Number Of Endoscopic Dilations Research Articles

Management of esophageal strictures after endoscopic resection for early neoplasia.

Background:Endoscopic resection of extensive esophageal neoplastic lesions is associated with a high rate of esophageal stricture. Most studies have focused on the risk factors for post-endoscopic esophageal stricture, but data on the therapeutic management of these strictures are scarce. Our aim is to describe the management of esophageal strictures following endoscopic resection for early esophageal neoplasia.Methods:We included all patients with an endoscopic resection for early esophageal neoplasia followed by endoscopic dilatation at a tertiary referral center. We recorded the demographic, endoscopic, and histological characteristics, and the outcomes of the treatment of the strictures.Results:Between January 2010 and December 2019, we performed 166 endoscopic mucosal resections and 261 endoscopic submucosal dissections for early esophageal neoplasia, and 34 (8.0%) patients developed an esophageal stricture requiring endoscopic treatment. The indication for endoscopic resection was Barrett’s neoplasia in 15/34 (44.1%) cases and squamous cell neoplasia (SCN) in 19/34 (55.9%) cases. The median [(interquartile range) (IQR)] number of endoscopic dilatations was 2.5 (2.0–4.0). Nine of 34 (26.5%) patients required only one dilatation, and 22/34 (65%) had complete dysphagia relief following three endoscopic treatment sessions. The median number of dilatations was significantly higher for SCN [3.0 (2–7); range 1–17; p = 0.02], and in the case of circumferential resection [4.0 (3.0–7.0); p = 0.03]. Endoscopic dilatation allowed a sustained dysphagia relief in 33/34 (97.0%) patients after a mean follow-up of 25.3 ± 22 months.Conclusion:Refractory post-endoscopic esophageal stricture is a rare event. After a median of 2.5 endoscopic dilatations, 97.0% of patients were permanently relieved of dysphagia. Circumferential endoscopic esophageal resections should be considered when indicated.

Prevention of esophageal strictures after circumferential endoscopic submucosal dissection.

Endoscopic submucosal dissection or widespread endoscopic resection allow the radical removal of circumferential or near-circumferential neoplastic esophageal lesions. The advantage of these endoscopic methods is mini-invasivity and low risk of major adverse events compared to traditional esophagectomy. The major drawback of these extensive resections is the development of stricture - the risk is 70-80% if more than 75% of the circumference is removed and almost 100% if the whole circumference is removed. Thus, an effective method to prevent post-ER/ESD esophageal stricture would be of major benefit, because treatment of strictures requires multiple sessions of endoscopic dilatation and may carry a risk of perforation. Moreover, not all strictures are easy to treat and some patients may develop refractory strictures. There are several techniques and methods, which have been tested in both experimental and/or clinical studies but no one has received general acceptance based on results of high-quality evidence. The studies are usually small with a limited number of patients, there is a lack of randomized controlled trials and some techniques have been described only in experimental studies. Thus, prevention of post-ESD strictures remains an unresolved issue. On the other hand, because of the high risk of stricture and partially proven effectiveness of some preventive techniques, a preventive strategy should be considered in patients undergoing extensive ER/ESD in the esophagus. There is, however, no evidence about the superiority or inferiority of a particular preventive strategy compared to other techniques, moreover, there is paucity of data assessing the effectiveness of the combination of different preventive methods. The best preventive strategies known so far include 1) oral or local administration of corticosteroids; and 2) preventive stenting. Other strategies (preventive sessions of endoscopic dilatation or tissue engineering methods) have unproven efficacy or are too demanding for practical use. Nevertheless, the use of (any) preventive strategy after extensive ER/ESD of the esophagus probably reduces the risk of stricture and the number of endoscopic dilatations, therefore, it should be considered in these patients. However, there is a need for high quality evidence as well as for new ideas and approaches to resolve this important clinical problem.

Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach

BackgroundPatients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient’s autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution.MethodsThis study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events.ResultsSeventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11–27] procedures during a median period of 9 (IQR 6–36) months to 1.5 (IQR 0–3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5–33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13–15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage.ConclusionsIn this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.

P-44 The influence of circular stapler diameter on post-operative outcome following laparoscopic gastro-jejunal anastomosis in morbid obesity: meta-analysis

Background: Laparoscopic Roux-en-Y gastric bypass is a wellpracticed surgical option for the treatment of morbid obesity. The aim of this study was to provide pooled analysis of individually small trials comparing 21mm versus 25mm circular stapled laparoscopic gastro-jejunal (GJ) anastomosis in morbid obesity surgery. Methods: A systematic literature search of Medline, Embase and Cochrane library databases was performed to identify all relevant studies comparing 21mm versus 25mm Circular stapled laparoscopic GJ anastomosis in morbid obesity surgery. Primary outcomes were gastro-jejunal stenosis and interval to GJ stenosis. Secondary outcomes were estimated weight loss, GJ diameter and number of endoscopic dilatations. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes. Results: Five trials were included comprising 1,217 patients (393 with 21mm vs. 824 with 25mm Circular GJ anastomoses). Primary outcome analysis revealed significantly increased intra-luminal stenosis associated with the 21mm circular stapler (pooled odds ratio 3.54; P 0.0001). Secondary outcome analysis revealed a significantly reduced GJ anastomotic diameter on endoscopy with the 21mm Circular Stapler group (weighted mean difference -1.67; P 0.002). Statistical analysis revealed no significant difference between the groups for interval to stenosis, number of endoscopic dilatations and estimated weight loss. Conclusion: The results of this pooled analysis demonstrate significantly increased stenosis associated with the use of 21mm circular stapler compared with the 25mm. This serves as evidence to validate the preferential use of the 25mm circular stapler in laparoscopic gastro-jejunal bypass.