Asunto(s)

Anastomosis Quirúrgica , Endosonografía , Humanos , Masculino , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Constricción Patológica/cirugía , Constricción Patológica/etiología , Endosonografía/métodos , Estenosis Esofágica/cirugía , Estenosis Esofágica/etiología , Esófago/cirugía , Esófago/diagnóstico por imagen , Yeyunostomía/métodos , Yeyuno/cirugía , Ultrasonografía Intervencional

RESUMEN

Anastomotic stricture is a typical complication of esophageal atresia surgery. Remote ischemic conditioning (RIC) has demonstrated multiorgan benefits, however, its efficacy in the esophagus remains unclear. This study aimed to investigate whether applying RIC after esophageal resection and anastomosis in rats could attenuate esophageal stricture and improve inflammation. Sixty-five male Sprague-Dawley rats were categorized into the following groups: controls with no surgery, resection and anastomosis only, resection and anastomosis with RIC once, and resection and anastomosis with RIC twice. RIC included three cycles of hind-limb ischemia followed by reperfusion. Inflammatory markers associated with the interleukin 6/Janus kinase/ signal transducer and activator of transcription 3 (IL-6/JAK/STAT3) and tumor necrosis factor-alpha/nuclear factor-κB (TNF-α/NF-kB) signaling pathways were evaluated with RNA and protein works. The RIC groups showed significantly lower stricture rates, lower inflammatory markers levels than the resection and anastomosis-only group. The RIC groups had significantly lower IL-6 and TNFa levels than the resection and anastomosis-only group, confirming the inhibitory role of remote ischemic conditioning in the IL-6/JAK/STAT3 and TNF-α/NF-kB signaling pathways. RIC after esophageal resection and anastomosis can reduce the inflammatory response, improving strictures at the esophageal anastomosis site, to be a novel noninvasive intervention for reducing esophageal anastomotic strictures.

Asunto(s)

Anastomosis Quirúrgica , Modelos Animales de Enfermedad , Estenosis Esofágica , Precondicionamiento Isquémico , Ratas Sprague-Dawley , Factor de Transcripción STAT3 , Animales , Masculino , Ratas , Precondicionamiento Isquémico/métodos , Estenosis Esofágica/etiología , Estenosis Esofágica/prevención & control , Factor de Transcripción STAT3/metabolismo , FN-kappa B/metabolismo , Interleucina-6/metabolismo , Interleucina-6/sangre , Transducción de Señal , Esófago/cirugía , Factor de Necrosis Tumoral alfa/metabolismo , Factor de Necrosis Tumoral alfa/sangre , Quinasas Janus/metabolismo

RESUMEN

BACKGROUND/AIMS:  There is a lack of effective and safe methods for preventing esophageal stricture after large endoscopic submucosal dissection (ESD) in patients with superficial esophageal cancer. We aimed to compare the effectiveness of oral prednisolone alone versus a combination of oral prednisolone and nasogastric tube in preventing esophageal stricture following extensive ESD. MATERIALS AND METHODS:  We retrospectively gathered clinical data from a single center on patients with early esophageal cancer who underwent ESD. Patients were categorized into 2 groups: the steroid group (receiving only oral prednisolone) and the steroid+nasogastric tube retention (NGT) group. We analyzed the incidence of esophageal stricture and identified risk factors for its development. RESULTS:  The study included 79 patients, with 30 in the steroid group and 49 in the steroid+NGT group. The incidence of stricture was significantly higher in the steroid group (9/30, 30.0%) compared to the steroid+NGT group (3/49, 6.1%) (P = .004). Notably, we observed a significant difference in the stricture rates between the 2 groups, particularly in patients with a complete circumferential defect (100% and 16.7%) (P = .015). Multivariate logistic regression analysis revealed that a full circumferential defect of the esophageal mucosa (OR 12.501; 95% CI 1.907, 81.047; P = .008), invasion depth beyond the lamina propria (OR 5.635; 95% CI 1.039, 30.559; P = .045), and the absence of NGT retention (OR 12.896; 95% CI 2.099, 79.219; P = .006) were independent risk factors predicting the development of a stricture. CONCLUSION:  The combination of steroids with NGT retention is more effective than using oral steroids alone in preventing esophageal stricture after extensive ESD.

Asunto(s)

Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Estenosis Esofágica , Intubación Gastrointestinal , Prednisolona , Humanos , Estenosis Esofágica/prevención & control , Estenosis Esofágica/etiología , Masculino , Femenino , Neoplasias Esofágicas/cirugía , Prednisolona/administración & dosificación , Estudios Retrospectivos , Resección Endoscópica de la Mucosa/efectos adversos , Resección Endoscópica de la Mucosa/métodos , Persona de Mediana Edad , Anciano , Intubación Gastrointestinal/métodos , Administración Oral , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Resultado del Tratamiento , Incidencia , Modelos Logísticos

Asunto(s)

Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Estenosis Esofágica , Humanos , Resección Endoscópica de la Mucosa/efectos adversos , Resección Endoscópica de la Mucosa/métodos , Estenosis Esofágica/etiología , Factores de Riesgo , Neoplasias Esofágicas/cirugía , Complicaciones Posoperatorias/etiología

RESUMEN

BACKGROUND: Ganglioneuromatosis is a rare type of benign neurogenic tumor that usually affects the sites of the major sympathetic ganglia in the retroperitoneum and the posterior mediastinum. Affection of the gastrointestinal tract is rare, and involvement of the esophagus is exceptional. To the best of our knowledge, only 4 cases of esophageal ganglioneuromatosis in adults were reported in the literature. No cases have been reported in the pediatric age group. CASE PRESENTATION: An 11-year-old boy presented with dysphagia due to severe esophageal stenosis caused by esophageal ganglioneuromatosis. CONCLUSIONS: Despite its rarity, the present case implies that ganglioneuromatosis should be considered in children with idiopathic esophageal stenosis.

Asunto(s)

Neoplasias Esofágicas , Estenosis Esofágica , Ganglioneuroma , Humanos , Masculino , Niño , Ganglioneuroma/complicaciones , Ganglioneuroma/diagnóstico , Estenosis Esofágica/etiología , Neoplasias Esofágicas/complicaciones , Neoplasias Esofágicas/diagnóstico , Trastornos de Deglución/etiología

RESUMEN

INTRODUCTION: esophageal replacement in children is indicated when it is impossible to maintain the native esophagus, which in the pediatric population includes patients with esophageal atresia and esophageal caustic stenosis. The objective of this communication is to report the experience of a university service with two techniques of esophageal replacement. METHODS: this is a retrospective study based on the revision of hospital files. The study population consisted of patients who underwent esophageal replacement from 1995 to 2022, at the Hospital de Clínicas of the State University of Campinas. The analyzed data were age, sex, underlying disease, technical aspects, complications, and long-term results. RESULTS: during the study period, 30 patients underwent esophageal replacement. The most common underlying diseases were esophageal atresia (73.33%) and caustic stenosis (26.67%). Twenty-one patients underwent gastric transposition (70%), and nine underwent esophagocoloplasty (30%). The most frequent postoperative complication was fistula of the proximal anastomosis, which occurred in 14 patients. Most of the patients with fistulas had a spontaneous recovery. There were three deaths. Of the 27 survivors, 24 can feed exclusively by mouth. CONCLUSION: esophageal replacement in children is a procedure with high morbidity and mortality. Esophagocoloplasty and gastric transposition have similar results and complications, with the exception of proximal anastomotic fistulas, which are generally self-resolving and are more common in esophagocoloplasty. The choice of the best surgical technique must be individualized according to the patients characteristics and the surgeons experience, as both techniques offer the ability to feed orally in the short or medium term.

Asunto(s)

Atresia Esofágica , Estenosis Esofágica , Hospitales Universitarios , Humanos , Estudios Retrospectivos , Femenino , Masculino , Niño , Preescolar , Lactante , Atresia Esofágica/cirugía , Estenosis Esofágica/cirugía , Estenosis Esofágica/etiología , Adolescente , Esófago/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Esofagoplastia/métodos , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: The aim of this study was to assess the risk factors for anastomotic stricture in esophageal cancer patients undergoing esophagectomy. Esophageal anastomotic stricture is the most common long-term complication for esophagectomy. The risk factors for esophageal anastomotic stricture still remain controversial. METHODS: MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for esophageal anastomotic stricture after esophagectomy. A meta-analysis was conducted to investigate the impact of various risk factors on esophageal anastomotic stricture. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels. RESULTS: This review included 14 studies evaluating 5987 patients.The meta-analysis found that anastomotic leakage (odds ratio [OR]: 2.75; 95% confidence interval[CI]:2.16-3.49), cardiovascular disease [OR:1.62; 95% CI: 1.22-2.16],diabete [OR: 1.62; 95% CI: 1.20-2.19] may be risk factors for esophageal anastomotic stricture.There were no association between neoadjuvant therapy [OR: 0.78; 95% CI:0.62-0.97], wide gastric conduit [OR:0.98; 95% CI: 0.37-2.56],mechanical anastomosis [OR: 0.84; 95% CI:0.47-1.48],colonic interposition[OR:0.20; 95% CI: 0.12-0.35],and transhiatal approach[OR:1.16; 95% CI:0.81-1.64],with the risk of esophageal anastomotic stricture. CONCLUSIONS: This meta-analysis provides some evidence that anastomotic leakage,cardiovascular disease and diabete may be associated with higher rates of esophageal anastomotic stricture.Knowledge about those risk factors may influence treatment and procedure-related decisions,and possibly reduce the anastomotic stricture rate.

Asunto(s)

Anastomosis Quirúrgica , Neoplasias Esofágicas , Estenosis Esofágica , Esofagectomía , Humanos , Esofagectomía/efectos adversos , Factores de Riesgo , Estenosis Esofágica/etiología , Estenosis Esofágica/epidemiología , Anastomosis Quirúrgica/efectos adversos , Neoplasias Esofágicas/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Fuga Anastomótica/etiología , Fuga Anastomótica/epidemiología , Oportunidad Relativa

RESUMEN

Endoscopic submucosal dissection (ESD) is the gold-standard surgical procedure for superficial esophageal cancer. A significant and challenging complication of this technique is post-ESD esophageal stricture. In this study, the feasibility of endoscopic catheter delivery of bioadhesive to esophageal lesions in a porcine model was tested. Injectable bioadhesive was composed of oxidized dextran (ODA) and chitosan hydrochloride (CS), its physicochemical properties, injectability, antibacterial activity, and cytocompatibility were investigated beforein vivotest. ODA-CS bioadhesive was delivered to the wound bed of the esophageal tissue using a custom-made catheter device after ESD in a porcine model. Our results show that the ODA-CS bioadhesive is of good injectability, tissue adhesive strength, antibacterial capacity, and blood compatibility.In vivodelivery was achieved by endoscopic spraying of ODA and CS in separate catheters fixed on the endoscopic probe. ODA and CS can be mixed well to allow in situ bioadhesive formation and firmly adhere to the esophageal wound surface. After two weeks, the bioadhesive maintained structural integrity and adhered to the surface of esophageal wounds. However, histological analysis reveals that the ODA-CS bioadhesive did not show improvement in attenuating inflammatory response after ESD. This pilot study demonstrates the feasibility of ODA-CS bioadhesive for shielding esophageal wounds after ESD, whereas efforts need to improve its anti-inflammatory activity to reduce fibrosis for stricture prevention.

Asunto(s)

Quitosano , Dextranos , Esófago , Adhesivos Tisulares , Animales , Proyectos Piloto , Porcinos , Quitosano/química , Adhesivos Tisulares/química , Dextranos/química , Ensayo de Materiales , Materiales Biocompatibles/química , Inyecciones , Resección Endoscópica de la Mucosa/métodos , Neoplasias Esofágicas/cirugía , Cicatrización de Heridas/efectos de los fármacos , Estenosis Esofágica

RESUMEN

OBJECTIVE: To analyze the efficacy of intralesional steroid treatment in refractory caustic esophageal stricture. MATERIALS AND METHODS: An analytical, retrospective study of patients receiving intralesional steroid treatment with triamcinolone acetonide as a result of refractory caustic esophageal stricture was carried out. Demographic variables, stricture characteristics, number of dilations, steroid injections, and dilation score (no. of dilations/follow-up period in months) pre- and post-treatment were collected. Stricture characteristics (diameter and length) and dilation score pre- and post-treatment were compared using the T-Test or Wilcoxon test. RESULTS: N= 5. Median age: 5 years (17 months-7 years). Follow-up: 6.60 ± 2.70 years. Swallowed products included NaOH, KOH, and ClH. Zargar classification at follow-up initiation was IIb (n= 2), IIIa (n= 1), and two chronic strictures. 6.6 ± 9.23 esophageal dilations were carried out before steroid treatment initiation. The mean number of intralesional therapy sessions was 11.20 ± 6.14. Stricture length decreased by 3.60 ± 2.63 cm (t= 3.06; p= 0.019). No differences were found in terms of diameter increase: -1.60 ± 3.58 mm (t= -1.00; p= 0.187). The dilation score diminished from 1.47 ± 0.86 to 0.47 ± 0.18 dilations per month of follow-up (Z= -2.02; p= 0.043). CONCLUSIONS: Even though there is limited evidence available in the pediatric population, intralesional triamcinolone treatment is seemingly useful in the treatment of refractory caustic esophageal stricture, since it reduces length and dilation score.

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OBJETIVO: Analizar la eficacia del tratamiento intralesional con corticosteroide en estenosis esofágicas cáusticas refractarias. MATERIAL Y METODOS: Estudio analítico y retrospectivo de pacientes tratados con corticosteroide intralesional (triamcinolona acetónido) por estenosis esofágicas cáusticas refractarias. Se recogieron variables demográficas, características de la estenosis, número de dilataciones, inyecciones de corticosteroide e índice de dilatación (nº dilataciones/periodo de seguimiento en meses) pre y post tratamiento. Se compararon las características de la estenosis (diámetro y longitud) e índice de dilatación pre y post tratamiento con T-Test o Test de Wilcoxon. RESULTADOS: N= 5. Edad mediana 5 años (17 meses-7años) y seguimiento de 6,60 ± 2,70 años. Los productos ingeridos fueron NaOH, KOH y ClH. La clasificación de Zargar al inicio del seguimiento fue IIb (n= 2), IIIa (n= 1) y dos estenosis crónicas. Se realizaron 6,6 ± 9,23 dilataciones esofágicas previas al tratamiento con corticosteroide. El número de sesiones de terapia intralesional promedio fue 11,20 ± 6,14. La longitud de la estenosis mostró una reducción de 3,60 ± 2,63 cm (t= 3,06 ; p= 0,019). No encontramos diferencias en el incremento del diámetro: ­1,60 ± 3,58 mm (t= ­1,00 ; p= 0,187). El índice de dilatación se redujo de 1,47 ± 0,86 a 0,47 ± 0,18 dilataciones por mes de seguimiento (Z= ­2,02 ; p= 0,043). CONCLUSIONES: Aunque la evidencia disponible en población pediátrica es limitada, la terapia con triamcinolona intralesional parece ser útil en el tratamiento de estenosis esofágicas cáusticas refractarias, al reducir su longitud y el índice de dilatación.

Asunto(s)

Quemaduras Químicas , Cáusticos , Dilatación , Estenosis Esofágica , Inyecciones Intralesiones , Triamcinolona Acetonida , Humanos , Estenosis Esofágica/inducido químicamente , Estenosis Esofágica/tratamiento farmacológico , Estudios Retrospectivos , Preescolar , Quemaduras Químicas/tratamiento farmacológico , Quemaduras Químicas/complicaciones , Masculino , Niño , Triamcinolona Acetonida/administración & dosificación , Cáusticos/toxicidad , Femenino , Lactante , Estudios de Seguimiento , Dilatación/métodos , Resultado del Tratamiento , Glucocorticoides/administración & dosificación

RESUMEN

BACKGROUND: This study aimed to investigate the utility of intensive triamcinolone acetonide (TA) injections after extensive esophageal endoscopic submucosal dissection (ESD). METHODS: This retrospective study included 27 lesions in 27 consecutive patients who underwent ESD (ulcers encompassing ≥3/4 of the esophageal circumference) and received TA injections without oral steroid administration. Groups A and B included patients undergoing ESD with and without complete circumferential resection, respectively. All patients received TA injections (100 mg/session) immediately after ESD. In Group A, weekly based TA injections were performed until near-complete ulcer epithelialization. In Group B, patients did not receive additional injections or received weekly or biweekly TA injections. The primary outcome was stricture rate, and the secondary outcomes were the proportion of patients requiring endoscopic balloon dilation (EBD) and the number of TA injections. RESULTS: Group A included 7 lesions, and Group B included 20 lesions. The median (range) tumor lengths were 40 (30-90) and 45 (30-110) mm in Groups A and B, respectively. In Group A, the median circumferential resection diameter was 40 (20-80) mm. The stricture rate and the proportion of patients requiring EBD were 0 (0%) in Group A and 1 (5.0%) in Group B. The number of TA injection sessions was significantly higher in Group A than in Group B (8 [5-25] vs 1.5 [1-3]; p < 0.001). CONCLUSIONS: Intensive weekly or biweekly based TA injections might aid in preventing post-ESD stricture and the need for EBD in patients undergoing extensive resection involving the entire esophageal circumference.

Asunto(s)

Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Estenosis Esofágica , Triamcinolona Acetonida , Humanos , Triamcinolona Acetonida/administración & dosificación , Masculino , Femenino , Estudios Retrospectivos , Resección Endoscópica de la Mucosa/efectos adversos , Anciano , Persona de Mediana Edad , Neoplasias Esofágicas/cirugía , Estenosis Esofágica/prevención & control , Estenosis Esofágica/etiología , Anciano de 80 o más Años , Esofagoscopía , Complicaciones Posoperatorias/prevención & control , Resultado del Tratamiento , Glucocorticoides/administración & dosificación , Dilatación/métodos

RESUMEN

Eosinophilic esophagitis (EoE) is an increasingly prevalent immune-mediated disease that leads to chronic changes in the oesophagus. These changes can include strictures, narrowing, and stenosis, mediated by an interleukin (IL)-13 pathway, which leads to remodelling and fibrosis through increasing migration of fibroblasts and subepithelial fibrosis via collagen deposition 1. IL-13 downregulates TSPAN12, a gene whose expression regulates fibrosis and causes changes in barrier function and higher rates of fibrostenosis in EoE. Dupilumab, a biologic therapy aimed at blocking IL-13, has been shown to improve EoE-related inflammation and fibrosis in clinical trials. We report here four unique patients with documented oesophageal stenosis with inability to pass a paediatric endoscope due to structuring disease, requiring dilation, who had resolution of their oesophageal narrowing following dupilumab therapy.

Asunto(s)

Anticuerpos Monoclonales Humanizados , Esofagitis Eosinofílica , Humanos , Esofagitis Eosinofílica/tratamiento farmacológico , Esofagitis Eosinofílica/patología , Anticuerpos Monoclonales Humanizados/uso terapéutico , Anticuerpos Monoclonales Humanizados/farmacología , Masculino , Femenino , Niño , Fibrosis , Resultado del Tratamiento , Estenosis Esofágica/tratamiento farmacológico , Estenosis Esofágica/patología , Preescolar , Adolescente

RESUMEN

BACKGROUND: Children who experience alkaline injury are at risk for the development of esophageal strictures and the need for esophageal dilations. OBJECTIVE: We aimed to assess predictors for a higher number of esophageal dilatations in children following alkali ingestion. METHODS: Single-center retrospective cohort study including children who underwent esophagogastroduodenoscopy (EGD) after alkali ingestion. Possible predictive factors for the need for esophageal dilatations were evaluated. RESULTS: A total of 34 patients were included, and 19 were female (55.9%). The median age at the time of the accidents was 20.6 months (IQR 15-30.7). All alkali ingestions were accidental, in all cases involving liquid products, and most (24/34; 70%) occurred at the child's home. Homemade liquid soap was the agent in half of the cases. The most frequently reported symptom at presentation was vomiting (22/34, 64.7%). The median follow-up time was 3.2 years (IQR 1.1-7.4). On follow-up, the median number of esophageal dilatations required for these patients was 12.5 (IQR 0-34). Among demographic factors, male gender (P=0.04), ingestion of homemade products (P<0.01), and accidents happening outside of the household environment (P=0.02) were associated with a greater number of esophageal dilations on follow-up. An endoscopic classification Zargar of 2B or higher (P=0.03), the presence of stricture at the time of the second EGD (P=0.01), and gastroesophageal reflux disease (GERD) as a late complication (P=0.01) were also associated with a greater number of esophageal dilations on long term follow-up. CONCLUSION: Beyond the endoscopic classification severity - a well-known risk factor for the strictures after alkali ingestions, we found that male gender, accidents with homemade products, and accidents occurring outside the household environment were significantly associated with a greater number of esophageal dilatations in the long-term follow-up of children following alkali ingestion.

Asunto(s)

Álcalis , Quemaduras Químicas , Estenosis Esofágica , Humanos , Femenino , Masculino , Estudios Retrospectivos , Estenosis Esofágica/inducido químicamente , Preescolar , Álcalis/efectos adversos , Lactante , Quemaduras Químicas/etiología , Dilatación , Endoscopía del Sistema Digestivo , Factores de Riesgo , Cáusticos/envenenamiento

RESUMEN

INTRODUCTION: Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05. RESULTS: During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001). CONCLUSION: Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.

Asunto(s)

Bases de Datos Factuales , Vigilancia de Productos Comercializados , Falla de Prótesis , Stents Metálicos Autoexpandibles , United States Food and Drug Administration , Humanos , Stents Metálicos Autoexpandibles/efectos adversos , Estados Unidos/epidemiología , Estenosis Esofágica/etiología , Estenosis Esofágica/terapia

RESUMEN

An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.

Asunto(s)

Dilatación , Estenosis Esofágica , Esofagoscopía , Humanos , Estenosis Esofágica/terapia , Estenosis Esofágica/cirugía , Estenosis Esofágica/etiología , Esofagoscopía/instrumentación , Dilatación/métodos , Stents , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Trastornos de Deglución/fisiopatología , Trastornos de Deglución/cirugía , Cuidados Paliativos , Neoplasias Esofágicas/complicaciones , Neoplasias Esofágicas/cirugía , Neoplasias Esofágicas/terapia , Resultado del Tratamiento , Algoritmos

RESUMEN

A man in his late 50s presented with severe dysphagia caused by a complex refractory benign stenosis that was completely obstructing the middle oesophagus. The patient was unsatisfied with the gastrostomy tube placed via laparotomy as a long-term solution. Therefore, we performed robot-assisted minimally invasive oesophagectomy (video). Mobilisation of the stomach and gastric conduit preparation were more difficult due to the previously inserted gastrostomy tube; thus, the conduit blood supply was assessed using indocyanine green fluorescence. After an uncomplicated course, the patient was referred directly to inpatient rehabilitation on the 16th postoperative day. At 9 months after surgery, the motivated patient returned to full-time work and achieved level 7 on the functional oral intake scale (total oral diet, with no restrictions). At the 1-year follow-up, he positively confirmed all nine key elements of a good quality of life after oesophagectomy.

Asunto(s)

Esofagectomía , Gastrostomía , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Esofagectomía/métodos , Gastrostomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Persona de Mediana Edad , Estenosis Esofágica/cirugía , Estenosis Esofágica/etiología , Trastornos de Deglución/etiología , Calidad de Vida , Resultado del Tratamiento

RESUMEN

BACKGROUND: Patients with benign esophageal strictures may not maintain a response to endoscopic dilation, stenting, incisional or injectional therapies. For patients with these refractory esophageal strictures, esophageal self-dilation therapy (ESDT), performed to maintain luminal patency, may provide persistent symptomatic benefit while reducing patients' reliance on healthcare services and the risk associated with repeated endoscopic procedures. AIMS: The aim of this study was to evaluate the efficacy and safety of EDST in a randomized controlled trial and prospective observational study. METHODS: Twenty-five patients with refractory benign esophageal strictures were recruited at two esophageal clinics between November 2018 and June 2021. Twelve patients participated in the randomized trial and 13 in the prospective observational study. The number of endoscopic dilations, impact of therapy on dysphagia, adverse events, and complications were recorded. RESULTS: In the randomized study, 50% of patients performing ESDT and 100% of controls required endoscopic dilation during follow-up (P = 0.02). In the observational study, the median (IQR) number of endoscopic dilations fell from 7 [7-10] in the 6 months prior to commencing ESDT to 1 [0-2] in the 6 months after (P < 0.0001). Most patients (22/25) were able to learn self-dilation. Few serious adverse events were noted. Dysphagia severity remained unchanged or improved. CONCLUSIONS: ESDT appears to be a safe effective therapy for benign esophageal strictures refractory to endoscopic treatment. CLINICAL TRIAL NUMBER: NCT03738566.

Asunto(s)

Dilatación , Estenosis Esofágica , Humanos , Estenosis Esofágica/terapia , Estenosis Esofágica/etiología , Masculino , Femenino , Persona de Mediana Edad , Dilatación/métodos , Estudios Prospectivos , Anciano , Resultado del Tratamiento , Esofagoscopía/métodos , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Autocuidado/métodos , Adulto

RESUMEN

A 3-month-old and a 4-year-old cat were presented in the clinic due to regurgitation. The kitten had displayed the symptoms since it had been fed solid foods and was smaller than the litter mates. The 4-year-old cat showed sudden-onset symptoms for 5 days prior to presentation and had a good general condition. Positive contrast thoracic radiographs of both cats in lateral recumbency showed an esophageal dilatation cranial to the heart base and raised a suspicion of foreign material with soft tissue density in this area. In the 4-year-old cat, findings of ventrodorsal thoracic radiographs were compatible with a dextroposition of the aorta and a slightly marked focal left curve of the trachea. The echocardiographic examination of the kitten pictured a right sided aorta, hence a vascular ring anomaly with a dextroposition from the aorta was suspected. Aberrant blood flow as it is seen in a persistent ductus arteriosus was not apparent in the echocardiography. As a result of the sudden development of the clinical signs in the older cat without displaying any former history of regurgitation, an esophagoscopy was performed to exclude an intraluminal esophageal cause for the stricture as well as to extract the foreign material. In this cat, computed tomography imaging also displayed an aberrant left subclavian artery. Both cats recovered well after surgical correction.The diagnosis of a ring anomaly in the kitten via echocardiography is a rare situation. As is the diagnosis of a high-grade esophageal stricture due to a vascular ring anomaly at the age of 4 without a former history of regurgitation.Recovery was excellent in the younger cat. There were no signs of regurgitation 6 months after surgery. The adult cat was in good general condition without clinical symptoms according to the owners when presented for stitch removal. Unfortunately, the adult cat was lost to follow up.

Asunto(s)

Aorta Torácica , Enfermedades de los Gatos , Estenosis Esofágica , Animales , Gatos , Aorta Torácica/anomalías , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Enfermedades de los Gatos/diagnóstico , Enfermedades de los Gatos/diagnóstico por imagen , Enfermedades de los Gatos/cirugía , Estenosis Esofágica/veterinaria , Estenosis Esofágica/diagnóstico por imagen , Estenosis Esofágica/diagnóstico

RESUMEN

BACKGROUND: This study evaluated the safety and efficacy of salvage endoscopic submucosal dissection (ESD) for Barrett's neoplasia recurrence after radiofrequency ablation (RFA). METHODS: Data from patients at 16 centers were collected for a multicenter retrospective study. Patients who underwent at least one RFA treatment for Barrett's esophagus and thereafter underwent further esophageal ESD for neoplasia recurrence were included. RESULTS: Data from 56 patients who underwent salvage ESD between April 2014 and November 2022 were collected. Immediate complications included one muscular tear (1.8%) treated with stent (Agree classification: grade IIIa). Two transmural perforations (3.6%; treated with clips) and five muscular tears (8.9%; two treated with clips) had no clinical impact and were not considered as adverse events. Seven patients (12.5%) developed strictures (grade IIIa), which were treated with balloon dilation. Histological analysis showed 36 adenocarcinoma, 17 high grade dysplasia, and 3 low grade dysplasia. En bloc and R0 resection rates were 89.3% and 66.1%, respectively. Resections were curative in 33 patients (58.9%), and noncurative in 22 patients (39.3%), including 11 "local risk" (19.6%) and 11 "high risk" (19.6%) resections. At the end of follow-up with a median time of 14 (0-75) months after salvage ESD, and with further endoscopic treatment if necessary (RFA, argon plasma coagulation, endoscopic mucosal resection, ESD), neoplasia remission ratio was 37/53 (69.8%) and the median remission time was 13 (1-75) months. CONCLUSION: In expert hands, salvage ESD was a safe and effective treatment for recurrence of Barrett's neoplasia after RFA treatment.

Asunto(s)

Esófago de Barrett , Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Recurrencia Local de Neoplasia , Ablación por Radiofrecuencia , Terapia Recuperativa , Humanos , Esófago de Barrett/cirugía , Esófago de Barrett/patología , Resección Endoscópica de la Mucosa/efectos adversos , Resección Endoscópica de la Mucosa/métodos , Masculino , Femenino , Anciano , Estudios Retrospectivos , Terapia Recuperativa/métodos , Persona de Mediana Edad , Neoplasias Esofágicas/cirugía , Neoplasias Esofágicas/patología , Ablación por Radiofrecuencia/efectos adversos , Ablación por Radiofrecuencia/métodos , Adenocarcinoma/cirugía , Adenocarcinoma/patología , Estenosis Esofágica/etiología , Anciano de 80 o más Años , Resultado del Tratamiento , Esofagoscopía/métodos , Esofagoscopía/efectos adversos

RESUMEN

BACKGROUND: Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. METHODS: A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. RESULTS: A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. CONCLUSION: Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Asunto(s)

Anastomosis Quirúrgica , Estenosis Esofágica , Esofagectomía , Gastrectomía , Complicaciones Posoperatorias , Humanos , Esofagectomía/efectos adversos , Esofagectomía/métodos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Anastomosis Quirúrgica/efectos adversos , Estenosis Esofágica/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Constricción Patológica/etiología , Recurrencia , Dilatación/métodos

RESUMEN

BACKGROUND AND AIM: Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety. METHODS: A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months. RESULTS: The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture. CONCLUSIONS: The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.

Asunto(s)

Estenosis Esofágica , Calidad de Vida , Humanos , Estenosis Esofágica/terapia , Estenosis Esofágica/cirugía , Masculino , Estudios Prospectivos , Femenino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto , Anciano , Esofagoscopía/métodos , Esofagoscopía/instrumentación