Prevention of esophageal stricture after endoscopic resection

Stricture formation after esophageal endoscopic resection has a negative impact on patients’ quality of life because it causes dysphagia and requires multiple endoscopic dilations. Various methods by which to prevent stricture have recently been developed and reported. Among these methods, local steroid injection is the most commonly used and is currently considered the standard method for noncircumferential resection. However, local steroid injection has a limited effect on circumferential resection. Thus, oral steroid administration is used for such cases because it may have a stronger effect than local injection. Steroid treatment, both by local injection and oral administration, is effective and low‐cost; however, it may cause fragility of the esophageal wall, resulting in adverse events such as perforation during balloon dilatation. Many innovative approaches have been developed, such as tissue‐shielding methods with polyglycolic acid, tissue engineering approaches with autologous oral mucosal epithelial cell sheet transplantation, and stent insertion. These methods may be promising, but they are limited by a scarcity of data. Further investigations are needed to confirm the efficacy of these methods.     

Prevention and management of complications after colon interposition for corrosive esophageal burns

SUMMARY. We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric‐esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow‐up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re‐operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co‐ordination needs attention. Peri‐operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.     

Endoscopic bougienage of benign anastomotic strictures in patients after esophageal resection: the effect of the extent of stricture on bougienage results

SUMMARY. The aim of our retrospective study was to determine the incidence of benign anastomotic strictures (BAS) in patients after esophageal resection and to examine the influence of the extent of BAS on the results of bougienage therapy. From January 2001 to July 2006, 79 patients at risk of BAS development were included in the study. BAS was diagnosed with a median delay of 8 weeks (4–26) postoperative in 23 patients (29%). A median of 4 bougienage sessions (2–20) was needed for success (success rate 100%). The mean follow‐up time was 22 months [range 3–47]. There were no late recurrences of BAS. Five patients had an anastomosis diameter <5.5 mm and 14 patients >5.5 mm. There was no difference in median number of bougienage procedures in these subgroups (4.5 [2–9] vs. 4 [2–20]). Patients who presented with BAS earlier than 6 weeks postoperative had more procedures (median 8 [2–20] vs. 4 [2–9]) than those presenting later. Patients in whom first bougienage was possible to only 16 mm diameter needed more procedures than patients in whom first dilation was possible to more than 16 mm (median 5.5 [3–20] vs. 3 [2–9]). In conclusion, both early BAS development and the diameter of bougienage at first endoscopy, but not the extent of stricture, seem to be predictive factors for longer bougienage therapy. In order to influence the BAS formation early, we now routinely examine every patient after esophageal resection endoscopically in the 6th postoperative week.     

Endoscopically treated esophageal lipoma presenting with recurrent dysphagia after esophagectomy for esophageal carcinoma

We have reported a case of endoscopically treated lipoma of the cervical esophagus. The patient was referred to our hospital with a chief complaint of dysphagia and underwent an esophagectomy through right thoracotomy, followed by esophagogastrostomy for superficial esophageal cancer 3¹/₂ months before. However, this benign lesion was not revealed by preoperative check‐up. He again complained of dysphagia after esophagectomy and lipoma of the cervical esophagus was confirmed. Esophageal lipomas are relatively rare in the digestive tract; however, lipoma of the cervical esophagus can cause upper airway obstruction in the case of regurgitation of the tumor. Therefore, this disease must be considered in the examination of the patient with dysphagia.     

A case of esophageal stricture after corrosive esophagitis successfully treated by frequent endoscopic balloon dilation

A 14-year-old girl was admitted to our hospital for treatment of abdominal pain after an attempt to commit suicide by swallowing a caustic soda solution. Severe esophageal stricture following corrosive esophagitis occurred 2 weeks after admission. First, we tried to dilate the stenotic esophagus by using an esophageal bougie, but it was not effective and was also painful, and the treatment was stopped. Next, we tried endoscopic balloon dilation. This procedure was less painful and more effective for dilating the stenotic esophagus than was the bougie. At first, we used a pneumatic balloon and injected a steroid locally under the mucosal layer after dilation. The same procedure was continued in the outpatient clinic, but each interval of the procedures, about 3 weeks, was not changed for about 1 year. After 1 year of consecutive trials of frequent dilatation using a pneumatic balloon, the type of balloon was changed to a hydrostatic type. Three months after changing the type of balloon, treatment with tranilast, which was expected to be effective for prevention of restenosis, was started instead of steroid injection to the stenotic portion. After starting tranilast treatment, the interval of dilation became longer and the stricture itself gradually became dilated. Twenty-one months later, the interval of dilation was 3–4 months and oral intake had improved greatly. We therefore concluded that frequent endoscopic balloon dilation is effective for dilating stenosis after corrosive esophagitis. In addition, this case suggests that treatment with tranilast could be effective for preventing esophageal restenosis after balloon dilation.     

被膜食管支架治疗食管贲门良性狭窄32例

目的:评价被膜食管支架治疗食管贲门良性狭窄的疗效和安全性.方法:选择食管贲门良性狭窄患者32例,根据不同患者选择合适的被膜食管支架置入狭窄段.观察操作成功率、吞咽困难改善情况、术中术后并发症的发生及其处理等.结果:32例均一次性成功置入支架,支架置入后吞咽困难症状均得到持续改善.所有患者未出现食管穿孔、出血等严重并发症,但均出现不同程度的胸骨后闷胀隐痛不适,其中4例患者胸痛较明显,肌注止痛荆后缓解:3例出现支架脱落:1例出现支架近端肉芽组织增生.支架置入后可有效封闭食管气管瘘、食管纵隔瘘等.术后6 mo可经内镜成功取出支架.结论:内镜下置入被膜食管支架是治疗食管贲门良性狭窄的一种安全、有效的方法.     

The effects of oral steroid duration on stricture prevention after extensive endoscopic submucosal dissection for superficial esophageal cancer

BackgroundEsophageal stricture is a major complication of endoscopic submucosal dissection (ESD) in patients with superficial esophageal cancer (SEC). Oral steroids have been used to prevent esophageal stricture in patients with more than 75% of the esophageal circumference resected. However, there are no established guidelines regarding the optimal duration of steroid use. This retrospective observational study aimed to compare the incidence of esophageal stricture according to the period of prophylactic oral steroid use and to identify the risk factors for esophageal stricture.MethodsEighty-one patients who were prescribed prophylactic steroid after undergoing ESD for SEC with more than 75% of esophageal circumference resected were enrolled. Patients were classified into the four-week steroid group (n=72) or eight-week steroid group (n=9) to compare the incidence of esophageal stricture. In addition, the patients were subdivided into those who developed esophageal stricture (n=24) and those who did not (n=57) to identify the risk factors for esophageal stricture.ResultsTwenty patients (27.8%) in the four-week oral steroid group and four patients (44.4%) in the eight-week oral steroid group developed esophageal stricture (P=0.44). The univariable analysis identified tumor size, longitudinal length of semi-circumferential resection, and proportion of circumferential resection as risk factors of esophageal stricture. The multivariable analysis identified the proportion of circumferential resection as an independent risk factor. After adjusting for the proportion of circumferential resection, the incidence of stricture was marginally higher in the eight-week steroid group [P=0.05; odds ratio (OR): 5.69; 95% confidence interval (CI): 1.01–32.15].ConclusionsEight weeks of oral steroid prophylaxis does not reduce the risk of stricture after extensive ESD more than four weeks of oral steroid prophylaxis. The proportion of circumferential resection is the strongest risk factor for stricture in patients with SEC undergoing ESD.     

Effect of polyglycolic acid sheet plus esophageal stent placement in preventing esophageal stricture after endoscopic submucosal dissection in patients with earlystage esophageal cancer: A randomized,controlled trial

AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophageal cancer(EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows:(1) PGA plus stent group(PGA sheet-coated stent placement was performed); and(2) Stent group(only stent placement was performed). This study was registered on http://www.chictr.org.cn(No. chictrinr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5%(n = 7), which was lower than that in the stent group(46.9%, n = 15)(P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group(P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4(2-5) vs 6(1-14), P = 0.007]. The length(P = 0.080) and diameter(P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location(P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement(P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third(P = 0.034) and circumferential range = 1/1(P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with earlystage disease.     

Gastric secretion of acid and pepsin in patients with esophageal stricture and appropriate controls

Most cases of esophageal stricture are associated with acid/peptic reflux esophagitis. While patients with strictures commonly have disordered lower esophageal sphincters and poor clearance and neutralization mechanisms, it is not known whether they also have abnormal gastric secretion. This study examined fasting, basal, and stimulated acid and pepsin secretion. With an endoscopic diagnosis of esophagitis, patients with stricture (<12.5 mm) were matched for age, sex, concurrent gastrointestinal disease (duodenal ulcer,N=9), Zollinger-Ellison syndrome (N=6), and postgastric surgery state (N=5), as well as the absence of ulcer disease (non-DU,N=37). Fasting, basal, and pentagastrin-stimulated acid and pepsin secretion were measured. Overall, the 57 stricture patients had the same acid and pepsin secretion as their matched controls with esophagitis; the same was true for each of the subgroups (ZES, DU, non-DU, and postsurgical). Stricture patients weighed less and had a lower body mass index (P<0.01). Patients with esophageal peptic stricture have the same acid and pepsin output as control patients matched for sex, age, background gastrointestinal disease, and the presence of esophagitis.     

不同形状食管支架术后病理形态变化观察

目的通过食管再狭窄动物模型的制作，研究实验犬食管支架术后不同时间局部组织的病理形态，并比较“喇叭状”和“酒杯状”支架术后再狭窄形成有无不同。方法选择健康成年实验犬6条，随机分成2组，采取自体阔筋膜移植固定法分别置人“喇叭状”或“酒杯状”支架，术后第1、3、8周分别处死，取出置架部位的食管组织，进行大体标本观察、光学显微镜检查，并比较2组的差异。结果肉眼观察：随着时间的延长，支架上下端增生越显严重，食管壁厚度相应增加，局部肉芽组织形成及纤维化。术后第1、3、8周2组支架上下端未覆膜处食管组织、食管管腔、支架金属丝被增生组织覆盖情况等表现基本一致，只是在第8周“酒杯状”支架下端金属丝多处断裂，食管组织增生明显较上端轻。结论再狭窄均发生于支架两端未覆膜处，“喇叭状”和“酒杯状”2种形状食管支架术后病理学变化基本没有差异。     

Thoracoscopic radical esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach: A single-center retrospective study of 30 cases

To evaluate the necessity, safety, and feasibility of left inferior pulmonary ligament lymphadenectomy during video-assisted thoracic surgery (VATS) radical esophagectomy via the right thoracic approach.Thirty patients (20 men, 10 women) with thoracic esophageal squamous cell carcinoma (ESCC) were recruited for this study. The patients’ age ranged from 50 to 80 years, with an average age of 66.17 ± 7.47 years. After the patients underwent VATS radical esophagectomy and left inferior pulmonary ligament lymph node dissection (LIPLND) via the right thoracic approach, the operative outcomes included operative time, length of hospital stay, postoperative complications, number of lymph nodes removed, and postoperative pathologic results were evaluated.There were no massive hemorrhages of the left inferior pulmonary vein during the operation. The operative time of LIPLND was 8.67 ± 2.04 minutes, and the length of postoperative hospital stay was 12.23 ± 2.36 days. The postoperative complications included 2 cases of left pneumothorax, 4 pulmonary infection cases, and no chylothorax. Moreover, 68 LIPLNs were dissected, 5 of which were positive, and the degree of metastasis was 7.4%. The postoperative pathologic results showed that 3 cases of LIPLNs were positive, with a metastasis rate of 10.0%. Among them, 2 cases were SCC of the lower thoracic esophagus, and 1 case was SCC of the middle thoracic esophagus, which involved the lower segment.Thoracoscopic esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach will not increase the difficulty of operation, increase the incidence of postoperative complications or prolong the postoperative hospital stay, and can theoretically reduce tumor recurrence. Therefore, we believe that LIPLND is necessary, safe, and feasible and is worthy of clinical popularization and application.     

Totally minimally invasive Ivor‐Lewis esophagectomy with single‐utility incision video‐assisted thoracoscopic surgery for treatment of mid‐lower esophageal cancer

The study aims to evaluate the safety and availability of totally minimally invasive Ivor‐Lewis esophagectomy (MIIE) with single‐utility incision video‐assisted thoracoscopic surgery. Forty‐one patients with mid‐lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic‐thoracoscopic procedures were performed. The first 29 patients were treated with four‐port video‐assisted thoracoscopic surgery (Group 1); the others were treated with single‐utility incision video‐assisted thoracoscopic surgery (Group 2). Short‐term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late‐stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late‐stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single‐utility incision video‐assisted thoracoscopic surgery is feasible in patients with mid‐lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.     

Prolonged postoperative length of stay is associated with poor overall survival after an esophagectomy for esophageal cancer

Background

To investigate the impact of prolonged length of stay (LoS) on long-term mortality in patients who have undergone curative resection for esophageal cancer (EC).

Methods

Between January 2001 and December 2009, patients who underwent an esophagectomy for EC at Fudan University Shanghai Cancer Center were enrolled in this study. We retrospectively analyzed the medical charts of all of the enrolled patients. To determine the effect of postoperative LoS on long-term survival, we separated the patients into three groups based on the lengths of their postoperative LoS, including an LoS of less than 2 weeks (Group 1, ≤2 W), an LoS between 2 and 3 weeks (Group 2, ≤3 W) and an LoS of more than 3 weeks (Group 3, >3 W). Perioperative and long-term outcomes were compared between the groups.

Results

In total, 348 patients were included in this study. All of the patients underwent an esophagectomy with 3-field lymph node dissection (3FLND). The median postoperative hospital stay was 14 days (range: 8-153 days). Complications were observed in 123 patients (15.9% in Group 1 vs. 73.2% in Group 2 vs. 96.6% in Group 3, P<0.001). The median duration of follow-up was 39 months (range: 3-120 months). There were significant reductions in preventive adjuvant therapy (P=0.003) and postoperative salvage therapy (P<0.001) among the three groups. The 5-year survival rate was significantly different among the groups (43% vs. 36% vs. 29%, respectively, P=0.006). There was no difference in the 5-year disease-free survival rate among the three groups (23% vs. 21% vs. 19%, P=0.238).

Conclusions

Prolonged LoS was significantly associated with reduced rates of overall survival (OS). The insufficient administration of adjuvant therapy may partly account for these findings.     

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

SUMMARY.  Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86% vs 25%, P  = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI ( P <  0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II ( P <  0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1β and tumor necrosis factor-α were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1β of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.     

食管癌三维适形和调强放疗中肺损伤的剂量学研究

目的应用三维治疗计划比较食管癌三维适形放疗（3DCRT）、diding window调强（SMLC—IMRT）中肺组织受量上的情况,探讨食管癌放射治疗理想的计划模式。方法采用Varian公司Eclipse三维治疗计划系统对10例食管癌病人设计放射治疗计划,每例均做4个计划5野适形、7野适形和5野SMLC调强、7野SMLC调强,在规定PTV至少达到95％处方剂量前提下．用剂量体积直方图（DVH）比较肺组织受照射剂量的差异。结果（1）采用3DCRT技术时,肺所受的剂量在5野与7野照射技术中基本相同。（2）采用SMLC—IMRT技术时肺所受的剂量在5野与7野照射技术中基本相同。（3）3DCRT和SMLC—IMRT相比较,SMLC—IMRT组肺的平均剂量、V20、V30低于3DCRT,两组有差异（P〈0．01）,其余无差异。结论采用3DCRT和SMLC—IMRT技术时,5野和7野在肺组织保护上无明显差异;SMLC—IMRT与3DCRT相比可减少肺平均剂量,有利于肺组织的保护.     

Relationships of early esophageal cancer with human papillomavirus and alcohol metabolism

BACKGROUND It is well known that an alcohol consumption habit together with inactive heterozygous aldehyde dehydrogenase-2(ALDH2) is an important risk factor for the development of esophageal squamous cell carcinoma(ESCC). It remains controversial whether human papillomavirus(HPV) infection contributes to the occurrence/development of ESCC. There has been no study in which the relationship between ESCC and HPV in addition to alcohol dehydrogenase-1 B(ADH1 B) and ALDH2 genotypes was evaluated.AIM To evaluate relationships between HPV infection and development of esophageal cancer, particularly early esophageal cancer, based on ADH1 B/ALDH2 polymorphisms.METHODS We conducted an exploratory retrospective study using new specimens, and weenrolled 145 patients who underwent endoscopic resection for superficial ESCC and had been observed for more than two years by both physical examination and endoscopic examination in Hokkaido University Hospital. Saliva was collected to analyze genetic polymorphisms of ADH1 B/ALDH2. We performed in situ hybridization for resected specimens to detect HPV by using an HPV type 16/18 probe.RESULTS HPV was detected in 15(10.3%) of the 145 patients with ESCC. HPV-positive rates in inactive ALDH2*1/*2 and ALDH2*1/*1 + *2/*2 were 10.8% and 9.8%, respectively(P = 1.00). HPV-positive rates in slow-metabolizing ADH1 B*1/*1 and ADH1 B*1/*2 + *2/*2 were 12.0% and 10.0%, respectively(P = 0.72). HPV-positive rates in the heavy or moderate alcohol consumption group and the light or rare consumption group were 11.1% and 8.7%, respectively(P = 0.68). HPV-positive rates in the heavy smoking group and the light or no smoking group were 11.8% and 8.3%, respectively(P = 0.59). The 3-year incidence rates of secondary ESCC or head and neck cancer after initial treatment in the HPV-positive and HPVnegative groups were 14.4% and 21.4%(P = 0.22), respectively.CONCLUSION In the present situation, HPV status is considered to be less important than other risk factors, such as alcohol consumption, smoking habit, ADH1 B/ALDH2 polymorphisms, and HPV status would therefore have no effect on ESCC risk management.