Refractory Anastomotic Strictures Research Articles

Comparison between endoscopic incision and balloon dilation for refractory anastomotic stricture after surgery of sigmoid colon and rectum

Objective To compare the safety and efficacy between endoscopic incision (EI) and endoscopic balloon dilation (EBD) for treating refractory anastomotic stricture after surgery of sigmoid colon and rectum. Methods Clinical data of the 24 patients with refractory benign anastomotic stricture after surgery of sigmoid colon and rectum who received EI or EBD at the second Xiangya hospital from June 2009 to September 2015 were retrospectively analyzed. They were divided into group EI and group EBD. Safety and efficacy between the two groups were compared based on preoperative, intraoperative, and 1, 6, 12, 24 months postoperative data. Results There were 12 patients in each group, and all patients received EI or EBD treatment successfully with the success rate of 100%. No patient developed serious complications such as obvious bleeding, perforation during or after treatment. All strictures were successfully managed and the obstruction symptoms were relieved. As for the short-term efficacy, the symptom relief rate and endoscopic patency rate of EI and EBD 1 and 6 months after a single treatment were comparable (P>0.05). As for the medium to long-term efficacy, the symptom relief rate and endoscopic patency rate of EI 12 and 24 months after a single treatment was higher than that of EBD (P<0.05). The mean follow-up of EI and EBD group was 24.4 months and 28.5 months, and the median treatment sessions in each group was 1.0 and 2.5 respectively, the total treatment session in the EI group was less than that in the EBD group(1/12 VS 9/12), and the anastomotic diameter of EI group at final check was larger than that of EBD group (1.833±0.293 cm VS 1.608±0.183 cm, P<0.05). Conclusion EI could result in a better medium-to-long-term efficacy than EBD and reduce the rate of recurrence. Key words: Constriction, pathologic; Surgical stomas; Sphincterotomy, endoscopic; Balloon dilation; Comparative effectiveness research

Sa2075 off-Label Use of Biliary Stent for Treatment of Severe Refractory Esophageal Anastomotic Stricture in a Case of Long Gap Esophageal Atresia

Sa2075 off-Label Use of Biliary Stent for Treatment of Severe Refractory Esophageal Anastomotic Stricture in a Case of Long Gap Esophageal Atresia

Tu1577 Effective Salvage Treatment Using a Novel Fully Covered Self-Expandable Metal Stent for the Refractory Anastomotic Stricture Developed After Liver Transplantation

Tu1577 Effective Salvage Treatment Using a Novel Fully Covered Self-Expandable Metal Stent for the Refractory Anastomotic Stricture Developed After Liver Transplantation

Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children.

The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients. We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up. All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3-4 to 0-1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2-5 mm) to 10.6 mm (range 8-12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up. EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.

Endoscopic needle-knife stricturoplasty in Esophageal Crohn's Disease – Case report

Background: Crohn's disease of the esophagus is rare, but if present, it may cause stricture of the involved parts. Even though the primary therapeutic intervention is endoscopic balloon dilation, some patients with refractory strictures require surgical resection. However radial electroincision of refractory esophagogastric anastomotic stricture after surgery is mentioned, Crohn's disease related needle-knife stricturoplasty is not known in the literature. Case report: A 64 years old female patient was diagnosed with buccal and esophageal manifestation of Crohn's disease 5 years ago. No other part of the gastrointestinal tract was involved. Balloon dilation was performed in 2010 and 2011. She was admitted to our gastroenterology department in May 2014 with relapsing dysphagy. The former buccal ulcers scarred, while in the esophagus a ring-like stricture was revealed starting at 20 cm from incisors. The next 10 cm was narrowed by pseudopolyps without active ulceration. We used needle knife to perfom three radial incisions at the level of the ring. One incision was clipped thereafter due to its deepness. The patient was discharged some days later. After 10 months of follow-up the patient was symptom-free, the gastroscopy revealed a tight ring with easy passage of the scope. Conclusion: In case of ring-like fibrotic stricture of the esophagus caused by Crohn's disease beside balloon dilation, the needle knife incision can be useful method to reveal the symptoms for a long-term duration.

Su1676 Safety and Efficacy of Endoscopic Incision for the Treatment of Refractory Colorectal Anastomotic Stricture

Su1676 Safety and Efficacy of Endoscopic Incision for the Treatment of Refractory Colorectal Anastomotic Stricture

Fully covered self-expanding metal stents for refractory anastomotic colorectal strictures.

Some patients with benign colorectal obstruction do not respond to endoscopic balloon dilation. Fully covered self-expandable metal stents (FCSEMSs) have several potential advantages over non-covered stents, including a higher likelihood of retrieval owing to limited local tissue reaction. However, the efficacy and safety of FCSEMSs in benign colorectal strictures have not yet been established. Retrospective analysis of prospectively collected data concerning patients with post-surgical benign symptomatic anastomotic colorectal strictures, refractory to endoscopic dilation and in whom FCSEMSs had been placed at our center. Technical success was defined as successful stent placement and deployment at the stricture site. Early clinical success was defined as symptom relief persisting at least for 3 days. Follow-up was based on monthly clinical evaluation and quarterly endoscopic assessment. Endoscopic stent removal was planned on the basis of clinical or endoscopic assessment. Prolonged clinical success was defined as persistent symptom relief during follow-up. Technical and early clinical success were obtained in 16 of 16 (100%) patients. The median follow-up was 21 months. Prolonged clinical success was achieved in 9/16 (56%) cases. There was no major complication, including perforation and bleeding. Stent migration occurred in 3 (19%) cases, in two of them associated with clinical failure. The median stent diameter was significantly higher in patients with successful than in those with unsuccessful clinical outcome (26 vs. 20 mm, P = 0.006). The clinical success rate was 1/6 (17%) in patients who received a 20-22 mm stent and 8/10 (80%) in those who received a 24-26 mm stent, respectively (P = 0.035). FCSEMSs can represent effective and safe treatment for refractory anastomotic colorectal strictures. Large diameter stents are warranted for better results.

Sa1607 A Novel Method for Enteral Stent Placement - Retrograde Endoscopic Guidance

generally performed in the anastomotic stricture of the lower rectum with a high frequency of restenosis. Although it has been reported that radial incision and cutting (RIC) using electrosurgical insulated tip (IT) knife is effective for refractory anastomotic stricture after esophagectomy, little is known regarding RIC for anastomotic stricture after ISR or LSR. Aim: To evaluate retrospectively the efficacy and safety of RIC for anastomotic stricture in the lower rectum after ISR or LAR. Methods: Between December 2008 and November 2011, a total of 405 patients underwent ISR or LAR in our hospital and the patients who were treated by RIC for severe anastomotic severe stricture were enrolled. We assessed the patients’ characteristics, clinical course and complications. The indications for RIC were followed: 1) the endoscope (GIF Q260, Olympus) could not pass through the stricture before colostomy closure, 2) the patients had difficulty in defecation such as constipation and abdominal distension after colostomy closure. Results: Of 405 patients, 38 (9.4%) had postoperative anastomotic stricture and 7 (1.7%) with severe stricture received dilatation by RIC. The male to female ratio was 6 to 1, with median age of 66 years ranging from 56 to 72. ISR and LAR were performed in 4 and 3 patients, respectively, and all patients received a temporary colostomy. Before RIC, stricture diameter less than 2mm, 3 to 5mm, and 6 to 10mm were found 4, 1, and 2 patients, respectively. A total of 16 sessions of RIC was performed. Of 16 sessions, 14 sessions were performed in hospitalization with the median length of 3 days (range, 2 5), while 2 sessions were performed as an outpatient. The median procedure time of RIC was 18 minutes (range, 7 34), and no complications such as penetration, bleeding, and high fever were observed. The median follow-up time after the RIC procedure was 27 months (range, 18 55). During follow-up periods, restenois occurred to 2 patients and more than 4 times RIC was required. However, 5 patients did not suffer restenosis and improve the defecation. Conclusions: Dilatation by RIC was feasible, effect and safe for severe anastomotic stenosis in the lower rectum after ISR or LAR. RIC can be a novel method in patients with refractory anastomotic stricture for existing dilatation such as balloon or bougie.

Sa1606 Efficacy and Safety of Endoscopic Radial Incision and Cutting (RIC) Method for Benign Anastomotic Severe Stricture After Surgery of Lower Rectal Cancer

Intersphincteric resection (ISR) and low anterior resection (LAR) can preserve anal function, however, anastomotic stricture sometimes occurs as complications after surgery. Endoscopic balloon dilation (EBD) or bougie is generally performed in the anastomotic stricture of the lower rectum with a high frequency of restenosis. Although it has been reported that radial incision and cutting (RIC) using electrosurgical insulated tip (IT) knife is effective for refractory anastomotic stricture after esophagectomy, little is known regarding RIC for anastomotic stricture after ISR or LSR.

Tu1378 Clinical and Procedural Predictors of Refractory Anastomotic and Radiation-Induced Strictures

more routinely. Perforation caused by endoscopic removal of foreign bodies is much rarer than has been described in the historical literature.

Sp605 A Solution for the Migrating Stent: Use Of The OTSC Device To Hold Fully Covered Esophgeal Stents In Place

Migration of fully covered self-expandable metal stents (FCSEMS) remains a significant limitation, especially in benign diseases. The lack of a stricture (leaks, fistulae) can further increase the migration rates of FCSEMS. Hemostatic clips are notoriously poor at securing SEMS in place. We describe the use of an over-the-scope clipping (OTSC) device (Ovesco, Tübingen, Germany) to secure the proximal end of FCSEMS [23mm X 155mm Wallflex stent, Boston Scientific, Natick, MA, (case1) and 18mm x 60mm Niti-S stent, Taewoong, Seoul, Korea, Case 2,3)] to prevent migration. Data was collected prospectively on 3 patients who underwent placement of an OTSC device to secure FCSEMS in place from 8/2012 to 11/12. Case 1: 40 YM developed a leak 2 weeks after a vertical sleeve gastrectomy, unsuccessfully treated with an OTSC, FCSEMS and PCSEMS, that migrated. Therefore the proximal end of FCSEMS was secured in place with an OTSC for 10 weeks, leading to closure of the leak. The OTSC was easily cut with argon plasma coagulator (APC) and removed with the SEMS. Case 2: 73 YM developed a retrocardiac abscess after an esophagectomy for esophageal adenocarcinoma. After migration of a FCSEMS, he was treated with a naso-sinus drain and a FCSEMS secured in place with an OTSC which has resulted in resolution of the abscess, removal of naso-sinus drain and is pending stent removal in 4 weeks. Case 3: 79 YF developed a high-grade refractory (to dilations) anastomotic stricture 3 months after esophagectomy for esophageal adenocarcinoma . After spontaneous migration of a FCSEMS, the same stent was secured in place with an OTSC device successfully for 4 weeks to date and is pending removal. The OTSC device has successfully secured FCSEMS in place in all 3 patients for a median dwell time of 6 weeks. There have been no adverse events at placement (3/3) or removal (1/1) of the OTSC device. The OTSC device is pending removal in 2 patients. We therefore conclude that the OTSC device can be used to secure FCSEMS and prevent migration. Using APC to cut the joint of the OTSC device, removal is feasible. However, larger case series are needed to confirm the efficacy and safety of this technique to preclude prosthesis migration.

A retrospective analysis of early and late outcome of biodegradable stent placement in the management of refractory anastomotic colorectal strictures

Benign colorectal strictures are treated conventionally by endoscopic dilation. Experience using SEMS for benign colonic strictures is limited, and outcomes to date have been disappointing. Refractory colorectal strictures remain challenging to be treated with surgery. Polydioxanone-based stent are biodegradable (BD) stent CE approved for esophageal strictures. This study was designed to investigate retrospectively the safety and the efficacy of these stents for the management of strictures refractory to multiple sessions of dilation. Patients with postsurgical benign strictures located within 20 cm from anal verge, refractory to mechanical or pneumatic dilation (at least 3 sessions) were included in this analysis. Clinical success was defined as the absence of occlusive symptoms and the ability to pass through the stricture with a regular size colonoscope. All patients were predilated before stent placement. Stents were released under fluoroscopic control. All patients were under stool softeners for 3 months. Follow-up was scheduled with endoscopic and fluoroscopic controls within 90 days from stent deployment and afterwards by telephone interview and/or ambulatory consultation. Eleven patients (7 males, mean age 62.3 ± 8.5 years) were included. Technical success was achieved in all the patients. Stent migration was observed in four patients within the first 2 weeks after stent placement. Stent migration was followed by recurrence of stricture and obstructive symptoms in all the cases. Among the seven patients who completed the process of stent biodegradation, five of them had complete resolution of the stricture and relief of symptoms. Two of 11 patients required surgical treatment during the follow-up period (mean 19.8 (range 42-15) months). The overall success rate of the BD stent was 45 %. This retrospective analysis of a limited number of patients demonstrated that nondedicated esophageal BD stents are associated with high risk of migration and clinical success in less than 50 % of patients. Dedicated stents with large diameter and antimigration findings could potentially improve the outcome of patients with refractory benign colorectal strictures.

Resolution of a Refractory Anastomotic Stricture With a Novel Biodegradable Esophageal Stent

Resolution of a Refractory Anastomotic Stricture With a Novel Biodegradable Esophageal Stent

Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video)

There is no effective treatment for gastroesophageal anastomotic strictures that are refractory to repeated endoscopic balloon dilation (EBD). However, EBD is still selected worldwide to manage such refractory strictures. To relieve the symptoms of dysphagia and keep a wide lumen, we developed a new incisional treatment, radial incision and cutting (RIC). To evaluate the efficacy and safety of the RIC method for the treatment of refractory anastomotic strictures. Retrospective cohort study. National Cancer Center and University Hospital. This study involved 54 consecutive patients with refractory anastomotic stricture after esophagogastric surgery. RIC. The safety and clinical success of RIC and the long-term patency after RIC compared with those of continued EBD. The median procedure time of RIC was 14 minutes (range, 4-40 minutes). No serious adverse events associated with RIC were observed. Immediately after RIC, 81.3% (26/32) of patients were able to eat solid food without symptoms of dysphagia. As a short-term effect, the dysphagia improved after RIC in 93.8% (30/32) of the patients. As a long-term effect, 63% (17/27) and 62% (13/21) of patients were able to eat solid food 6 and 12 months after RIC, respectively. The 6-month and 12-month patency rates were significantly different between the RIC group and the continued EBD group (65.3% vs 19.8%, P < .005; 61.5% vs 19.8%, P < .005). Nonrandomized retrospective study. RIC is an effective and safe method. The demonstration of the validity of this method may place RIC as a new medical treatment for patients with refractory stricture after surgical resection for esophagogastric diseases.

Sa1608 Radial Incision and Cutting (RIC) Method Is More Effective Than Continued Endoscopic Balloon Dilation (EBD) for Refractory Anastomotic Stricture: A Comparative Study

Sa1608 Radial Incision and Cutting (RIC) Method Is More Effective Than Continued Endoscopic Balloon Dilation (EBD) for Refractory Anastomotic Stricture: A Comparative Study

Endoscopic treatment of benign anastomotic esophagogastric strictures with a biodegradable stent

Postoperative benign fibrotic strictures of a cervical esophagogastric anastomosis have a reported incidence of 26% to 46%. 1 van Heijl M. Gooszen J.A. Fockens P. et al. Risk factors for development of benign cervical strictures after esophagectomy. Ann Surg. 2010; 251: 1064-1069 Crossref PubMed Scopus (118) Google Scholar Factors independently related to development of benign anastomotic strictures are cardiovascular disease, gastric tube compared with colonic interposition, and postoperative anastomotic leakage. 1 van Heijl M. Gooszen J.A. Fockens P. et al. Risk factors for development of benign cervical strictures after esophagectomy. Ann Surg. 2010; 251: 1064-1069 Crossref PubMed Scopus (118) Google Scholar These strictures bring about morbidity because of dysphagia and weight loss, leading to a decreased quality of life. Several methods have been described to treat these strictures, including balloon dilation, Savary bougie dilation, and Eder Puestow olive dilation. None of these conventional methods has proved to be superior over others with regard to efficacy and safety. 2 Hordijk M.L. Siersema P.D. Tilanus H.W. et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc. 2006; 63: 157-163 Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar The median number of dilation sessions varies between 2 and 9 per patient when conventional dilation techniques are used to achieve remission. 2 Hordijk M.L. Siersema P.D. Tilanus H.W. et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc. 2006; 63: 157-163 Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar To reduce the number of treatment sessions, dilation has been combined with intralesional steroid injections, revealing a reduction of dilation sessions in uncontrolled series. 3 Kochhar R. Makharia G.K. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc. 2002; 56: 829-834 Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar

Refractory strictures after Roux-en- Y gastric bypass: operative management

Background Stricture of the gastrojejunostomy after Roux-en- Y gastric bypass (RYGB) is common in the early postoperative period, with a reported incidence of 3–27%. Late recalcitrant strictures are much less common. Treatment has varied from endoscopic therapy to operative revision of the gastrojejunostomy with or without additional anatomic revisions. The origin of the late strictures varies, with the most common causes being excessive acid, aspirin, or nonsteroidal anti-inflammatory drug use, postoperative anastomotic leak, or, as some have maintained, smoking. We sought to identify the predictors of gastrojejunostomy strictures that require operative management after RYGB and to evaluate the clinical outcomes of patients requiring operative revision of the gastrojejunostomy stricture after failed nonoperative therapy at an academic institution. Methods A retrospective review was performed of all patients undergoing operative intervention for gastrojejunostomy stricture from 1990 to 2009 after having undergone RYGB for medically complicated obesity. Results A total of 24 patients required revision of their gastrojejunostomy stricture after multiple attempts at nonoperative therapy. The mean interval from RYGB to reoperation was 4.3 years (range .5–25). The interval to operative revision for anastomotic stricture was substantially less in patients with active anastomotic ulcers (n = 6), those who had had a gastrojejunostomy leak after RYGB (n = 5), and those with gastrogastric fistulas (n = 7; 20, 23, and 44 months, respectively). Of the 24 patients, 23 experienced relief of their symptoms. The postoperative morbidity rate was 21%, and the mortality rate was 0%. Conclusion Operative revision of strictured gastrojejunostomy is a safe and effective procedure for those patients in whom endoscopic therapy has failed. Most refractory anastomotic strictures have been secondary to excessive acid (too large a proximal pouch), chronic ulceration, or postoperative anastomotic leak.

Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture

Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm x 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.

Successful treatment of severe refractory anastomotic stricture in an infant after esophageal atresia repair by endoscopic balloon dilation combined with systemic administration of dexamethasone

A boy with a history of esophageal atresia repair received an esophagoesophagostomy at 14 months for a severe refractory anastomotic stricture, which had already required repeated balloon dilation with intralesional dexamethasone injection. Anastomotic leakage and stricture was again evident after the second surgery, and the patient underwent five procedures of balloon dilations with intralesional dexamethasone injection. Dysphagia was persistent and the patient required dilation every 2-3 weeks. After the sixth dilation, the patient was given 1 mg/kg per day of dexamethasone i.v. for 3 days. Dexamethasone i.v. was tapered during the following 3 days and finished at day 6. A week later, endoscopic findings showed an apparent improvement in the stricture. Another dilation was followed by 1 mg/kg per day dexamethasone i.v. for 7 days, and 0.75 kg/mg per day oral dexamethasone for another 7 days. The stricture improved completely and the anastomosis was patent after the second dilation. The patient is doing well without dysphagia and has not required additional dilation for over 18 months after the last dilation. Balloon dilation in combination with systemic dexamethasone administration may be an effective treatment that could substitute invasive techniques including surgical manipulation for severe refractory strictures.

Electrocautery therapy for refractory anastomotic strictures of the esophagus

Anastomotic esophageal stenoses after esophageal resection are common and sometimes are refractory to Savary bougie dilation. The efficacy of electrocautery needle-knife treatment in these patients is described. Twenty patients with a refractory anastomotic stricture of the esophagus were treated with electrocautery and were followed for 12 months. All patients had recurrence of dysphagia despite repeated bougienage. All 12 patients with a stricture shorter than 1 cm remained without dysphagia after a single treatment. In all 8 patients with a long-segment stenosis of 1.5 to 5 cm, dysphagia recurred, and a mean of 3 treatments were necessary. The interval between electrocautery treatments was significantly longer compared with bougienage. There were no complications. The body weight of all patients increased. Electrocautery seems to be a good single-treatment modality for refractory short-segment anastomotic strictures, whereas longer-segment stenoses appear to require repeated treatment sessions before similar results are obtained.