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PubMed1985

Morphological findings in peptic esophageal stenosis with Barrett's ulcer in children.

The morphological findings in three resected specimens of Barrett's ulcer in children are discussed. Nearly identical morphologic changes are found in all cases, even in adults. This pathologic condition is understood as the third or fourth stage of reflux esophagitis. Perforation or even malignant degeneration is described in these cases. Therefore mainly all therapeutic aims must be to prevent these stages.

Barrett Esophagus↗
PubMed1993

Esophageal stricture following esophageal atresia repair: endoscopic assessment and dilation.

A retrospective review from 1981 to 1986 was made of 51 neonates who were treated for congenital esophageal atresia at the Royal Alexandra Hospital for Children, Sydney, Australia. Thirty of the 51 had primary repair and 15 (50%) developed esophageal stricture requiring one or more dilations. Stricture dilations were performed with open-tube rigid esophagoscopes, rigid telescopes, and Jackson dilators. The number of dilations performed until the patient was asymptomatic ranged from 1 to 12 (mean 4.5). The minimal follow-up time was 4 years. There was one esophageal perforation with full recovery following conservative management. One child died of septicemia caused by continued aspiration of unknown cause. A surprising finding, contrary to other reports, was the stricture formation did not appear to be related to the size of the "gap" found at the time of esophageal repair. Gastroesophageal reflux, however, was an important factor. We conclude that esophageal stricture following repair of tracheoesophageal atresia can be satisfactorily and relatively safely managed by direct vision antegrade endoscopic dilation using graduated dilators, although treatment may be prolonged and repeated. New esophagoscopes and dilators, in graduated sizes and designed for pediatric use, are recommended. The technique of esophageal dilation in infants is described in detail. Pediatric laryngobronchoesophagologists will become more involved in the care of infants born with esophageal atresia with or without tracheoesophageal fistula.

Dilatation↗
PubMed1987

A transparent over-tube for endoscopic injection sclerotherapy and results in patients with esophageal varices.

This report describes our data regarding repeated injection sclerotherapy using a newly designed over-tube. We treated 17 consecutive patients with esophageal varices, (3 acute, 6 elective and 8 prophylactic). An intravariceal injection of 5 per cent ethanolamine oleate was administered, using a newly designed transparent over-tube containing a second lumen for a flexible injection needle. This over-tube provides an easier, safer, shorter-in-time method of sclerosing esophageal varices. One of the 17 patients died as a result of liver failure associated with advanced cirrhosis and a concomitant hepatoma. Eradication of esophageal varices was attained in the remaining 16 patients, after an average of 5.0 injections over an average period of 5.8 weeks (range: 3-7 injections during 3-11 weeks). No complications, such as esophageal perforation or aspiration pneumonia were encountered. Recurrent variceal bleeding has not occurred during the 9 months follow-up.

Adult↗
PubMed2001

Resection and advancement of esophageal mucosa. A potential therapy for Barrett's esophagus.

BACKGROUND: Barrett's esophagus affects 5-10% of patients with gastroesophageal reflux disease (GERD) and is associated with a 40-fold increased risk of malignant transformation. Ablative therapies may lead to esophageal perforation or stricture formation if applied too liberally and residual glandular tissue and persistent cancer risk if utilized too sparingly. METHODS: Ten pigs underwent gastrotomy. Mucosa below the gastroesophageal (GE) junction was elevated by saline injections, circumferentially incised, and secured to an orogastric tube. By traction, the distal esophageal mucosa was inverted 10 cm proximally, then returned to the gastric lumen. In group A (n = 4), the mucosa (5 cm) was resected and the remnant was allowed to retract. In group B (n = 4), the mucosa was simply sutured back into its native position. In group C (n = 2), the mucosa (5 cm) was resected and the proximal segment was advanced and sutured to the gastric mucosa. At 6 weeks, or sooner if stricture developed, the animals were killed. Stricture formation was determined by ex vivo barium esophagram and gross assessment. The extent of fibrosis and epithelial healing were established histologically. RESULTS: Group A (mucosa resected) developed weight loss and anorexia within 4 weeks. Pathology revealed dense fibrotic stricture without reepithelialization. Group B (mucosa elevated/replaced) gained weight after the operation. Histology demonstrated mucosal healing without significant stricture or fibrosis. Group C (mucosa resected/advanced) also thrived postoperatively. Histology confirmed mucosal healing without evidence of retraction or dense stricture. CONCLUSIONS: Exposure of submucosal tissues causes esophageal stricture. Mucosal coverage minimizes submucosal fibrosis after injury. Mucosal resection and advancement allows healing without stricture and may have therapeutic potential for patients with Barrett's esophagus.

Anastomosis, Surgical↗
PubMed2001

Self-expandable metallic stents for patients with recurrent esophageal carcinoma after failure of primary chemoradiotherapy.

BACKGROUND: Recent advances in chemoradiotherapy for esophageal carcinoma have resulted in improved survival rates. However, there are few options for recurrent dysphagia due to refractory carcinoma after failure of primary chemoradiotherapy. The aim of this study was to evaluate the safety and efficacy of self-expandable metallic stent placement for patients with recurrent esophageal carcinoma where definitive chemoradiotherapy has failed. METHODS: Thirteen consecutive patients with recurrent squamous cell carcinoma of the esophagus, in whom self-expandable metallic stents were placed after failure of primary chemoradiotherapy, were studied retrospectively. All patients had esophageal obstruction or malignant fistula. RESULTS: The oral alimentation status of nine of 13 patients (69%) improved after successful placement of the stent. Following placement of the stent, fever (>38 degrees C) and severe chest pain occurred in 85% (11/13) of the patients. In all patients examined, C-reactive protein was elevated within 1 week of the operation. Esophageal perforation occurred in three patients. Stent-related mediastinitis and pneumonia developed in six (46%) and three (23%) patients, respectively. Seven of the 13 patients (54%) died of stent-related pulmonary complications. CONCLUSION: Although the placement of a self-expandable metallic stent for patients with recurrent esophageal carcinoma after failure of chemoradiotherapy improved their oral alimentation status, we found that this treatment increases the risk of life-threatening pulmonary complications.

Adult↗
PubMedDate not supplied

High-activity intraluminal 192iridium endocurietherapy for treatment of esophageal cancer.

Intraluminal endocurietherapy (ECT) with high-activity 192Iridium administered via catheter following megavoltage external-beam radiotherapy, allows delivery of 8,000-10,000 rad to the target volume without exceeding the normal tissue radiation tolerances of surrounding vital structures. The endocurietherapy does not require surgery, general or local anesthesia. The technique is accurate, cost-effective, and allows safe delivery of higher radiation doses than could be tolerated by multiple-field external-beam megavoltage radiotherapy techniques alone. In a pilot Phase-1 toxicity study of six patients treated with minimum tumor doses of 8,000 rad, the majority of patients developed benign esophageal stricture 2-6 months following ECT which was managed by dilatation or gastrostomy. No patients developed esophageal perforation. Local tumor control was excellent, but a high proportion of patients developed distant metastatic disease.

Adenocarcinoma↗
PubMed2001

Fixation of a modified covered esophageal stent: its clinical usefulness for preventing stent migration.

BACKGROUND AND STUDY AIMS: Membrane-covered self-expandable metal stents are effective in preventing tumor ingrowth and stent obstruction in patients with inoperable esophageal cancer, but migration of stents continues to be a major problem. We therefore constructed a modified covered self-expandable esophageal metal stent capable of being fixed using a silk thread. The stent was studied prospectively to define its palliative characteristics and whether it is effective in preventing migration. PATIENTS AND METHODS: Modified covered self-expandable metal stents were placed in 17 patients with malignant gastric cardiac cancer involving the esophagogastric junction, 41 patients with esophageal cancer, and three patients with tracheoesophageal fistulas. Clinical and radiographic follow-up examinations were carried out at regular intervals. RESULTS: Placement of the stent was successful in all patients, with good symptomatic relief and no serious stent-related complications such as esophageal perforation or hemorrhage. Acute stent placement problems, such as incomplete expansion or acute angulation of the stent, were noted in four patients. However, during a mean follow-up period of 7.5 months (range 1 to 17 months), there was no stent migration. CONCLUSIONS: Modified covered self-expandable esophageal metal stents of this type would be very effective in preventing stent migration, especially in patients with malignant gastric cardiac cancer extending to the lower esophagus, those with short-segment esophageal cancer, and those with tracheoesophageal fistulas.

Adult↗
PubMed1985

[Transluminal esophagoplasty (TE)].

The authors analyze their experience on 9 cases of esophageal stenosis dilated by "Grüntzig" type balloon catheter under fluoroscopic examination (transluminal esophagus plastica: TE). This procedure also allows dilatation of severe narrowing, offering distinct advantages represented by: low risk, easy performance, good tolerance, reduction or disappearance of disphagia. Esophageal perforation is possible, though it never appeared in author's experience.

Barrett Esophagus↗
PubMed2005

Modern management of achalasia.

The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.

Journal Article↗
PubMed1997

[Endoscopic treatment of benign esophageal stenosis].

Benign esophageal stenosis is the most frequent type of stenosis of the digestive tract. Surgical treatment is still affected by a high percentage of morbidity and mortality. This is not acceptable for a condition which is not neoplastic in nature. The introduction of modern endoscopic instruments has significantly simplified the technique also reducing the complications, therefore oesophageal dilatation has a fundamental role. The main indications to endoscopic treatment are represented by postoperative stenosis, and those caused by caustics, peptic acid, actinic lesions and achalasia. During the past 15 years, the Authors performed 205 endoscopic dilatation including 26 cases affected by esophageal achalasia. In the experience of the Authors, olivarian metallic probes were gradually abandoned in favour of Celestin & Savary polimetric dilators while pneumatic dilators were preferred only in achalasic cases. Endoscopic therapy was resolutive in 24 patients affected by achalasia (92.3%). In 158 patients, mechanic dilatation was employed (88.2%) and among them, 4 cases (2.19%) of esophageal perforation were observed. Overall, mortality rate was zero. As far as the average number of dilatation employed, the highest number was registered among caustic lesions (5), followed by peptic (4), and post-operative stenosis (1). The results obtained confirm the validity and efficacy of the endoscopic treatment for benign esophageal stenosis also considering the good compliance of the patients and the fact that no general anaesthesia is required.

Burns, Chemical↗
PubMedDate not supplied

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients.

PURPOSE: To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rösch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS: GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS: Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION: GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Aged↗
PubMedDate not supplied

[Results of treatment of deep neck abscesses and phlegmons].

INTRODUCTION: Neck, as a structure very closely connected with oral cavity and pharynx, with great number of lymph nodes, (about 2, 3 of all are in the neck), is sometimes a localization of purulent inflammatory process but its incidence is not so high as the incidence of inflammations of surrounding organs and tissue. Deep neck abscesses are localized under the upper fascial layer. They have a serious clinical picture which could be further complicated if inflammation spreads on vessels or neck organs. If the processes spread toward the mediastinum because of the communication space between medial and deep fascial layer with mediastinum, it could be mediastinal inflammation with high mortality. The aim of this study is evaluation of results of treatment in patients with deep neck abscesses and phlegmons treated at Clinic in a ten year period (1988-1997). MATERIAL AND METHODS: This study comprised 21 patients who were treated at the ENT Clinic in Novi Sad during 1988-1997. The group consisted of 5 female and 16 male patients from one to 65 years of age. Sixteen (76.2%) patients were treated with antibiotics in general practice, and 5 were admitted without previous therapy, 8 patients were afebrile, with temperatures between 37-38 degrees C and 5 with fever and high temperature. In 17 patients 5 days passed from onset of symptoms to admittance at the Clinic, and 4 patients had enlarged neck lymph nodes a few months. Unknown primary site of infections were in 13 (61.9%) patients, that means abscesses developed as colliquation of inflammatory changed lymph node. In the rest of 8 patients abscesses developed as: oropharyngeal inflammation (4 patients), foreign body perforation of esophagus, chronic otitis media, neck injury, malignant lymphoma. Lateral side of the neck was the most frequent site of neck abscesses and phlegmon in 16 (76%) patients. Red skin over the abscesses didn't appear in 4 patients. In 2 patients neck emphysema developed: anaerobic inflammation in one patient and esophageal perforation in the second. In a patient with SE over the 50 per hour the length of the abscess was over 7 cm, and in those with SE over 100 per hour, the whole neck inflammed. All patients underwent surgical therapy between 24 to 48 h after admission with incision or excision of the abscesses. Pus was collected for culture during the incision or excision of the abscesses and phlegmon. Bacteria were discovered in specimens taken during the incision in 4 (19%) of patients. Different aerobic and anaerobic bacteria were isolated: Enterococcus, Peptostreptococcus sp, Streptococcus viridans, Clostridium species. Surgery was the basic therapy of neck phlegmons and abscesses. In all patients incision was sutured in the second stage. Only one patient got paralysis of n. accesorius. One patient died with gas gangrene of the neck. DISCUSSION AND CONCLUSION: Deep neck abscesses and phlegmons are relatively rare inflammations in spite of high incidence of surrounding tissue inflammations. The most frequent causes are inflammatory changes of lymph nodes. Treatment has to be urgent, because of vital neck structures and communications between deep neck space and mediastinum. We consider that surgery is the basic principle of therapy although we have not had experience with needle aspiration. Antimicrobial agents must be given only parenterally.

Abscess↗
PubMed1992

Indigenous silicone rubber endoprosthesis for malignant esophago-pulmonary fistula.

Endoscopic placement of an esophageal endoprosthesis is the most rational therapy for relieving the distress of malignant esophago-pulmonary fistula. The commercial prostheses are very expensive for widespread use in India. We have indigenously prepared silicone rubber endoprostheses. The wall of the prosthesis was hardened in a graded manner until the desired resistance to compression with flexibility is achieved. This prosthesis was placed successfully in five patients with malignant esophago-pulmonary fistula. Dysphagia and aspiration were relieved in all the patients. One patient had delayed esophageal perforation and died of massive bleeding 3 weeks after the placement of prosthesis. The indigenous endoprosthesis is cost-effective and safe.

Adult↗
PubMed1988

Response of canine esophagus to intraoperative electron beam radiotherapy.

Tolerance of esophagus to intraoperative radiotherapy (IORT) was investigated in dogs. Thirteen adult foxhounds were subjected to right thoractomy, mobilization of the intrathoracic esophagus, and IORT to a 6 cm full-thickness esophageal segment using 9 MeV electrons at doses of 0, 2,000, or 3,000 cGy. Dogs were followed clinically and were evaluated at regular intervals after treatment with fiberoptic esophagoscopy, barium swallows, and postmortem histologic evaluations. One sham-irradiated control dog showed no abnormalities during follow-up of 24 months. Seven dogs receiving 2,000 cGy IORT showed transient mild dysphagia and mild esophagitis, but no clinically or pathologically significant complications. Five dogs receiving 3,000 cGy demonstrated severe ulcerative esophagitis within 6 weeks of treatment which progressed to chronic ulcerative esophagitis with stricture formation by 9 months following IORT. One 3,000 cGy dog died at 13 months from an esophageal perforation. On the basis of a pilot experience using 13 experimental animals, it was concluded that intact canine esophagus tolerates IORT well to doses of 2,000 cGy, but doses of 3,000 cGy pose serious and potentially lethal risks. The clinical application of IORT to the treatment of human intrathoracic neoplasms requiring esophageal irradiation should be approached with caution, particularly at doses exceeding 2,000 cGy.

Animals↗
PubMed1999

Photodynamic therapy for treatment of malignant dysphagia.

Photodynamic therapy (PDT) was recently approved by the Food and Drug Administration for palliating obstructing esophageal cancer. This report reviews our initial experience using PDT to treat malignant dysphagia. Patients with inoperable, obstructing esophageal cancer were considered for PDT. Photofrin was injected 48 hours before endoscopic laser activation. Dysphagia score was assessed. Thirty patients underwent 53 PDT courses. Improvement in dysphagia occurred in 83%. Mean dysphagia score decreased from 2.8 to 1.8 (p < 0.05). Complications included esophageal stricture (9.4%), candida esophagitis (5.7%), symptomatic pleural effusion (5.7%), contained esophageal perforation (1.9%), aspiration pneumonia (1.9%), and sunburn (13.2%). Seventeen patients (57%) required more than one PDT treatment, and in 10 an expandable metal stent was used as an adjunct. The 30-day mortality rate was 7%. PDT is effective in palliating patients with malignant dysphagia. The ideal patient for PDT has an obstructing, primarily endoluminal esophageal tumor with minimal extrinsic compression.

Aged↗
PubMed1990

Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft.

A 65-year-old woman sought treatment for sentinel upper gastrointestinal hemorrhage. Three years previously she had undergone graft replacement of her ascending aorta for aneurysm. In the interim she was followed for chronic dissection of her remaining aorta, and 6 months before this admission she had undergone graft replacement of a large abdominal aortic aneurysm. Arteriography and CT scanning of the thorax revealed an 8 cm aneurysm of the descending thoracic aorta. Operation was undertaken at which time an aortoesophageal fistula, as a result of erosion of the aneurysm into the esophagus, was identified. The descending thoracic aortic aneurysm was replaced with a Dacron tube graft, the esophageal defect was repaired primarily, and a viable pedicle flap of omentum was used to reinforce the esophageal repair and cover the aortic graft. Her postoperative recovery was free of infection but complicated by rapid expansion of the upper abdominal aorta at the visceral arterial level. Eight weeks after initial operation she underwent graft replacement of her remaining thoracoabdominal aorta with direct reattachment of her celiac axis, superior mesenteric artery, and both renal arteries. Recovery after her second procedure was uneventful, and she continues to do well at 13 months after operation. Development of a primary aortoesophageal fistula caused by aneurysms of the aorta is a rare but lethal complication. We present a technique for treatment of primary aortoesophageal fistula using omentum and preservation of gastrointestinal continuity as a one-stage operation. It is possible in selected cases to manage the esophageal perforation with primary closure and omental coverage to achieve healing free of infection without temporary or permanent discontinuity of the gastrointestinal tract.

Aged↗
PubMed1997

[Dilatation of esophageal strictures with balloon catheter. Safety and effectiveness of balloon dilatation].

Radioscopically-guided balloon dilation of esophageal stenosis is an effective and easily performed palliative procedure. Our experience with balloon dilation of esophageal stenosis in 12 patients was reviewed. Every patient underwent 2-5 sessions. Dysphagia disappeared completely in 2 patients. Ten patients had significant improvement. No case of esophageal perforation occurred during balloon dilation.

Adolescent↗
PubMed1994

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.

OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.

Anesthesia, General↗