of information about individual patients was retrievable from the electronic database. The variations in the demographic characteristics and the treatment practice allude to differences in the underlying pathophysiology of these 2 benign obstructing lesions of the esophagus.

Endoscopic Management of Esophageal Strictures in Children

Endoscopic Management of Esophageal Strictures in Children

Mitomycin C as an Alternative to Stent for Conservative Management of Esophageal Strictures in Children

Mitomycin C as an Alternative to Stent for Conservative Management of Esophageal Strictures in Children