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PubMedDate not supplied

Nd:YAG laser versus polidocanol injection for palliation of esophageal malignancy: a prospective, randomized study.

Palliation is often the only treatment that can be offered to patients affected by esophageal malignancy. This prospective study was carried out in order to compare two endoscopic palliative treatments: Nd:YAG laser and local injection of 3% polidocanol. We randomized 34 patients with inoperable malignancies to one of the two treatments. After the first course, 88.8% of the patients in the laser group and 81.5% in the polidocanol group were able to swallow a normal oral caloric intake. Only one major complication (esophageal perforation) was observed (polidocanol group) and was successfully treated with endoscopic placement of a prosthesis. We believe that both techniques are safe and effective for the palliation of esophageal malignant strictures but that polidocanol injection is cheap, simple, and more widely available.

Adenocarcinoma↗
PubMed2001

Benign esophageal strictures in infants and children: results of Savary-Gilliard bougie dilation in 107 Indian children.

BACKGROUND: Little information is available regarding the safety and efficacy of dilation of esophageal strictures in children with Savary-Gilliard bougies. This is a report of our experience with this form of dilation in Indian children. METHODS: One hundred seven Indian children age 14 years or younger with benign esophageal strictures underwent dilation. Clinical information including etiology was recorded. Dilation was performed at 2- to 3-week intervals by using Savary-Gilliard bougies under ketamine sedation and was considered adequate if the esophageal lumen could be dilated to 15 mm diameter (12.8 mm in children <5 years of age) with complete relief of symptoms. Subsequently, dilation was performed on an "as needed" basis. RESULTS: Mean age was 4.8 +/- 3.4 years; male to female ratio was 3:1. Fifty-four children had corrosive strictures (acid 34, alkali 20). Noncorrosive strictures were sclerotherapy-induced (23), postsurgical (14), congenital (10), peptic (4), and due to other causes (2). Dilation was successful in all but 3 cases. Corrosive strictures required a significantly higher number of sessions to achieve adequate initial dilation (2.4 +/- 1.9 vs. 1.3 +/- 0.5, p < 0.01). Patients with corrosive strictures also required a higher number of subsequent sessions for recurrence (7.3 +/- 6.5 vs. 0.7 +/- 1.3, p = 0.10). Dilation was also successful in patients with strictures 5 cm or more in length and/or patients with multiple corrosive strictures, although these required a higher number of sessions to achieve adequate dilation (p < 0.05) and also higher number of subsequent sessions for recurrence. Six esophageal perforations occurred during 648 dilation sessions (0.9%); 5 occurred in patients with corrosive strictures. One patient required surgery. CONCLUSIONS: Corrosive injury is the most common cause of benign esophageal strictures in Indian children. Savary-Gilliard bougie dilation is safe and effective, even for long and/or multiple corrosive strictures.

Burns, Chemical↗
PubMed1993

Achalasia associated with hiatal hernia: prevalence and potential implications.

Although hiatal hernia is reported with a 40-50% frequency in the general population, its occurrence and potential implications in achalasia are less well known. We reviewed the medical records and radiographic examinations of 120 patients with achalasia to assess the prevalence of hiatal hernia and its importance in evaluation and management of this motility disorder. Hiatal hernia was present in only 10 (8.3%) patients. Age, sex distribution, prevalence of dysphagia and regurgitation, and lower esophageal sphincter pressure measured manometrically were not significantly different in patients having hiatal hernia compared to those without hernia. Most patients (88%) underwent pneumatic dilatation and five esophageal perforations occurred, but all in patients without hiatal hernia. In conclusion, hiatal hernia is uncommon in patients with achalasia for reasons not known. Age, sex, symptoms, and results of esophageal manometry were not significantly different in those with hiatal hernia. Finally, the presence of hiatal hernia is not a contraindication to treatment of achalasia by pneumatic dilatation.

Adolescent↗
PubMed2006

Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance.

BACKGROUND: Laparoscopic Heller myotomy is the standard operation for achalasia. The incidence of esophageal perforation is approximately 5% to 10%. Data about the safety and utility of robotically assisted Heller myotomy (RAHM) are scarce. The aim of this study was to assess the efficacy and safety of RAHM for the treatment of esophageal achalasia. METHODS: From a prospectively maintained database, demographic data, symptoms, esophagograms, manometries, and perioperative data from all the RAHMs performed between September 2002 and February 2004 were analyzed. RESULTS: A total of 54 patients underwent RAHM, including 26 men. The mean age of these patients was 43 years (range, 14-75 years). Dysphagia was present in 100% of the patients. Of the 54 patients, 26 (48%) had undergone previous treatment including pneumatic dilation (17 patients), Botox injections (4 patients), or both of these treatments (5 patients). The dissection was performed laparoscopically, and the myotomy was performed with robotic assistance. The operative time, including the robot setup time, averaged 162 min (range, 62-210 min). Blood loss averaged 24 ml. No mucosal perforations were observed. The hospital length of stay was 1.5 days. There were no deaths. At 17 months, 93% of the patients had relief of their dysphagia. CONCLUSIONS: The findings showed RAHM to be safe and effective, with a 0% incidence of perforation and relief of symptoms for 91% of the patients.

Adolescent↗
PubMed1990

Method of endoscopic esophageal intubation using a rigid esophagoscope.

Endoscopic intubation of malignant esophageal strictures carries a substantial risk of esophageal perforation. We have developed a method of endoscopic intubation that reduces to a minimum the elements of the procedure that have to be performed "blind." The use of this method has been associated with a reduction in perforation rates when compared with other series.

Equipment Design↗
PubMed2006

Transthoracic esophagectomy and lobectomy performed in a patient with synchronous lung cancer and combined esophageal cancer and esophageal leiomyosarcoma.

We report a pitfall deriving from the assumption of metastatic disease based upon seemingly identical histology in a pulmonary lesion and in the esophagus. In a 60-year-old patient, cT1 esophageal squamous cell carcinoma was found. One of the two pulmonary nodules was histologically diagnosed as metastasis. When esophageal perforation occurred during palliative therapy, esophagectomy became necessary together with the right lower lobectomy for the removal of the remaining pulmonary lesion. Definitive histology showed pT1N0 cancer of the esophagus, primary esophageal sarcoma and pT4N0 bronchogenic carcinoma. The other pulmonary lesion was re-evaluated and defined as intralobar M1 of bronchogenic carcinoma.

Carcinoma, Bronchogenic↗
PubMed1999

Expanding mesh stent in the emergency treatment of Boerhaave's syndrome.

Boerhaave's syndrome, or spontaneous esophageal perforation, is a life threatening condition demanding early diagnosis and rapid aggressive management to prevent fulminant mediastinitis and death. We describe a patient treated in an emergency situation with an expanding esophageal mesh stent to bridge the esophageal rent together with chest and mediastinal drainage, resulting in complete recovery and return to the community. We also describe the partial recovery of the stent in the convalescent period.

Aged↗
PubMed2003

Predictors of radiation-induced esophageal toxicity in patients with non-small-cell lung cancer treated with three-dimensional conformal radiotherapy.

PURPOSE: To evaluate the incidence and clinical/dosimetric predictors of acute and late Radiation Therapy Oncology Group Grade 3-5 esophageal toxicity in patients with non-small-cell lung cancer (NSCLC) treated with definitive three-dimensional conformal radiotherapy (3D-CRT). METHODS AND MATERIALS: We retrospectively reviewed the charts of 207 consecutive patients with NSCLC who were treated with high-dose, definitive 3D-CRT between March 1991 and December 1998. This population consisted of 107 men and 100 women. The median age was 67 years (range 31-90). The following patient and treatment parameters were studied: age, gender, race, performance status, sequential chemotherapy, concurrent chemotherapy, presence of subcarinal 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. All doses are reported without heterogeneity corrections. The median prescription dose to the isocenter in this population was 70 Gy (range 60-74) delivered in 2-Gy daily fractions. All patients were treated once daily. Acute and late esophageal toxicities were graded by Radiation Therapy Oncology Group criteria. Patient and clinical/dosimetric factors were coded and correlated with acute and late Grade 3-5 esophageal toxicity using univariate and multivariate regression analyses. RESULTS: Of 207 patients, 16 (8%) developed acute (10 patients) or late (13 patients) Grade 3-5 esophageal toxicity. Seven patients had both acute and late Grade 3-5 esophageal toxicity. One patient died (Grade 5 esophageal toxicity) of late esophageal perforation. Concurrent chemotherapy, maximal point dose to the esophagus >58 Gy, and a mean dose to the entire esophagus >34 Gy were significantly associated with a risk of Grade 3-5 esophageal toxicity on univariate analysis. Concurrent chemotherapy and maximal point dose to the esophagus >58 Gy retained significance on multivariate analysis. Of 207 patients, 53 (26%) received concurrent chemotherapy. Fourteen (88%) of the 16 patients who developed Grade 3-5 esophageal toxicity had received concurrent chemotherapy (p = 0.0001, Pearson's chi-square test). No case of Grade 3-5 esophageal toxicity occurred in patients who received a maximal point dose to the esophagus of <58 Gy (p = 0.0001, Fisher's exact test, two-tail). Only 2 patients developed Grade 3-5 esophageal toxicity in the absence of concurrent chemotherapy; both received a maximal esophageal point dose >69 Gy. All assessable patients who developed Grade 3-5 esophageal toxicity had a mean dose to the entire esophagus >34 Gy (p = 0.0351, Pearson's chi-square test). However, the mean dose was not predictive on multivariate analysis. CONCLUSION: Concurrent chemotherapy and the maximal esophageal point dose were significantly associated with a risk of Grade 3-5 esophageal toxicity in patients with NSCLC treated with high-dose 3D-CRT. In patients who received concurrent chemotherapy, the threshold maximal esophageal point dose for Grade 3-5 esophageal toxicity was 58 Gy. An insufficient number of patients developed Grade 3-5 esophageal toxicity in the absence of chemotherapy to allow a valid statistical analysis of the relationship between the maximal esophageal point dose and esophagitis.

Acute Disease↗
PubMed1987

Effect of intravenous and intraperivenous injections of sclerosants (sodium tetradecyl sulfate and hydroxy polyethoxy dodecan) on the rat femoral vein.

The sclerosant effect of injected tetradecyl sulfate of sodium (STS) and hydroxy polyethoxy dodecan (HPD) was studied in the rat femoral vein. Intravenous (i.v.) and intravenous plus perivenous (i.v. + p.v.) injections of both sclerosants and physiologic saline were compared as to vein lumen occlusion, fibrosis, phlogosis, and damage to the artery and surrounding nervous and muscular tissues. The study was carried out in 30 rats treated by STS, in 30 treated by HPD, and 15 animals were injected with saline. The neurovascular bundle and adjacent muscle were removed at 48 h, 7 and 30 days and examined histologically. I.v. injections of STS produced a solid occlusion of the vein in a significant number of cases, after 30 days (P less than 0.01). A statistically significant number of solid occlusions of the femoral vein resulted after i.v. + p.v. injection of STS and HPD, at 48 h, 7 and 30 days (P less than 0.05; P less than 0.01). There was no significant difference between STS and HPD after i.v. + p.v. injection. After i.v. + p.v. we recorded a marked inflammation of muscle with signs of focal necrosis, at 48 h and 7 days. Our study indicated that i.v. + p.v. injection of STS and HPD provided a high degree of efficacy as regards vein occlusion. On the other hand, i.v. + p.v. injection induced a severe inflammation and necrosis of the tissues surrounding the sclerosed vein. Extrapolating our results to the endoscopic sclerotherapy for esophageal variceal bleeding, we conclude that paravariceal injection of sclerosants is a dangerous procedure, even though efficacious to reduce variceal hemorrhage, owing to the high risk of iatrogenic ulcers and esophageal perforation caused by muscular and mucosal necrosis.

Animals↗
PubMed1991

Management of dysphagia in suspected esophageal motor disorders.

Fifty-three patients suffering from dysphagia because of suspected esophageal motor disorders were treated by pneumatic dilatation using the Rider-Moeller technique. Fifteen had achalasia demonstrated by manometric studies. Forty-nine of them had remarkable clinical improvement after the procedure. During the mean period of follow-up (average 5 years, range 1-11), 75% of the patients needed a new dilatation, with a delay of two years. The results of the dilatation were excellent or good in 80% of the cases. Early complications consisted in two esophageal perforations surgically treated. There was no mortality. We did not observe late complications of the procedure. We conclude that pneumatic dilatation should be the initial procedure in the treatment of dysphagia in suspected esophageal motor disorders.

Aged↗
PubMed1996

Esophagectomy for carcinoma in the octogenarian.

BACKGROUND: Esophageal carcinoma is predominantly a disease of the elderly, a group often only considered for palliative therapies. METHODS: A case note review identified 31 octogenarians undergoing resection for carcinoma of the esophagus or gastric cardia over a 12-year period ending December 1994. RESULTS: Nineteen patients made either an uncomplicated postoperative recovery (n = 12) or suffered minor complications (n = 7). Of the 12 patients who suffered moderate or severe complications, 5 died (in-hospital mortality, 16%). The deaths included 2 of 3 patients who underwent emergency operation for esophageal perforation and 3 of 28 patients who underwent elective esophagectomy (elective mortality rate, 10.7%). Nineteen of the 26 survivors (73%) experienced no further dysphagia. The 5-year survival rate was 17%. CONCLUSIONS: Elective esophageal resection can be performed safety in selected octogenarians who have no or few coexisting medical problems and present with a localized carcinoma that is technically easy to resect. Patients undergoing emergency operations or in whom moderate or severe postoperative complications develop often have poor physiologic reserve and are therefore at risk of early postoperative death.

Adenocarcinoma↗
PubMedDate not supplied

Endoscopic dilatation of esophageal strictures in children and adolescents.

OBJECTIVE: To assess the causes of esophageal stricture in pediatric patients and their response to endoscopic dilatation. METHODS: Retrospective analysis of clinical and endoscopic data obtained from children and adolescents with esophageal stricture submitted to endoscopic dilatation between July 1993 and January 2003. RESULTS: A total of 125 patients aged between 1 month and 16 years were included in the study. Among the types of stenosis, postoperative (43.2%), corrosive (27.2%) and peptic (21.6%) strictures were the most prevalent. Those patients with corrosive esophageal stricture needed more dilatation sessions. Five cases of esophageal perforation and one case of hemorrhage occurred due to complications during the procedure. Good response to endoscopic treatment was described in 74.4% of cases, but better results were obtained from patients with peptic esophageal stricture. CONCLUSIONS: Endoscopic treatment of esophageal strictures in children and adolescents yields good results and has a low rate of complications. Corrosive esophageal strictures have a higher morbidity and require more dilatation sessions.

Adolescent↗
PubMed1995

[Esophageal dilatation in pediatrics: study of 33 patients].

BACKGROUND: Esophageal dilatation is usually regarded as an effective therapy in a majority of esophageal stenosis in childhood. However, the limited number of pediatric data does not allow definite conclusions on indications and complications of such a procedure. PATIENTS AND METHODS: The files of 33 children whose esophageal stenosis had been treated by dilatation by the same operator between 1983 and 1992 were retrospectively reviewed. The structure mechanisms were: group 1: repair of esophageal atresia (n = 9), group 2: caustic esophagitis (n = 6), group 3: peptic esophagitis (n = 12), group 4: unclassified structures (congenital esophageal stenosis, achalasia) (n = 6). The dilatations were performed under general anesthesia, and the dilatator guide was introduced under endoscopic control. Two methods were used: Savary esophageal bougies and balloon dilatation. A thoracic X-ray was systematically performed after each dilatation. RESULTS: One hundred and fourteen dilatations (3.5 dilatations/child) were performed (range: 1-32 dilatations). Twenty-five of the 33 children (76%) were dramatically improved after mechanical dilatation. Esophageal dilatation was unsuccessful in the eight other patients, seven of them requiring a surgical repair. Complications occurred in 3.4% of the dilatations: one esophageal perforation, one pneumomediastinum and two cardiac arrests (one of vagal origin and 1 after accidental extubation). All patients survived. Efficacy, duration of dilatation and complication rates were not similar in the four groups. CONCLUSIONS: Esophageal dilatation should be considered as a simple and effective procedure when strict security rules are respected by a trained operator.

Adolescent↗
PubMed1989

Medical and surgical management of esophageal foreign body in a ferret.

A ferret was examined because of anorexia, repeated episodes of regurgitation, and subsequent dehydration. Radiography had revealed a radiodense midesophageal foreign body. Results of endoscopy of the esophagus, however, could not confirm the diagnosis. Contrast radiography revealed esophageal perforation, with subsequent penetration of the foreign body into the right pleural space, causing pleural effusion. Surgical repair of the esophagus was performed, and a gastrostomy feeding tube was inserted to provide adequate nutrition during esophageal healing. Nine days after surgery, radiography revealed a severe stricture at the esophageal surgical site. Surgery was repeated; the esophagus was transected, the stricture was removed, and esophageal tissues were closed in 2 layers. Systemically administered antibiotics and gastrostomy tube feedings were continued throughout the post-operative healing period. The esophagus healed with a mild stricture that diminished over time in response to corticosteroid administration.

Animals↗
PubMed2003

Laparoscopic Heller myotomy with bolstering partial posterior fundoplication for achalasia.

BACKGROUND: The ideal antireflux procedure following laparoscopic Heller myotomy for achalasia is controversial. We present a novel laparoscopic technique of partial posterior fundoplication to bolster the myotomy. METHODS: Between August 1998 and March 2002, eight patients (five females and three males; median age, 40 years) underwent a laparoscopic Heller myotomy with bolstering partial posterior fundoplication. Results of barium swallow and manometry studies were consistent with achalasia. Failed medical treatments included balloon dilation, botulinum injection, and calcium channel blockers. RESULTS: The preoperative weight loss was 33 lb (range, 10-50) with a mean duration of symptoms of 29 months (range, 12-72). Seventy-one percent of the patients had reflux. Myotomy was confirmed with endoscopic guidance. Partial posterior fundoplication was performed with the edges of the myotomy on the right and left sides sutured to the stomach, which covered the myotomy. No conversion was required. In one patient, a perforation was recognized, repaired, and bolstered. The mean operative blood loss was 72 mL (range, 30-150). The mean operative time was 4 hours. Patients resumed solids at 2.5 days (range, 2-5). Postoperative complications included subcutaneous emphysema (n = 1), pneumothorax (n = 1), and umbilical port hernia (n = 1). None of the patients had reflux symptoms at 3 to 18 months of follow-up. CONCLUSION: Laparoscopic Heller myotomy with partial posterior fundoplication is technically feasible and effectively prevents reflux symptoms. Bolstering the myotomy may help heal small esophageal perforations.

Adult↗
PubMed2004

Management of malignant strictures of the cervical esophagus with a newly-designed self-expanding metal stent.

Recently, the use of self-expanding metal stents has become a well-established method of palliative treatment for stenotic malignant diseases in the middle and distal esophagus. However, published results on the use of self-expanding metal stents in cervical esophageal cancer are somewhat limited by a paucity of clinical details and experience. A new self-expanding esophageal metal stent with a short upper flange 0.7 cm in length was studied prospectively in order to assess its efficacy for palliative treatment. This report presents experience in three patients in whom this new stent was used in the treatment of cervical esophageal cancers. Stent placement was successful in all three patients, with no serious complications such as esophageal perforation, hemorrhage, or foreign-body sensation. All of the patients experienced rapid improvement in dysphagia and clinical symptoms. The newly designed self-expanding stent can be of value in the treatment of stenotic cervical esophageal cancer.

Aged↗
PubMed2006

Two cases of thoracoscopic resection of esophageal duplication in children.

We report two cases of thoracoscopic resection of esophageal duplication cysts. Both patients underwent successful thoracoscopic excision. They were discharged on postoperative day 2 and 4, respectively. They made uneventful recoveries and were completely asymptomatic at 1-month followup. One child was lost to long-term follow-up. In the other child, barium swallow study 10 months after surgery demonstrated a pseudodiverticulum at the site of cyst excision. Thoracoscopic resection of esophageal duplications is safe. Complete excision is possible even if the cyst shares a common muscular wall with the esophagus. Pseudodiverticulum may develop at the site of excision: follow- up is necessary and consideration should be given to closure of the muscular defect at the time of excision. To help avoid esophageal injury and, should it occur, recognize esophageal perforation, we recommend performing the dissection under intraesophageal endoscopic supervision.

Barium Sulfate↗