Repeat Dilation Research Articles

P1121 Longterm Outcomes of Balloon Assisted Endoscopic Stricture Dilation in Patients with Small Bowel Crohn’s Disease: A Tertiary Referral Center’s Retrospective Experience

Abstract Background The natural history Crohn’s disease (CD) can be complicated by strictures. Balloon-assisted endoscopy (BAE) has significantly improved the ability to assess and treat small bowel CD, allowing for stricture dilation to improve patient symptoms and potentially delay or avoid surgery. We present a single-centre CD cohort of patients that have undergone BAE for stricture dilation. We assess procedural success, outcomes and safety, evaluate factors associated with a risk of requiring surgical management. Methods All patient who underwent BAE for CD from the period oof April 2012 to January 2024 were assessed and recorded. Within this group, we identified patients who had undergone assessment and/or dilation of structuring CD. Patient demographic and procedural details were extracted. Long-term outcomes, including requirement for repeat dilation and requirement for surgery were recorded from time initial of initial BAE as surrogates for the durability of dilation in these patients. Patients required surgery post initial BAE were compared to the non-surgical group. Results At the University of Alberta Hospital, out of 532 BAE procedures in 231 patients, 157 pt underwent 282 BAE procedures with 629 strictures dilated. In our cohort, 16 strictures were non-traversable and 3 were failed dilations. We had a > 95% successful dilation rate. One perforation occurred requiring emergent surgery (n=1). 65 pts required surgery and 92 pts were managed with dilation. and pharmacotherapy. Overall, 28/65 patients were active smokers (43.08%) in the surgical group vs. 24/92 (26.09%). Biologic use was comparable (76.9% vs 73.9%). The average minimum diameter dilated was lower 15.2 mm (+/- 0.25) vs 16.2 mm(+/- 0.16) in the surgical group. Non-traversable strictures post-dilation was higher in the surgical group (14.72% vs 9.20%). A total 65 patients undersent surgery with an average time of 32.22 months (excluding emergent/urgent surgeries) from index BAE and avg 8.79 months from most recent BAE. There was a total of 3 emergent surgeries (<24 hours from BAE to surgery, including one perforation from intraprocedural complication), 7 urgent surgeries (<30 days from BAE to surgery). Conclusion Based on this cohort, the majority of patients with CD strictures CD can be successfully managed with BAE stricture dilation, and in those requiring surgery the average time from initial BAE to surgery was 32 months. BAE stricture dilation may play an important role in preventing emergent/unplanned surgical interventions and preventing surgeries in select patients. Although this study is currently descriptive, further data analysis of this group is ongoing currently.

Midterm Outcomes of Endovascular Pulmonary Artery Debanding in Children.

Pulmonary artery banding (PAB) palliates pulmonary over-circulation, while endovascular debanding (ED) offers a less invasive alternative to repeat surgery. To evaluate our experience with ED. Retrospective review of single-center data (2015-2023) on children with single, multiple, or "Swiss-cheese" muscular ventricular septal defects (MVSDs) undergoing ED. Ten patients (50% male) underwent ED at a median age of 5 years (IQR, 1.8-6.8) and weight of 15 kg (IQR, 10.6-19.7). Four patients had single MVSD, six had multiple MVSDs. Debanding occurred at a median of 52.8 months (IQR, 18.4-76.6) post-PAB, utilizing six non-compliant Numed Z-MED and four semi-compliant Balt Cristal high-pressure balloons. Median pulmonary valve annulus (PVA) diameters were 15.5 mm (IQR, 12.5-16.8) angiographically. Median balloon-to-PVA diameter ratio was 1 (IQR, 1-1), and median balloon-to-band diameter ratio was 2 (IQR, 1.8-2). Median trans-PAB gradient decreased from 100 mmHg (IQR, 86-108) to 40 mmHg (IQR, 26-46) (p < 0.01) and oxygen saturation improved from a median of 92% (IQR, 86%-97%) to 98% (IQR, 96%-98%) (p < 0.05). There were no procedural complications. Four patients underwent MVSD device closure a median of 7 months (IQR, 3-15) before ED, while seven had concomitant closures, including two with prior closures. Over a median follow-up of 91.7 months (IQR, 71.8-130.7), two patients required redo ED at 23 and 36 months, one with a contained vessel tear. Last recorded maximal Doppler gradient was 27 mmHg (IQR, 9-39). Total ED is safe with satisfactory midterm outcomes, though repeat dilations may be necessary during follow-up.

Gestational trophoblastic neoplasm: Patient outcomes and clinical pearls from a multidisciplinary referral center.

To describe clinical outcomes and pearls for patients with gestational trophoblastic neoplasm (GTN). Patients with GTN treated at a referral center from 1/2006 to 12/2022 were included. Clinical characteristics, World Health Organization risk score (low-risk 0-6, high-risk ≥7), and treatments/outcomes were evaluated using summary statistics, stratified by initial treatment at a referral center versus locally. Histologies included complete hydatidiform mole (CHM), partial hydatidiform mole (PHM), choriocarcinoma (CCA), placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). Of 189 patients with GTN, 125 were treated initially at a referral center and 64 locally. Median age at diagnosis was 34years (range, 17-70). Most patients were White (n=132, 70%); 80 patients had CHM, 26 PHM, 52 CCA, 11 PSTT, 19 ETT, and 1 ETT/CCA. For low-risk GTN, first-line treatment was primarily methotrexate, although some were cured with repeat dilation and curettage. For high-risk disease, first-line therapy consisted of multiagent chemotherapy regimens at a referral center (n=18/18) compared to 7 of 15 patients with high-risk GTN treated with methotrexate at local institutions. Patients with low-risk and high-risk disease who received initial care at a tertiary referral institution had cure rates of 100% (n=87/87) and 89% (n=16/18), respectively, while patients with initial care locally had cure rates of 87% (n=33/37) and 47% (n=7/15), respectively. GTN is a rare gynecologic malignancy with high cure rates, particularly in low-risk disease. Treatment consolidation at a tertiary referral institution is critical for improved outcomes, particularly in those with high-risk disease or PSTT/ETT.

Repeated endoscopic dilation and needle-knife stricturotomy for Crohn’s disease strictures

Crohn's disease strictures are usually treated by a single endoscopic balloon dilation (EBD). We postulated repeat EBD and needle-knife stricturotomy (NKSt), together with inflammation controlled by intense drug therapy, may be more effective. Twenty-one patients with symptomatic strictures were randomized to a single EBD or intensive treatment with 3 balloon dilations 3 weeks apart and/or NKSt. Of 21 patients, 2 of 5 (40%) undergoing a single EBD and 12 of 16 (72%) undergoing intensive treatment had symptom improvement (odds ratio, 4.49; 95% confidence interval, .54-37.4; P= .164). Eleven patients received >1 EBD without NKSt and 5 underwent≥1 NKSt. NKSt-treated patients and those with concurrent intensified drug treatment had the best outcomes. Treatment for Crohn's disease strictures with repeat dilations or stricturotomy is feasible and safe and may improve stricture outcomes. Concurrent intensified drug treatment to eliminate inflammation is also associated with improved outcomes. (Clinical trial registration number: NCT03222011.).

P320 Impact of Enterography on the Outcomes of Endoscopic Balloon Dilation for Ileocolonic Anastomotic Strictures in Crohn's Disease

Abstract Background Ileocolonic anastomotic stricture (ICAS) is a common complication following surgery for complicated Crohn's Disease (CD). Endoscopic balloon dilation (EBD) has emerged as a non-invasive therapeutic modality for symptom relief and delaying surgical interventions. However, the impact of enterography, utilizing magnetic resonance imaging (MRI) or computed tomography (CT), in characterizing ICAS and its influence on short- and long-term EBD outcomes remain unclear. Methods This retrospective study included patients who underwent EBD for ICAS. Demographic and clinical data were collected, encompassing short-term outcomes (procedure complications and symptom improvement) and long-term outcomes (need for surgery, hospitalization, or repeat dilation). Results A total of 15 patients with ICAS were included in the study, with 46.7% being females, and a mean age of 41.2±15.6 years at the time of EBD. Six patients (40%) had undergone enterography six months prior to EBD. The median balloon diameter used for dilation was 15mm (range: 10mm to 17mm) and during the procedure, significant mucosal inflammation of the anastomosis (Rutgeerts Score ≥2) was observed in seven patients (46.7%). EBD was successful in 12 patients (80%) without any immediate complications. In the 12-month post-procedure period, one patient experienced hospital admission due to intestinal occlusion, one patient required abdominal surgery, and another patient underwent two additional EBD procedures. We did not observe a trend for an increased occurrence of complications in patients submitted to EBD without prior recent enterography, in the 12 months following the procedure or thereafter. Conclusion In this small but homogeneous cohort, our findings suggest that recent enterography does not significantly improve ICAS EBD outcomes. Therefore, our data suggest that performing enterography should not delay EBD in symptomatic CD patients with ICAS.

Anastomotic Stricture After Minimally Invasive Esophagectomy

BackgroundDespite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America. MethodsWe performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models. ResultsOf 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001). ConclusionsAfter controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Esophageal Pseudomelanosis Causing Pseudoachalasia.

CASE REPORT An 86-year-old White man with a medical history of hypertension managed with hydralazine and dementia presented to our center for further evaluation of dysphagia complicated by weight loss. The patient was diagnosed 6 years ago with achalasia through a barium esophagram and received Botox injections every 6 months. His last esophagogastroduodenoscopy, 6 months before presenting to our center, reported achalasia, and he received balloon dilation and a Botox injection at the lower esophageal sphincter (LES). Esophageal manometry placement was not tolerated. Subsequent evaluation through a barium esophagram showed dysmotility (Figure 1), and endoscopy showed hyperpigmentation (Figure 2), diverticula (Figure 3), and a severely tight LES with a focal stricture but no mass. Biopsies of the distal esophagus demonstrated that the hyperpigmentation was due to dark granules without melanocytes (Figure 4). The patient was diagnosed with pseudoachalasia given endoscopic and esophagram findings of a tight LES with pseudomelanosis on histology. There are reported cases of hydralazine causing pseudomelanosis duodeni, although the patient had minimal response to stopping hydralazine.1 He was managed with serial dilations with an initial endoscopy balloon dilation from 8 to 12 mm, repeat dilation 1 month later from 8 mm to 15, and 4 months later dilation to 16.5 mm.Figure 1.: Barium esophagram demonstrating narrowing at the gastroesophageal junction.Figure 2.: Hyperpigmentation of the distal esophageal.Figure 3.: Two small diverticula in the distal esophagus.Figure 4.: Extensive pseudomelanosis with dark brown granular pigments within histiocytes without melanocytic infiltration with hematoxylin and eosin stain.Esophageal melanocytosis describes hyperpigmentation due to melanocytic proliferation, although pseudomelanosis involves pigmented macrophages without melanocytes.2 Pseudomelanosis has been described in the stomach and small intestine due to chronic medical conditions, such as renal disease, diabetes, and antihypertensive drugs, such as hydralazine and furosemide.3 Treatment is focused on the underlying disorder, cessation of potential causative medications, and symptom management. Pseudomelanosis in the duodenum is the most common location, and the hyperpigmentation is often attributed to iron deposition. This leads to proposed mechanisms involving iron and sulfur deposition in the mucosa secondary to either medication use or impeded clearance.4 Esophageal pseudomelanosis is rare with only case reports in the literature and no clear etiology; it has never been described to cause strictures or pseudoachalasia. Further studies are needed to evaluate esophageal pseudomelanosis and its clinical significance. DISCLOSURES Author contributions: All authors reviewed and approved the final manuscript. A. Jain: study concept and design, revision of the manuscript, and is the article guarantor. AG Issac: acquisition of data and drafting of the manuscript. W. Zheng: pathology image acquisition. Financial disclosure: None to report. Informed consent was obtained for this case report.

MP70-09 HIGH PRESSURE BALLOON DILATION FOR OBSTRUCTIVE MEGAURETER PATHOLOGIES IN THE PEDIATRIC PATIENT: STENT MIGRATIONS AND OTHER LESSONS LEARNED

You have accessJournal of UrologyCME1 Apr 2023MP70-09 HIGH PRESSURE BALLOON DILATION FOR OBSTRUCTIVE MEGAURETER PATHOLOGIES IN THE PEDIATRIC PATIENT: STENT MIGRATIONS AND OTHER LESSONS LEARNED Timothy Boswell, Carol Davis-Dao, Kai-Wen Chuang, Heidi Stephany, Elias Wehbi, and Antoine Khoury Timothy BoswellTimothy Boswell More articles by this author , Carol Davis-DaoCarol Davis-Dao More articles by this author , Kai-Wen ChuangKai-Wen Chuang More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , Elias WehbiElias Wehbi More articles by this author , and Antoine KhouryAntoine Khoury More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: High pressure balloon dilation (HPBD) is a treatment option for obstructive pathologies at the ureterovesical junction (UVJ). While it is less invasive than open reimplant, little has been described regarding technical factors or stent migrations which may pose challenges to its successful completion. METHODS: All patients from a single institution who underwent HPBD between 2009 and May 2022 were retrospectively reviewed. Those with obstructive pathologies at the UVJ included primary obstructive megaureter, obstructed refluxing megaureter, and obstructive megaureter secondary to neurogenic bladder or posterior urethral valves. Patients with prior treatment at the UVJ including reimplantation or endoscopic injection were excluded. Following HPBD, each patient had two indwelling ureteral stents placed. Success rates, technical factors, and stent migrations were analyzed. RESULTS: A total of 42 patients and 43 ureters were treated for obstructive pathologies at the UVJ. Median age was 14 months (IQR 7 – 89). Thirty four patients (81%) had primary obstructive megaureter (one bilateral), 4 (9%) had obstructed refluxing megaureter, and 4 (9%) had obstructive megaureter with underlying neurogenic bladder or posterior urethral valves. With a median follow-up of 2.4 years (IQR 1.7 – 3.8), 34 (79%) ureters were successfully managed endoscopically and did not require subsequent open surgery. Eight (19%) required reimplant and 1 (2%) diverting ureterostomy. Operative notes did not describe procedural difficulty in 19 (44%) cases; the remainder referenced narrow stenosis making cannulation difficult, and/or difficulty passing wires and stents up tortuous ureters. Four (10%) patients had intraoperative proximal stent migration, which was recognized permitting immediate repositioning of the stents. Five (12%) patients experienced postoperative stent migrations (3 of both stents, 2 of one stent). Ten (24%) patients required an additional anesthetic to complete HPBD after passive dilation by a stent (n=7) or repeat dilation due to double stent migration (n=3). All 3 patients who experienced postoperative migration of both stents required open surgery due to progressive hydroureteronephrosis. CONCLUSIONS: Approximately 80% of obstructive pathologies at the UVJ can be managed endoscopically with HPBD. Surgeons should be prepared to address the tight stenosis and tortuous megaureter that can pose a challenge to the endoscopic approach and may predispose to ureteral stent migration. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1007 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy Boswell More articles by this author Carol Davis-Dao More articles by this author Kai-Wen Chuang More articles by this author Heidi Stephany More articles by this author Elias Wehbi More articles by this author Antoine Khoury More articles by this author Expand All Advertisement PDF downloadLoading ...

P669 Improving Crohn’s disease stricture dilation outcome: Effect of repeated dilation, needle knife stricturotomy, and ongoing active inflammation

Abstract Background Traditionally Crohn’s disease strictures have been treated by a single endoscopic balloon dilation (EBD), repeated only for obstructive symptom recurrence. We postulated that scheduled repeated EBD may result in greater dilation effect than a single EBD; and that needle-knife stricturotomy (NKSt) may be a valuable salvage intervention in patients with strictures. Methods In this prospective observational study, patients with endoscopically accessible and short (&amp;lt;5cm), symptomatic Crohn’s disease stricture were assessed clinically (using an Obstructive Symptom Score [OSS]) and by imaging (colonoscopy, MRI and IUS). All patients had drug treatment optimized to decrease inflammation. Patients were treated with 3 serial balloon dilatations each 3 weeks apart, single EBD, or needle-knife stricture incision. The primary endpoint was improved OSS at 6m. Secondary outcomes; ability to endoscopically pass the stricture, treatment failure / surgery, stricture morphology on imaging, and safety. Results Twenty-one consecutive patients were included in the analysis. Of these 17 (81%) were receiving treatment with a biologic therapy. Median stricture length at baseline was 20mm (IQR 20mm) and median estimated stricture diameter was 8mm (IQR 3mm). 18 (86%) had visible ulceration. Of the 21 patients 11 (52%) underwent more than one EBD, 5 (24%) had ≥1 NKSt and 5 (21%) underwent a single EBD. Four of the 21 patients (19%) strictures were passable before endoscopic treatment. All procedures were technically successful. 14/21 (67%) had improvement in OSS at 6m, including 8/11 (73%) with 3 serial EBD, 4/5 (80%) with NKSt and 2/5 (40%) patients undergoing a single EBD. Two patients required surgery. At 6m, 3/8 (38%) who had repeat dilations, 4/5 (80%) who had NKSt, and 2/5 (40%) having a single EBD had a passable stricture. All 4 patients with highly elevated stricture inflammation (stricture magnetic resonance index of activity [MaRIA] score ≥20) at the 6m MRI had a non-passable stricture at study endpoint, whilst 9/12 (75%) were passable when stricture MARIA was &amp;lt;20 (P=0.019). No major complications occurred. Conclusion Endoscopic stricture treatment was safe and technically successful in all patients with accessible Crohn’s disease strictures and was associated with symptom improvement in most. Progression to surgery in this symptomatic and advanced disease was low at 6m. The highest rates of symptom improvement were seen in patients who had NKSt. Lesser stricture inflammation on MRI was associated with a better outcome, suggesting that controlling inflammation is important in preventing stricture recurrence after dilation. NKSt should be considered when balloon dilation is not possible or has failed, as a salvage treatment alternative to surgery.

A Protocol for Managing Watery Eyes in Patients with Punctal Stenosis

Purpose • To elucidate all factors resulting in watery eyes in patients with punctal stenosis. • To treat these factors pre-operatively and post-operatively following a horizontal 3-snip punctoplasty to achieve surgical success. Methods: 77 consecutive cases presenting to a tertiary care oculoplastics centre with watery eyes due to punctal stenosis/ occlusion were included. The clinical type of stenois/occlusion was identified. Co-existing factors causing lacrimation and epiphora, besides punctal stenosis, were identified and treated preoperatively. All cases had a rectangular 3-snip punctoplasty followed by repeated punctal dilatation in clinic, weekly for one month, and then 2 monthly for 6 months. The anti-inflammatory therapy was continued post-operatively for 2-4 months. Results: All cases had severe watery eyes (Munk grade 4-5). 69 cases (89.6 %) cases were on steroid-antibiotic topical therapy for recurrent blepharitis, while 12 cases (15.7%) were on anti-glaucoma therapy. 58 cases (75.3%) had previously failed punctoplasty. Ocular surface inflammatory disease (OSD) was present in all 77 cases (100%) causing lacrimation. It was notably severe in cases with pinpoint punctae. Membranous punctal occlusion was more common in the elderly patients with less severe OSD. Repeated punctal dilatation was necessary to maintain punctal patency post-operatively, achieving success rate of 97.4%, and 100% patient satisfaction. Conclusion: Disturbed balance between tear production and its drainage exists in patients with watery eyes. A protocol is suggested to restore that balance in patients with punctal stenosis: • Thorough clinical assessment, identifying factors causing lacrimation and treating them pre-operatively. • Identifying lower lid margin pathology that may be contributing to epiphora besides punctal stenosis and correcting it simultaneously with punctoplasty. • Rectangular 3-snip punctoplasty should be the preferred surgical procedure as it maintains the structure and function of the punctum. • Repeated punctal dilatation post-operatively and continued topical anti-inflammatory therapy to avoid punctal re-stenosis. • Patient education regarding recurrent nature of OSD and its early treatment to prevent punctal re-stenosis

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

S2259 The Efficacy and Safety of Treatment Outcomes for Refractory Benign Esophageal Strictures Using a Novel Combination of Needle-Knife Stricturoplasty, Balloon Dilation, and Steroid Injection

Introduction: Benign esophageal strictures that are refractory to standard endoscopic techniques can significantly impair a patient’s quality of life leading to complications such as malnutrition and weight loss. When repeat dilations fail to achieve an adequate luminal diameter or resolve dysphagia, further therapy with needle knife or steroid injections are needed. However, patients can still clinically fail. In an effort to manage such strictures we employed a novel triple combination of needle-knife stricturoplasty, balloon dilation, and steroid injection to assess clinical outcomes and safety. Case Description/Methods: This was a single center retrospective study of all adult patients with benign strictures that were refractory to conventional endoscopic therapy and removable self-expanding metal stenting. The triple therapy consisted of at least 4 longitudinal needle knife incision followed by balloon dilation and then targeted 4 quadrant intralesional steroid injections (Figure). Primary success was defined as a 50% reduction in repeat endoscopic therapy needed. Secondary outcomes included periodic dilation index, esophageal diameter changes, technical success, and complications. Four patients (average age 49.7 years, average body mass index 22.8 kg/m2) underwent endoscopic therapy for complex benign strictures using our triple therapy technique (Table). Stricture etiologies included peptic strictures (n= 3) and an anastomotic stricture (n=1). All patients previously required esophageal stenting (range 1-3). There was 100% technical success rate with no adverse events. The average diameter of the esophagus before and after triple therapy was 4.2 ± 1.63 mm and 13 ± 1.36 mm, respectively. The periodic dilation index was 6.3 (range 12-2) before and 1.5 (range 5–0) after triple therapy. The mean length of follow up was 316 days (range 116-425). Discussion: Triple combination therapy may be useful in benign strictures that are refractory to standard techniques. We do recommend needle knife before dilation to enhance the efficacy of steroid injections. In light of our findings, this method should be considered when strictures are refractory after 2-3 dilation sessions and/or stent therapy. Larger studies are needed to validate these findings and identify predictive factors that can enhance clinical success using this novel combination.Figure 1.: Esophageal stricture (A) that was treated with needle knife (B), balloon dilation (C) and then steroid injections (D). Table 1. - Patient characteristics and clinical outcomes Patient Age/Sex Stricture Etiology Initial stricture diameter Stricture diameter after triple therapy Number of triple therapy procedures Length of follow up (days) 1 30/Male GERD 7 mm 13.5 mm 1 425 2 59/Male Anastomotic 3 mm 15 mm 2 421 3 57/Male GERD 3 mm 11.5 mm 4 304 4 53/Male GERD 4 mm 12 mm 2 116

S2417 A Diagnosis That Is Difficult to Swallow: Digging Deeper for Answers

Introduction: Esophageal parakeratosis (EP) is an uncommon finding with largely unknown clinical implications and malignant potential. Here, we report a case of severe esophageal parakeratosis. Case Description/Methods: Patient is a 69-year-old African American male with history significant alcohol and cocaine abuse, prior tobacco abuse, keloids, gastroesophageal reflux, food impaction, and progressive dysphagia for 20 years with 40-pound weight loss. Patient’s first esophagogastroduodenoscopy (EGD) in 2000 revealed moderate esophagitis and a distal esophageal stricture with 9 mm lumen bougie dilated to 12 mm, but dysphagia persisted. Repeat EGDs between 2006 and 2016 showed whitish plaques with no evidence of fungal organisms. Given classic appearance of EOE, he was trialed on empiric fluticasone and budesonide with no improvement in dysphagia. In September 2021, he was hospitalized with severe dysphagia. EGD (Figure) at this time showed gray, yellow frondlike lesion replacing esophageal lumen from mid to distal esophagus with mucosal friability. His dysphagia transiently responded to repeat dilations, but continued to recur and worsen. Unfortunately, patient continued to have weight loss and dysphagia unresponsive to dilations. The patient was then started on gastric tube feedings. He was offered surgery due to the severity of his symptoms, but he declined. Most recently, the patient underwent endoscopic mucosal resection with deeper tissue samples revealing superficial fragments of laterally spreading squamous cell carcinoma of the esophagus. Discussion: In this case, there was a high clinical suspicion for malignancy, leading the endoscopist to obtain deeper tissue samples via endoscopic mucosal resection as superficial fragments of the esophagus only revealed parakeratosis. It is important to trust clinical judgment, especially if there is a high suspicion for malignancy. Tylosis also has a known association with EP and often presents with areas of thickened skin plaques on palms and feet. Tylosis has a strong association with head, neck, and esophageal squamous cell carcinoma. The patient had no family history of tylosis and no cutaneous features. Despite this, a careful inspection of the entire EP area with targeted biopsies should be obtained to evaluate for dysplasia. This case represents EP with years of no evidence of squamous cell cancer despite aggressively searching for it, which at least anecdotally suggests a precancerous potential for EP.Figure 1.: A. Initial EGD B. Recent EGD.

539. SURGICAL TECHNIQUES AND OUTCOMES OF GASTRIC CONDUIT RECONSTRUCTION FOLLOWING ESOPHAGECTOMY BY HAND-ASSISTED LAPAROSCOPIC SURGERY (HALS) FOR ESOPHAGEAL CANCER

Abstract After esophagectomy with reconstruction using a gastric conduit for esophageal cancer, anastomotic leak can cause serious complications and has a significant impact on the postoperative course. At our institution, gastric conduit reconstruction by hand-assisted laparoscopic surgery (HALS) is the first-line technique for reconstruction following esophagectomy due to its reliability and shortened operative time. In this study, we performed a retrospective review of the surgical outcomes. We reviewed characteristics and perioperative outcomes of 124 patients who underwent esophagectomy with gastric conduit reconstruction for esophageal cancer by HALS from February 2011 to December 2021. Surgical procedure: We created a gastric tube via the HALS incision. A 3-cm wide gastric tube was fashioned using the linear staplers. We mobilized and manually stretched the stomach to ensure the length of the gastric tube. Then the blood flow in the gastric tube was evaluated by ICG fluorescence method followed by esophagogastric anastomosis using a 25-mm circular stapler on the greater curvature side. Among the 124 patients, there were 99 males and 25 females with a median age of 70 years (range, 46 – 85 years). Neoadjuvant therapy was performed in 50 patients. The median operative time was 259 minutes (135-454 minutes). Complications related to the gastric conduit reconstruction included anastomotic leak in two patients (1.6%) and anastomotic stricture requiring dilatation in 39 patients (31.5%), of whom 15 (12.1%) underwent repeat dilatation. Gastric tube stenosis, gastric tube hemorrhage, and gastric tube-to-pulmonary fistula were also observed in one case each. In the present study, while the incidence of anastomotic leak was low (1.6%) in patients received HALS esophagectomy with gastric conduit reconstruction, almost one-third (31.5%) of the patients had anastomotic stricture and required dilatation.

Analysis of pupil size by repeat dilation at shrinkage stage.

To compare the pupil size of the original mydriasis and repeat mydriasis at the pupil shrinkage stage. Randomized prospective study. In total, 60 eyes of 30 patients aged 50-70 with age-related cataracts were included. Pupil sizes were measured by the Sirius system before mydriasis, after the first batch of mydriasis, and after the second batch of mydriasis which was 5h later. Statistical analysis was performed using MedCalc statistical software version 20.0.3 RESULTS: The pupil size of the second batch of mydriasis 5h later was smaller than the first batch of mydriasis (3.94 ± 0.88mm vs 5.12 ± 0.96mm, P < 0.0001). Less efficiency repeat mydriasis several hours later compared with original mydriasis in our study suggests that preparation of mydriasis at an appropriate time is necessary for ophthalmological operations. The effect of repeat mydriasis again by tropicamide at the shrinkage stage still needs to be explored.

The Surgical Management of Ileal Pouch Strictures.

Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA. This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm. A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed. Randomized controlled trials, cohort studies, observational studies, and case reports were considered. Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included. Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass. Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience. Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.

Safety and Efficacy of Graded Gradual Pneumatic Balloon Dilation in Idiopathic Achalasia Patients: A 24-Year Single-Center Experience.

Pneumatic balloon dilation (PBD) is a first line treatment for idiopathic achalasia. Here we report the safety and efficacy of graded gradual PBD on short and long-term follow-up. We evaluated 1370 idiopathic achalasia patients over a period of 24 years (1994-2018), prospectively. 216 patients did not undergo PBD due to comorbid diseases. Ultimately, 1092 achalasia patients were enrolled. All patients underwent graded gradual PBD, with repeat dilation if symptoms relapsed. Response to treatment was evaluated by Vantrappen scoring system. Of 1092 achalasia patients, 937 patients were treated by PBD and 155 patients were treated by combined therapy (PBD 1 month after Botulinum toxin injection). In short-term follow-up, 728 of 1092 patients underwent one PBD and 77.3% of them had excellent or good response (responders), 163 patients (58.6%) who underwent two PBDs were responders, and 44 (51.2%) patients who underwent three PBDs were responders. Overall, 2193 balloon dilations were performed on 1092 patients (mean 2 PBDs/patient). Of 786 patients with long-term follow-up, 259 patients had excellent or good response with one PBD. The responders with two, three, and four or more dilations were 149, 67, and 67, respectively. The overall response rate was 69%. No any serious complications were noted by using the graded gradual method. Our results show that graded gradual PBD is a safe and effective method for treatment of achalasia patients, and achieves sufficient short and long-term symptomatic remission with high cumulative success rate.

S1998 Two Scopes Are Better Than One: Esophageal Recanalization With the Rendezvous Procedure

Introduction: Esophageal strictures can occur in patients with head & neck cancers treated with radiotherapy. Rate of stricture in these cases is estimated to be between 2-16%. We present a case of severe esophageal stricture treated with combined antegrade-retrograde endoscopic dilation and biliary stent placement. Case Description/Methods: 76-year-old female with squamous cell carcinoma of the hypopharynx, with PEG tube for nutrition, presented with persistent dysphagia following completion of radiotherapy. Barium esophagram showed severe pharyngeal dysphagia with esophageal backflow and aspiration. Laryngoscopy and transnasal esophagoscopy revealed a blind ending pouch in the proximal esophagus. After unsuccessful attempts to pass a guidewire through the stenosis under direct visualization, we were consulted to discuss a combined approach. Rendezvous recanalization with access through both the mouth and gastrostomy site was planned. An endoscope was passed through the mouth to the level of the esophagus, revealing severe stenosis with complete obstruction in the hypopharynx. Under fluoroscopic guidance, we attempted to advance a guidewire through the stenosis, but were unsuccessful. An endoscope was then reintroduced through the mature gastrostomy. The scope was advanced to the esophageal stricture in retrograde. A transnasal esophagoscope was used through the mouth for antegrade access. From the retrograde endoscope, a guidewire was passed through the stenosis and captured through the mouth. Under fluoroscopy, a 6-7-8mm x 5.5cm CRE balloon dilator was passed over guidewire through the mouth, and dilation was performed to 6mm. We decided to use a biliary stent given the location of the stricture in the hypopharynx where placement of a larger esophageal stent is not feasible and would cause severe discomfort given the larger diameter. A 10mm x 60mm WallFlex biliary stent was successfully deployed across the stenosis. After repeat dilation was performed twice more 2 weeks apart, her esophagus remains patent at 18mm. On latest follow-up, she is able to tolerate PO liquids and pureed food. Discussion: High-grade stenosis is difficult to treat, often requiring a multidisciplinary approach. In cases of high-grade esophageal stenosis, an antegrade-retrograde endoscopic approach can be employed to dilate the esophageal segment. Recent meta-analysis shows esophageal recanalization using the rendezvous procedure to have a technical success rate >85%, dysphagia improvement rate >55%, and PEG-tube free rate >40%.Figure 1.: Endoscopic view of esophageal stricture (a), fluoroscopic image of antegrade and retrograde scope with wire passing through the stricture (b), endoscopic view of biliary stent in place (c), fluoroscopic image of biliary stent in place (d). Watch the video at https://bit.ly/3eNvMxi.

Defining the Long-Term Clinical Course and Need for Repeat Dilation for Patients With Schatzki Rings

Schatzki rings (SRs) are a well-known cause of intermittent solid-food dysphagia.1 Although some patients sustain improvement after 1 endoscopic dilation, others require repeated dilations for recurrent symptoms.2-4 SRs are believed to be distinct from strictures caused by gastroesophageal reflux disease. SRs are sharply localized lesions with clearly defined margins, whereas peptic strictures have a more gradual transition between normal and abnormal esophagus to produce a funnel-shaped narrowing.5,6 Consequently, it has been assumed that repeat dilation is less common in SRs dissimilar from medically untreated peptic strictures. The study aim was to identify clinical and radiologic predictors for repeated esophageal dilations in patients with SRs and to assess if peptic stricture-like characteristics of rings correspond to need for repeat dilation.

Usefulness of Fluoroscopy for Endoscopic Balloon Dilation of Crohn's Disease-Related Strictures.

Fluoroscopy is often used for endoscopic balloon dilation (EBD) of Crohn's disease (CD)-related strictures. However, its benefit remains unclear. To compare EBD with (EBDF) and without (EBDNF) fluoroscopic guidance in CD patients with strictures. Single-center, nested, case-control retrospective study of EBD for CD-related strictures. Technical and clinical success and safety outcomes were compared between EBDF and EBDNF. A total of 122 strictures in 114 CD patients who underwent EBD from 2010 to 2018 at a single institution were reviewed (44 patients EBDF vs. 70 EBDNF). Esophagogastroduodenoscopy was the approach in 8 strictures, colonoscopy in 86, and deep enteroscopy in 28. There were no significant differences in the rates of technical and clinical success, need for repeat dilation and surgery between the two groups, although the mean maximal endoscopic balloon diameter was larger in the EBDNF group (17.1 ± 1.9 vs. 14.1 ± 2.5; p < 0.001). There was one perforation in EBDF and no serious complications in EBDNF. In multivariate analysis, balloon size < 15mm (odds ratio [OR] 6.388; 95% CI 1.96-20.79; p = 0.002) and multiple strictures (OR 3.897; 95% CI 1.09-14.01; p = 0.037) were associated with repeat EBD, and age < 50years (OR 7.178; 95% CI 1.38-37.44; p = 0.019) and small bowel (vs. colon) location (OR 7.525; 95% CI 1.51-37.47; p = 0.014) were associated with the need for surgery after EBD. EBD for CD-related strictures can be performed safely and effectively without fluoroscopic guidance. Balloon size, patient age, stricture location, and multiplicity are associated with clinical success and avoidance of surgery.