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PubMed2006

Balloon catheter dilatation of benign esophageal strictures in children.

PURPOSE: This retrospective study evaluated the safety and efficacy of fluoroscopically guided balloon dilatation of benign pediatric esophageal strictures. MATERIALS AND METHODS: Between 2000 and 2005, 272 esophageal balloon dilatations were performed in 49 children, aged 18 days to 18 years. Chart and primary physician record reviews were used to assess complications, age-appropriate food intake, and dysphagia. Efficacy was calculated by time to recurrent symptoms requiring repeat balloon dilatation. Durability was assessed by the frequency of dilatations. RESULTS: Seventy-seven percent of patients required a second dilatation within 9 months. Survival analysis (Kaplan-Meier) demonstrated no significant difference for efficacy in relation to patient age (P = .76) or stricture cause (P = .56). A decrease in the number of dilatations occurred over time to achieve longer symptom-free intervals. Patients underwent an average of 5.6 dilatations with an average total intervention time of 2 years. Patients were able to remain symptom free for a mean of 110 days. The procedure had a success rate of 100%, the only major complication being an esophageal perforation (complication rate, 0.37%) in a patient with a stricture secondary to correction of a tracheoesophageal fistula. CONCLUSIONS: Balloon esophageal dilatation in children is an effective and safe first-line therapy. Complications are quite rare and manageable. Although cures are unusual, most children require less than one dilatation every 6 months. It is concluded that fluoroscopically guided balloon dilatation should be the primary method of treating benign esophageal strictures.

Adolescent↗
PubMed1988

The omentum in the management of complicated cardiothoracic problems.

The pedicled omentum finds use in cardiothoracic surgery for management of complicated problems and prevention of serious complications. Its blood supply is excellent and is capable of inducing neovascularity. Based on the right gastroepiploic artery, it reaches anywhere in the thorax or neck. Its bulk helps to fill infected spaces. Thirty-seven patients have been treated with the pedicled omentum. In 16 patients the goal was preventive, to avoid bleeding, anastomotic leakage, or infection or to provide a source of fibroplasia or neovascularity. In eight patients with cervical exenteration the flap protected against innominate artery erosion and esophageal leakage, generally in an irradiated field. In six patients it permitted primary healing of heavily irradiated trachea--formerly unlikely. It was also used to provide coverage of a chest wall prosthesis in two patients. In 21 patients the omentum was used to obtain healing in the presence of infection. Bronchopleural fistulas were successfully closed in eight of nine patients. Six mediastinal infections that developed after cardiac operations were successfully treated. Four unusual vascular infections necessitated the use of omentum. Two patients had closure of esophageal perforations buttressed with omentum. This series demonstrates the efficacy of the omentum in the management of complex cardiac, vascular, esophageal, tracheal, bronchial, pleural, and chest wall problems.

Bronchial Fistula↗
PubMed1997

Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses.

PURPOSE: To evaluate prospectively the efficacy of plastic-covered metallic endoprostheses in patients with malignant esophageal fistulas and perforations. MATERIALS AND METHODS: Thirty-nine patients with incurable esophageal carcinoma who developed esophagorespiratory fistulas (n = 20) or perforations (n = 19) were treated with plastic-covered metallic stents. RESULTS: Covered Wallstent endoprostheses were placed in 36 patients and covered Gianturco stents in three. All 19 perforations and 18 of 20 fistulas were successfully closed (clinical success rate, 95%). Symptoms of aspiration or dysphagia improved in all successfully treated patients. Mean survival was 81.8 days (range, 1-370 days). One patient with a closed perforation developed a fistula 16 weeks later and was treated with a second, overlapping stent; three patients with recurrent fistulas were treated with additional esophageal stents (one patient) or tracheal stents (two patients). In four patients, stent migration (two Gianturco and two Wallstent endoprostheses) necessitated placement of an additional stent. CONCLUSION: Covered metallic stents offer effective treatment for perforations and fistulas in patients with esophageal malignancy. Patients with recurrent fistulas can be treated with additional stents. Fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.

Aged↗
PubMed2006

Balloon dilation of anastomotic strictures secondary to surgical repair of esophageal atresia in a pediatric population: long-term results.

PURPOSE: To evaluate the clinical effectiveness and long-term results of balloon dilation treatment for strictures secondary to surgical repair of esophageal atresia (EA) in 29 children. MATERIALS AND METHODS: The study involved 29 children aged 1-60 months with strictures of greater than 50% at anastomotic sites. The interval between surgical repair and balloon dilation ranged from 1 to 36 months (mean, 6.4 months). All procedures were performed under general anesthesia with use of fluoroscopic guidance. Balloon catheter diameters ranged from 8 mm to 16 mm. Outcome parameters measured included the number of dilations, procedural success rates, primary and secondary clinical success rates, and complications such as esophageal perforation. Primary clinical success was defined as an absence of dysphagia for at least 1 year and weight gain appropriate to the patient's age after initial balloon dilation. Secondary clinical success was defined as an absence of dysphagia for at least 1 year after the final dilation and weight gain appropriate to the patient's age after one or more balloon dilation sessions. RESULTS: A total of 44 balloon dilation sessions were performed, with patients undergoing one to five dilation procedures (mean, 1.6 per patient; median, 1 per patient). Primary and secondary clinical success rates were 59% (17 of 29) and 93% (27 of 29), respectively. During the mean follow-up period of 3.1 years (range, 1-12 y), all 27 children with clinical success showed no recurring symptoms. In terms of complications, transmural perforation occurred in three children (10%), two of whom received conservative management and one of whom underwent surgery for combined esophageal rupture and esophagotracheal fistula. No mortalities occurred. CONCLUSION: Balloon dilation is a safe and effective procedure with excellent long-term results for the treatment of anastomotic strictures secondary to surgical repair of EA in a pediatric population.

Anastomosis, Surgical↗
PubMedDate not supplied

[Spontaneous rupture of the esophagus].

A series of 8 patients with spontaneous rupture of the esophagus is analysed. Correct diagnosis is difficult. The time lapse between the rupture and diagnosis nevertheless seems to be the most important single factor in the outlook for treatment of spontaneous rupture of the esophagus. Early primary closure of the tear and good drainage of the mediastinum and pleural cavity give the best results in such cases. Sometimes a conservative management should be advocated for the treatment of esophageal perforations.

Esophageal Diseases↗
PubMed1981

Spontaneous rupture of the esophagus.

The records of all patients with spontaneous esophageal perforations who were examined between August 1966 and December 1978 were reviewed. Eleven patients (six men and five women) whose mean age was 62.8 years were treated during this period. Precipitating factors that contributed to perforation were identified in all patients. Ten patients had epigastric or low sternal pain. Chest roentgenograms were abnormal for all patients. Two patients were treated conservatively, and both died. Of the nine patients treated by thoracotomy, the two who were treated within 24 hours of perforation survived. Of the seven patients treated later than 24 hours, only three survived. Late treatment consisted of either primary closure or esophageal exclusion. Prompt surgical intervention remains the treatment of choice.

Adult↗
PubMed1996

Benign esophageal strictures in children and adolescents: etiology, clinical profile, and results of endoscopic dilation.

BACKGROUND: The problem of dysphagia in children and adolescents differs from that in adults, and therefore requires special consideration. METHODS: Forty-one consecutive children and adolescents 16 years of age or younger (mean, 7.2 years), with benign esophageal strictures were evaluated in a prospective manner over a 7-year period. The most frequent causes of esophageal strictures were caustic ingestion and complications of endoscopic sclerotherapy of esophageal varices. Dilation was done on a weekly basis using bougies and was considered adequate if the esophageal lumen could be dilated to 15 mm diameter (11 mm in children less than 5 years old) with complete relief of dysphagia. RESULTS: Of the 30 patients who could be adequately followed after initial dilation, 16 had corrosive strictures and 14 had strictures due to other causes. Patients with corrosive strictures required a significantly higher number of sessions for adequate initial dilation (7.8 +/- 2.5 sessions vs 1.86 +/- 0.48 sessions; p < 0.01). Patients with corrosive strictures had a higher number of mean symptomatic recurrences per patient month as compared to the noncorrosive stricture group (0.15 +/- 0.01 vs 0.087 +/- 0.03, p < 0.01). Six esophageal perforations occurred during a total of 327 dilation sessions (1.8%); there was one fatality. CONCLUSIONS: From our experience, we conclude that benign esophageal strictures in young patients can be treated effectively and with acceptable safety by means of endoscopic dilation.

Adolescent↗
PubMed1999

Increased rate of complete EUS staging of patients with esophageal cancer using the nonoptical, wire-guided echoendoscope.

BACKGROUND: Incomplete endoscopic ultrasound (EUS) staging procedures in patients with esophageal cancer due to obstructing malignant strictures are prone to underestimate T stage and cannot detect celiac adenopathy. EUS staging in the setting of stenotic malignancies using the large caliber echoendoscope has been complicated by esophageal perforation. We report on the clinical utility of a newly developed, wire-guided echoendoscope for the complete staging of patients with esophageal cancer. METHODS: Pretreatment EUS examinations performed for esophageal cancer staging were evaluated and the ability to traverse the esophagus and examine the celiac axis were documented. Outcomes before and after the availability of the wire-guided echoendoscope were compared. RESULTS: One hundred thirty consecutive examinations were evaluated 100 before and 30 after the introduction of the wire-guided echoendoscope. Complete staging was accomplished in 60 of 100 (60%) cases before and 27 of 30 (90%) after its introduction (p = 0.002). The wire-guided echoendoscope was used in 14 of the 30 cases. Despite a trend toward fewer stage T4 tumors, metastatic disease was documented significantly more frequently after the introduction of the esophagoprobe (34% vs. 11%, p = 0.002). There were no complications. CONCLUSIONS: The introduction of the wire-guided echoendoscope markedly reduced the occurrence of incomplete esophageal cancer staging and improved the detection of metastatic disease.

Adenocarcinoma↗
PubMed2002

Esophageal intubation with duodenoscope in the presence of pharyngeal pouch by a guidewire and catheter-guided technique.

Esophageal perforation can occur during blind intubation with a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatogram (ERCP) in patients with pharyngeal or esophageal anomalies. We describe a case of difficult intubation during an ERCP due to an asymptomatic and unsuspected pharyngeal pouch (Zenker's diverticulum). The side-viewing duodenoscope was withdrawn once resistance was encountered during intubation, and a forward-viewing gastroscope was inserted carefully under direct vision to evaluate the upper esophagus. After the diagnosis was made, intubation of the duodenoscope was performed by exchanging scopes over a guidewire. Subsequent ERCP with sphincterectomy and stone removal was uneventful. We caution that a side-viewing duodenoscope should be withdrawn once resistance is encountered during blind intubation during ERCP. Our technique minimizes patient discomfort and is rapid and easy to perform. In addition, no extra device such as an overtube is required.

Aged↗
PubMed1992

Esophageal stricture: results of dilation of 300 patients.

Three hundred patients underwent 1,177 esophageal dilations over a nine-year period. There were 164 men and 136 women. Mean age was 63 years. Etiology of stricture was peptic (160), Schatzki's ring (124), cancer (8), post-surgical (3), post-radiation (2), caustic ingestion (1), and esophageal web (2). Dilators used were Maloney red-rubber mercury weighted (78.1%), Savary wire-guided (15.2%), Eder-Puestow (6.3%) and Balloon (0.4%). Fluoroscopy was used in 98% of cases. One hundred and two of the 111 patients with peptic strictures observed for longer than six months had successful dilation. Forty-five of these patients (40.5%) required 54 redilations to maintain relief of dysphagia. Nine patients were refractory to dilation, two needing serial dilation and seven surgery. All Schatzki's rings were treated successfully. Ten of 82 patients followed for greater than six months needed redilation (12%). Morbidity was 0.2% with two complications occurring, an esophageal perforation and one case of hematemesis. There was no mortality.

Catheterization↗
PubMed1994

Staged repair using omentum for posttraumatic aortoesophageal fistula.

Aortoesophageal fistulas from traumatic thoracic aortic pseudoaneurysms are almost uniformly fatal. We report a case of a young woman who nearly exsanguinated soon after diagnosis. Immediate operative intervention consisted of prosthetic graft replacement of the pseudoaneurysm and pleural patch coverage. Definitive treatment of the esophageal perforation was necessary later for mediastinal sepsis. Primary repair of the esophagus accompanied by mobilization of the omentum into the space between the esophageal closure and the prosthetic graft led to a successful outcome.

Adult↗
PubMed2005

Clinical and dosimetric factors of radiation-induced esophageal injury: radiation-induced esophageal toxicity.

AIM: To analyze the clinical and dosimetric predictive factors for radiation-induced esophageal injury in patients with non-small-cell lung cancer (NSCLC) during three-dimensional conformal radiotherapy (3D-CRT). METHODS: We retrospectively analyzed 208 consecutive patients (146 men and 62 women) with NSCLC treated with 3D-CRT. The median age of the patients was 64 years (range 35-87 years). The clinical and treatment parameters including gender, age, performance status, sequential chemotherapy, concurrent chemotherapy, presence of carinal or subcarinal lymph nodes, pretreatment weight loss, mean dose to the entire esophagus, maximal point dose to the esophagus, and percentage of volume of esophagus receiving >55 Gy were studied. Clinical and dosimetric factors for radiation-induced acute and late grade 3-5 esophageal injury were analyzed according to Radiation Therapy Oncology Group (RTOG) criteria. RESULTS: Twenty-five (12%) of the two hundred and eight patients developed acute or late grade 3-5 esophageal injury. Among them, nine patients had both acute and late grade 3-5 esophageal injury, two died of late esophageal perforation. Concurrent chemotherapy and maximal point dose to the esophagus > or =60 Gy were significantly associated with the risk of grade 3-5 esophageal injury. Fifty-four (26%) of the two hundred and eight patients received concurrent chemotherapy. Among them, 25 (46%) developed grade 3-5 esophageal injury (P = 0.0001<0.01). However, no grade 3-5 esophageal injury occurred in patients who received a maximal point dose to the esophagus <60 Gy (P = 0.0001<0.01). CONCLUSION: Concurrent chemotherapy and the maximal esophageal point dose > or =60 Gy are significantly associated with the risk of grade 3-5 esophageal injury in patients with NSCLC treated with 3D-CRT.

Adult↗
PubMed1979

Intramural hematoma (incomplete perforation) of the esophagus associated with esophageal dilatation.

Five cases of intramural hematoma of the esophagus complicating esophageal dilatation are presented along with a review of the literature. In all 5 patients, this complication developed during dilatation for benign stricture. The esophagram in each patient demonstrated double columns of contrast material separated by a radiolucent stripe, characteristic of incomplete tear of the esophagus. All 5 responded to conservative management without complication.

Adult↗
PubMedDate not supplied

Spontaneous midesophageal rupture.

Spontaneous rupture of the esophagus is rare. To date, 17 such cases, including our patient, have been reported in the literature. We present a case of true spontaneous rupture that occurred during sleep. Because the correct diagnosis was made 36 h after the rupture, treatment consisted of surgical drainage only. The drainage was extrapleural, though a posterior mediastinal approach, thereby avoiding the complication of empyema. The paraesophageal abscess was repeatedly irrigated with povidone-iodine solution. The patient recovered after a long period--56 days--of hospitalization. The report includes a review of the signs and symptoms of esophageal perforation, the current mode of therapy, and some speculation on the pathogenesis of true spontaneous perforation.

Drainage↗
PubMed1991

Treatment of severe peptic esophageal stricture with Roux-en-Y partial gastrectomy, vagotomy, and endoscopic dilation. A follow-up study.

Eleven patients with dysphagia caused by severe esophageal stricture (length 2 to 10 cm) resulting from reflux esophagitis were treated with fibroendoscopic dilation (Eder-Puestow) and Roux-en-Y partial gastrectomy with vagotomy during 10 years (1979 to 1988). There was no operative mortality, but complications developed in three patients: One patient had a mediastinal abscess demanding thoracotomy as a result of esophageal perforation after dilatation; one had postoperative pneumonia; and one patient had ileus. After a mean follow-up of 4 years (range 1 to 10 years) esophagitis healed in all cases, as judged by endoscopy. Eight patients were asymptomatic, but three had slight transient dysphagia. Postoperatively one to eight dilations (average three to four) were needed to relieve dysphagia in the first postoperative year, but later the stricture healed in every case. Postoperative pH measurement was performed in six latest patients and showed complete absence of reflux in all cases. It is concluded that Roux-en-Y partial gastrectomy with vagotomy and endoscopic dilation is an effective, simple, and safe procedure in the management of severe peptic esophageal (acid or alkaline esophagitis) stricture. However, occasional postoperative dilations at the outpatient clinic are often needed in severe cases in the first postoperative year.

Adult↗
PubMed1999

Primary esophageal repair for Boerhaave's syndrome.

BACKGROUND: Boerhaave's syndrome is the most sinister cause of esophageal perforation. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. METHODS: We present a series of 21 patients seen in our unit in the 10 years 1987 to 1996. Esophageal repair was performed in 17 (81%) of them. After the resuscitation of the patient in the intensive care unit, our strategy is primary esophageal repair with a single layer of interrupted absorbable sutures combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy. The majority of patients (12/21) were referred more than 24 hours after perforation. RESULTS: The mean age of the patients was 60+/-17 years. The mean stay in the intensive care unit was 1.6+/-1.8 days and the median hospital stay, 14 days. There were three deaths, an overall mortality rate of 14.3%. CONCLUSIONS: When combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy, primary esophageal repair for Boerhaave's syndrome gives an acceptable mortality and should not be reserved for patients seen within 24 hours after spontaneous rupture.

Aged↗
PubMed1990

[Carcinoma of the esophagus. Palliative treatment with endoscopic prosthesis].

The efficacy and safety of endoscopically inserted esophageal prosthesis was evaluated in 33 patients with non-operable carcinoma involving the esophagus. In 30 cases, the origin of the tumor was esophageal, and in 3 cases, bronchopulmonary. Esophago-pulmonary fistula was present in 9 patients. Histologic exam of the tumors revealed 11 adenocarcinomas and 22 epidermoid carcinomas. In every case, Atkinson prosthesis was used and previous esophageal dilatation was needed in 21 patients. Normal oral feeding was achieved in 29 patients. Mean hospital stay after insertion of the prosthesis was 5 days. Survival rate was 84.8% at one month, 63.6% at 4-6 months, 42.4% survived more than 6 months, and 21.2% were still alive one year after the procedure. Complications occurred in 3 patients (9%) -esophageal perforation in two cases, and pneumonia in one case. One patient died. In conclusion, in patients with advanced carcinoma involving the esophagus, palliative therapy with endoscopically inserted esophageal prosthesis is effective, relatively safe and cheap.

Adult↗