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1.
BMJ Case Rep ; 17(5)2024 May 02.
Article in English | MEDLINE | ID: mdl-38697681

ABSTRACT

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.


Subject(s)
Esophagectomy , Gastrostomy , Robotic Surgical Procedures , Humans , Male , Esophagectomy/methods , Gastrostomy/methods , Robotic Surgical Procedures/methods , Middle Aged , Esophageal Stenosis/surgery , Esophageal Stenosis/etiology , Deglutition Disorders/etiology , Quality of Life , Treatment Outcome
2.
Best Pract Res Clin Gastroenterol ; 69: 101899, 2024 Mar.
Article in English | MEDLINE | ID: mdl-38749578

ABSTRACT

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.


Subject(s)
Dilatation , Esophageal Stenosis , Esophagoscopy , Humans , Esophageal Stenosis/therapy , Esophageal Stenosis/surgery , Esophageal Stenosis/etiology , Esophagoscopy/instrumentation , Dilatation/methods , Stents , Deglutition Disorders/etiology , Deglutition Disorders/therapy , Deglutition Disorders/physiopathology , Deglutition Disorders/surgery , Palliative Care , Esophageal Neoplasms/complications , Esophageal Neoplasms/surgery , Esophageal Neoplasms/therapy , Treatment Outcome , Algorithms
3.
Otolaryngol Clin North Am ; 57(4): 581-587, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38575487

ABSTRACT

Swallowing is an elaborate process that requires neuromuscular coordination. Pediatric esophageal dysphagia is broadly categorized into structural and nonstructural causes. The structural causes of pediatric esophageal dysphagia are related to processes that narrow the lumen of the esophagus. Esophageal strictures are the result of scar tissue formation within the lumen of the esophagus, leading to stenosis. Vascular rings and slings cause external compression of the esophagus. Diagnosis requires an esophagram and computed tomography or magnetic resonance imaging. Treatment is guided by the patient's symptoms and underlying diagnosis, although it often requires surgical intervention when symptomatic.


Subject(s)
Deglutition Disorders , Esophageal Stenosis , Humans , Deglutition Disorders/etiology , Deglutition Disorders/diagnosis , Deglutition Disorders/therapy , Child , Esophageal Stenosis/therapy , Esophageal Stenosis/etiology , Esophageal Stenosis/diagnosis , Esophagus , Tomography, X-Ray Computed , Magnetic Resonance Imaging , Deglutition/physiology
4.
Pediatrics ; 153(5)2024 May 01.
Article in English | MEDLINE | ID: mdl-38655638

ABSTRACT

Esophageal stenosis can cause vomiting or dysphagia in children and is commonly treated with esophageal balloon dilation. However, surgery may be required if the stenosis does not respond to dilation. Although esophageal actinomycosis can cause severe esophageal strictures and be refractory to balloon dilation, it has been reported to respond effectively to antimicrobial therapy in adults. However, the course of the disease and appropriate treatment strategies in children are not well understood. We present a case of a previously healthy 2-year-old boy diagnosed with esophageal stenosis because of actinomycosis. The patient was treated with intravenous penicillin G, followed by oral amoxicillin for 8 weeks and 6 months, respectively. After completion of the antimicrobial treatment, the patient showed improvement in symptoms and endoscopic findings. At the 1-year follow-up, the patient showed consistent weight gain and normal growth without further intervention. This case highlights the importance of considering esophageal actinomycosis as a potential cause of esophageal stenosis in children and the potential effectiveness of antimicrobial therapy in avoiding surgical intervention.


Subject(s)
Actinomycosis , Amoxicillin , Esophageal Stenosis , Humans , Male , Esophageal Stenosis/etiology , Esophageal Stenosis/drug therapy , Actinomycosis/drug therapy , Actinomycosis/diagnosis , Actinomycosis/complications , Child, Preschool , Amoxicillin/therapeutic use , Amoxicillin/administration & dosage , Anti-Bacterial Agents/therapeutic use , Anti-Bacterial Agents/administration & dosage , Penicillin G/therapeutic use , Penicillin G/administration & dosage
5.
J Nanobiotechnology ; 22(1): 143, 2024 Apr 01.
Article in English | MEDLINE | ID: mdl-38561800

ABSTRACT

BACKGROUND: Endoscopic submucosal dissection (ESD) is the current standard treatment for early-stage esophageal neoplasms. However, the postoperative esophageal stricture after extensive mucosal dissection remains a severe challenge with limited effective treatments available. In this study, we introduced a chitosan/gelatin (ChGel) sponge encapsulating the adipose mesenchymal stem cells (ADMSCs)-derived exosomes (ChGelMSC-Exo) for the prevention of esophageal stenosis after ESD in a porcine model. RESULTS: Pigs were randomly assigned into (1) ChGelMSC-Exo treatment group, (2) ChGelPBS group, and (3) the controls. Exosome treatments were applied immediately on the day after ESD as well as on day 7. Exosome components crucial for wound healing were investigated by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and small RNA sequencing. ChGelMSC-Exo treatment significantly reduced mucosal contraction on day 21, with less fiber accumulation and inflammatory infiltration, and enhanced angiogenesis when compared with the control and ChGelPBS groups. The anti-fibrotic effects following MSC-Exo treatment were further found to be associated with the anti-inflammatory M2 polarization of the resident macrophages, especially within the M2b subset characterized by the reduced TGFß1 secretion, which sufficiently inhibited inflammation and prevented the activation of myofibroblast with less collagen production at the early stage after ESD. Moreover, the abundant expression of exosomal MFGE8 was identified to be involved in the transition of the M2b-macrophage subset through the activation of MFGE8/STAT3/Arg1 axis. CONCLUSIONS: Our study demonstrates that exosomal MFGE8 significantly promotes the polarization of the M2b-macrophage subset, consequently reducing collagen deposition. These findings suggest a promising potential for MSC-Exo therapy in preventing the development of esophageal stricture after near-circumferential ESD.


Subject(s)
Endoscopic Mucosal Resection , Esophageal Stenosis , Exosomes , Mesenchymal Stem Cells , Swine , Animals , Esophageal Stenosis/etiology , Esophageal Stenosis/prevention & control , Endoscopic Mucosal Resection/methods , Chromatography, Liquid , Tandem Mass Spectrometry , Collagen
7.
Pediatr Surg Int ; 40(1): 99, 2024 Apr 06.
Article in English | MEDLINE | ID: mdl-38581456

ABSTRACT

PURPOSE: Long-gap esophageal atresia (LGEA) is still a challenge for pediatric surgery. No consensus exists as to what constitutes a long gap, and few studies have investigated the maximum gap length safely repairable by primary anastomosis. Based on surgical outcomes at a single institution, we aimed to determine the gap length in LGEA with a high risk of complications. METHODS: The medical records of 51, consecutive patients with esophageal atresia (EA) with primary repair in the early neonatal period between 2001 and 2021 were retrospectively reviewed. Three, major complications were found in the surgical outcomes: (1) anastomotic leakage, (2) esophageal stricture requiring dilatation, and (3) GERD requiring fundoplication. The predictive power of the postsurgical complications was assessed using receiver operating characteristic analysis, and the area under the curve (AUC) and the cutoff value with a specificity of > 90% were calculated. RESULTS: Sixteen patients (31.4%) experienced a complication. The AUC of gap length was0.90 (p < 0.001), and the gap length cutoff value was ≥ 2.0 cm for predicting any complication (sensitivity: 62.5%, specificity: 91.4%). CONCLUSION: A gap length ≥ 2.0 cm was considered as defining LGEA and was associated with an extremely high complication rate after primary repair.


Subject(s)
Esophageal Atresia , Esophageal Stenosis , Tracheoesophageal Fistula , Infant, Newborn , Child , Humans , Esophageal Atresia/surgery , Esophageal Atresia/complications , Retrospective Studies , Treatment Outcome , Esophageal Stenosis/etiology , Tracheoesophageal Fistula/surgery , Tracheoesophageal Fistula/complications , Anastomosis, Surgical/adverse effects
9.
J Allergy Clin Immunol ; 153(6): 1465-1471, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38570041

ABSTRACT

Current treatments of eosinophilic esophagitis (EoE) aim to eliminate esophageal mucosal inflammation and attenuate, stabilize, or reverse stricture formation. However, our ability to study the long-term course of esophageal strictures in patients with EoE is hampered by the short-term existence of this disease. It is unclear to what degree of control of inflammation is needed to prevent stricture formation. Additionally, identified phenotypes of EoE may ultimately dictate different levels of concern and time intervals for developing fibrosis. Currently, multiple methods are used to monitor patients' disease progression to fibrosis, as symptoms alone do not correlate with disease activity. Endoscopic findings and mucosal histology are used to monitor disease activity, but these focus on improvements in inflammation with inconsistent evaluation of underlying fibrosis. The use of functional lumen impedance planimetry, barium esophagraphy, and endoscopic ultrasound continues to expand in EoE. The rapid advancements in EoE have led to an armamentarium of measuring tools and therapies that holistically characterize disease severity and response to therapy. Nevertheless, our ability to evaluate gross esophageal fibrosis and stricture formation from a transmural rather than mucosal view should be a focus of future investigations because it is essential to monitoring and modulating the trajectory of EoE.


Subject(s)
Eosinophilic Esophagitis , Eosinophilic Esophagitis/therapy , Eosinophilic Esophagitis/pathology , Eosinophilic Esophagitis/diagnosis , Humans , Disease Progression , Esophageal Stenosis/etiology , Esophagus/pathology , Esophagus/diagnostic imaging , Fibrosis
10.
Surg Endosc ; 38(6): 2995-3003, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38649492

ABSTRACT

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.


Subject(s)
Anastomosis, Surgical , Esophageal Stenosis , Esophagectomy , Gastrectomy , Postoperative Complications , Humans , Esophagectomy/adverse effects , Esophagectomy/methods , Gastrectomy/adverse effects , Gastrectomy/methods , Anastomosis, Surgical/adverse effects , Esophageal Stenosis/etiology , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Constriction, Pathologic/etiology , Recurrence , Dilatation/methods
13.
Surg Endosc ; 38(4): 2086-2094, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38438676

ABSTRACT

INTRODUCTION: Self-expandable metallic stents (SEMSs) can be used to treat esophageal stricture after circumferential endoscopic submucosal dissection (ESD), but its efficacy and placement timing remain to be determined. In this study, the treatment time and number of dilatations were compared between the SEMS placement group and the balloon dilatation (BD) group to clarify the efficacy and placement time of SEMSs in the treatment of esophageal stricture after circumferential esophageal ESD. METHODS: This was a retrospective cohort study. Patients with esophageal stricture after circumferential ESD between January 2015 and January 2020 were included. Data on the patients' demographic characteristics, esophageal lesion-related factors, esophageal stricture occurrence, and measures taken to treat the stricture were collected. The primary outcome was the treatment time, and the secondary outcome was the number of dilatations. RESULTS: The total number of dilatations was 30 in the SEMS group and 106 in the BD group. The average number of dilatations in the SEMS group (1.76 ± 1.64) was significantly lower than that in the BD group (4.42 ± 5.32) (P = 0.016). Among the patients who underwent SEMS placement first had a shorter treatment time (average 119 days) than those who underwent BD first (average 245 days) (P = 0.041), and the average number of dilatations inpatients who underwent SEMS placement first (0.71 ± 1.07) was significantly lower than that in the patients who underwent BD first (2.5 ± 1.54). CONCLUSION: SEMSs were more efficient in the treatment of esophageal stricture in a cohort of patients after circumferential esophageal ESD.


Subject(s)
Endoscopic Mucosal Resection , Esophageal Neoplasms , Esophageal Stenosis , Self Expandable Metallic Stents , Humans , Esophageal Stenosis/etiology , Esophageal Stenosis/surgery , Dilatation , Endoscopic Mucosal Resection/adverse effects , Retrospective Studies , Self Expandable Metallic Stents/adverse effects , China/epidemiology , Esophageal Neoplasms/etiology
14.
Zhongguo Dang Dai Er Ke Za Zhi ; 26(2): 169-173, 2024 Feb 15.
Article in Chinese | MEDLINE | ID: mdl-38436315

ABSTRACT

OBJECTIVES: To investigate the endoscopic ultrasonography (EUS) features of benign esophageal stenosis in children. METHODS: A retrospective analysis was conducted on the medical data of the children who were diagnosed with benign esophageal stenosis from February 2019 to February 2022. The clinical manifestations, EUS findings, and treatment outcome were analyzed to summarize the EUS features of benign esophageal stenosis in children. RESULTS: A total of 42 children with benign esophageal stenosis were included. Among these children, 19 (45%) had anastomotic stenosis after surgery for esophageal atresia, with unclear echogenic boundary of the esophageal walls and uneven thicknesses of the surrounding wall on EUS, and had 0-12 sessions of endoscopic treatment (average 2.1 sessions); 5 children (12%) had corrosive esophageal stenosis and 1 child (2%) had physical esophageal stenosis, with unclear stratification of the esophageal walls on EUS, and they had 2-9 sessions of endoscopic treatment (average 5.3 sessions); 1 child (2%) had patchy irregular hypoechoic areas of the esophageal walls on EUS and was diagnosed with tracheobronchial remnants with reference to pathology; 16 children (38%) had unexplained esophageal stenosis and unclear stratification of the esophageal walls on EUS, among whom 6 received endoscopic treatment. During follow-up, 95% (40/42) of the children had significant alleviation of the symptoms such as vomiting and dysphagia. CONCLUSIONS: For benign esophageal stenosis in children, EUS can help to evaluate the degree of esophageal wall involvement in esophageal stenosis lesions, possible etiologies, and the relationship between the esophagus and the lesion and provide an important basis for selecting treatment modality and avoiding complications, thereby helping to optimize the treatment regimen.


Subject(s)
Deglutition Disorders , Esophageal Stenosis , Child , Humans , Esophageal Stenosis/diagnostic imaging , Esophageal Stenosis/etiology , Esophageal Stenosis/therapy , Endosonography , Retrospective Studies
16.
Ann Surg Oncol ; 31(7): 4261-4270, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38413507

ABSTRACT

BACKGROUND: Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied. METHODS: This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP. RESULTS: Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20). CONCLUSION: LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted.


Subject(s)
Anastomosis, Surgical , Esophageal Neoplasms , Esophageal Stenosis , Esophagectomy , Ischemic Preconditioning , Laparoscopy , Postoperative Complications , Humans , Esophagectomy/adverse effects , Male , Female , Ischemic Preconditioning/methods , Middle Aged , Laparoscopy/adverse effects , Laparoscopy/methods , Case-Control Studies , Esophageal Neoplasms/surgery , Anastomosis, Surgical/adverse effects , Postoperative Complications/prevention & control , Postoperative Complications/etiology , Esophageal Stenosis/etiology , Esophageal Stenosis/prevention & control , Aged , Follow-Up Studies , Stomach/surgery , Stomach/blood supply , Prognosis , Constriction, Pathologic/etiology , Retrospective Studies , Anastomotic Leak/etiology , Anastomotic Leak/prevention & control
17.
Clin Res Hepatol Gastroenterol ; 48(3): 102290, 2024 Mar.
Article in English | MEDLINE | ID: mdl-38311060

ABSTRACT

The primary treatment for early esophageal cancer and precancerous lesions is endoscopic submucosal dissection (ESD). However, this approach leads to a high incidence of postoperative esophageal stenosis, which can significantly impact a patient's quality of life. While various methods are available to prevent post-ESD esophageal stenosis, their effectiveness varies. Therefore, this study aims to provide an overview of the currently employed methods for preventing post-ESD esophageal stenosis in clinical practice in view of assisting clinical practitioners.


Subject(s)
Endoscopic Mucosal Resection , Esophageal Neoplasms , Esophageal Stenosis , Humans , Esophageal Stenosis/etiology , Esophageal Stenosis/prevention & control , Endoscopic Mucosal Resection/adverse effects , Endoscopic Mucosal Resection/methods , Quality of Life , Esophageal Neoplasms/pathology , Postoperative Complications/prevention & control , Postoperative Complications/etiology
18.
Vet Med Sci ; 10(2): e1392, 2024 03.
Article in English | MEDLINE | ID: mdl-38389312

ABSTRACT

A 2-year-old neutered male Bengal cat presented with solid food dysphagia and chronic regurgitation for >5 months. There were no clinical abnormalities on haematological or radiographic examinations. Thoracic radiography revealed a soft tissue opacity mass adjacent to the diaphragm in the caudoventral thorax. Ultrasonography revealed a protruding liver lobe surrounded by a hyperechoic lining from the diaphragm towards the thorax, and a pleuroperitoneal hernia was diagnosed. An endoscopy was performed to examine the cause of regurgitation, and an oesophageal stricture was observed. Endoscopic balloon dilation of the oesophageal stricture was performed, and the regurgitation was resolved immediately. However, regurgitation relapsed 2 months later, and computed tomography was performed to ascertain the cause. Computed tomography revealed oesophageal mural thickening and true pleuroperitoneal hernia with partial liver lobe herniation. A second endoscopy with balloon dilation was performed to treat the relapsing oesophageal stricture, and the clinical signs resolved without the need for herniorrhaphy. Nevertheless, oesophageal stricture could occur due to gastroesophageal reflux related to a pleuroperitoneal hernia; however, a definite link could not be elucidated in this case. This report describes a case of oesophageal stricture and concurrent true pleuroperitoneal hernia in a cat.


Subject(s)
Cat Diseases , Esophageal Stenosis , Hernias, Diaphragmatic, Congenital , Male , Cats , Animals , Esophageal Stenosis/diagnostic imaging , Esophageal Stenosis/etiology , Esophageal Stenosis/veterinary , Hernias, Diaphragmatic, Congenital/veterinary , Tomography, X-Ray Computed , Thorax , Cat Diseases/diagnostic imaging , Cat Diseases/etiology
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