Use of a cutting balloon in the dilatation of caustic oesophageal stricture

A 14-year-old boy was admitted with absolute dysphagia 1 year after he had swallowed drain cleaner. Contrast swallow showed a tight stricture of the whole of the oesophagus below the level of T2. Attempted dilatation to 8 mm using conventional balloons was performed on two occasions, but there was residual waisting. An 8-mm cutting balloon (Peripheral Cutting Balloon, Boston Scientific) was used to abolish this waisting, and full dilatation to 10 mm was performed in the same procedure. Subsequent serial dilatation to 20 mm has been successful and the patient is now able to swallow normal food with cessation of gastrostomy feeding. This is believed to be the first report of the use of a cutting balloon to treat an oesophageal stricture.     

An experimental model for stricture studies in the anterior urethra of the male rabbit

In this study, an animal model was developed for the examination of urethral strictures (US). Through a resectoscope, a resection was made in the urethras of 15 male rabbits. After 30 days, the rabbits were evaluated with urethrography, impedance planimetry and either histology or the determination of collagen content. Fifteen rabbits serving as controls were evaluated in the same way. Three rabbits in the resection group and one in the control group died before evaluation. Urethrography demonstrated a stricture in the remaining 12 animals in the resection group. The urethras of the control animals were all normal. Impedance planimetry confirmed that the luminal cross sectional area (CSA) of the strictures was significantly smaller than the CSA of the corresponding part of the urethra in the control group. No difference in CSA was found 1 cm proximal to the stricture. The strictures consisted of densely woven collagen which sent tongues into the adjacent normal parts of the urethra. No difference in collagen content was found between the two groups either at the stricture site or 1 cm proximally. The described method of producing US in the rabbit model was very consistent with all operated animals developing a stricture. The model might prove valuable in evaluating new methods for the treatment of US.     

The management of treatment-related esophageal complications in children and adolescents with cancer

Background and Purpose

Serious treatment-induced esophageal strictures and tracheoesophageal fistulae are rare in the pediatric oncology population. This report details our experience with their management.

Methods

We retrospectively reviewed our experience with pediatric oncology patients treated for esophageal complications over a 23-year period. Serious complications were defined as development of strictures requiring dilatation or an esophageal fistula. Fifteen patients were identified, 5 of which had been previously reported.

Results

Thirteen patients developed esophageal stricture, and 2 progressed to tracheoesophageal fistulae. The remaining 2 patients developed tracheoesophageal fistulae without antecedent stricture. The median interval from cancer diagnosis until development of esophageal complications was 3.5 years (range, 0.4-11.8 years). Before development of esophageal complication, 14 patients (93%) were treated with mediastinal radiation and 7 (47%) for candidal esophagitis.Strictures were most commonly located in the distal esophagus (5), then midesophagus (3), cervical esophagus (3) and diffusely (2). A median of 5 dilatations (range, 1-50) were necessary before patients were able to resume a normal diet. The origin of tracheoesophageal fistulae was the midesophagus (3) and distal esophagus (1). All 4 patients with fistulae were treated with esophageal division and diversion followed by esophagocoloplasty.

Conclusions

Esophageal strictures and fistulae may occur because of cancer therapy in childhood. Prevention includes early treatment of esophagitis especially Candida mucositis, and minimization of radiation dose to the esophagus. Strictures usually respond to dilatation, but fistulae require esophageal diversion and secondary reconstruction.     

Radiological manifestations ofStrongyloides stercoralis

Nine patients with radiological changes due toStrongyloides stercoralis (SS) are described. A wide variation in appearance exists ranging from mild edema of the duodenal and small bowel mucosa to grossly enlarged, prominent valvulae conniventes. Small bowel dilatation is significant, and in overwhelming infestation toxic dilatation with paresis results. Spasm, ulceration, and stricture are encountered in addition. The appearances usually improve and reverse with treatment. Ampullary involvement is responsible for reflux of barium into the pancreatic duct and biliary tree through a patulous sphincter. In 1 patient the colonic changes resembled ulcerative colitis.     

Nd：YAG激光治疗食管贲门癌术后吻合口瘢痕狭窄

本文报告40例食管贲门癌术后吻合口瘢疤狭窄的Nd:YAG激光治疗经验,治疗前吻合口直径小于0.5cm,有吞咽困难、消瘦等症状,治疗后,吻合口均有不同程度增大,症状改善,吻合口直径大于1.0cm者20例(占50％),大于0.7cm者12例(占30％),大于0.5cm者8例(占20％),有效率达100％,未发生严重并发症。     

Esophageal stricture secondary to candidiasis

Esophageal candidiasis may rarely progress to stricture formation. All patients reported to date with stricture due to candidiasis have had an underlying immunologic deficiency or were undergoing chemotherapy for malignancies. Early diagnosis and adequate anti-fungal therapy are recommended to prevent this disabling complication.     

A new technique of anastomosis to avoid stricture formation in oesophageal atresia

Anastomotic stricture is a common problem following repair of oesophageal atresia (OA). We describe a technique of oesophageal anastomosis that may prevent this problem. A horizontal incision is placed on the anterior hemicircumference of the upper pouch approximately 0.5 cm proximal to its blind ending to raise a flap. A corresponding vertical incision is made at the open end of the lower pouch to spatulate it. The flap from the upper pouch is laid into the open V of the lower pouch. This creates a wide anastomosis, and the suture line is not restricted to one plane. In 11 cases of OA, oesophageal continuity was established with this technique over a period of 10 years. Only 1 child developed an anastomotic stricture, which responded to a single dilatation. Two patients required Nissen's fundoplication for a distal oesophageal stricture. In neither of the patients did the anastomosis become stenotic. The technique described here is simple and effective. A suture line is created that is long and not in a single plane. This minimises the risk of stricture formation. Accepted: 30 October 2000     

国产镍钛合金支架在食管良恶性狭窄应用中的进一步研究（附34例分析）

目的：通过分析国产镍钛合金支架应用于34例食管良恶性狭窄的结果,进一步评价其临床应用的可行性。方法：本组共收集34例,安放支架38 根（男性23例,女性11例,年龄4－76岁,平均56岁）。其中化学药物致食管狭窄2例、贲门失驰症6例、贲门－食管癌术后吻合口狭窄11例、食管－贲门癌或食管癌术后复发15例。全部支架置入均经胃镜在X线监视下进行。结果：支架置入均获得成功,改善患者的进食能力,提高患者的生活质量,术后随访观察1－16个月（平均6个月）,13例失去联系,其余21例定期随访观察。进一步证实使用国产镍钛合金支架治疗食管良恶性狭窄是安全有效的。结论：①置入支架以喇叭形被覆支架临床效果最好,成功率高、副作用少。②置放支架的同时要根据不同的病因制定相应的治疗措施。     

Oesophageal substitution with free and pedicled jejunum: short- and long-term outcomes

In children, the indications for oesophageal substitution are principally, long gap oesophageal atresia (OA), severe anastomotic disruption following primary repair of OA and severe caustic or peptic strictures. We present an outcome review of eight cases who underwent oesophageal substitution with jejunum at our institution between 1986 and 2001. The purpose of this study was to evaluate our experience with free/pedicled jejunal grafts and its long-term outcome as an oesophageal substitute. Operative and postoperative outcome with free and pedicled jejunal grafts in four cases of pure OA, two cases of OA and distal tracheo-oesophageal fistula (TOF), one patient with a high retrolaryngeal oesophageal web and one case of severe caustic oesophageal stricture. Six patients had an oesophagostomy and a gastrostomy fashioned previously. Eleven free jejunal grafts were performed in six patients (three intraoperative redo interpositions for immediate graft loss, three separate grafts in one patient and two free grafts in two patients). One patient’s pedicled jejunal graft proximally required microvascular anastomosis while the other had a pedicled graft without microvascular anastomosis. Early postoperative complications included four upper anastomotic leaks (three free grafts, one pedicled with microvascular support), pneumothorax requiring prolonged ventilation and Horner’s syndrome. Recurrent laryngeal nerve injury occurred in the patient who had a high retrolaryngeal oesophageal web. During follow up (5–18 years) late complications of upper anastomotic stricture in four patients and graft redundancy with subsequent kinking of the lower anastomosis were observed in one patient. Three patients established a complete oral diet; a further three patients relied on supplemental gastrostomy feeds and one patient is entirely gastrostomy fed. There were two late deaths, one from aspiration and the other from a severe asthmatic attack (5 and 7 months postoperatively, respectively). Our results indicate that there are significant complications related to the use of free jejunal grafts. Early recognition and treatment are of paramount importance in the ultimate achievement of a successful technical outcome.     

Colchicine in experimental alkaline burns of the rat esophagus: an old drug, a new indication?

Aim: An experimental study was performed to investigate the efficacy of colchicine in the prevention of fibrosis in the alkaline burn of the esophagus in rats. Method: A standard esophageal alkaline burn was produced by the application of 37.5% NaOH for a period of 90 s to the distal esophagus followed by a water rinse. The experiments were conducted twice with two different dosages of colchicine. In the first experiment, colchicine 1 mg/kg (i.p.) was applied once, on the first day. Group A (n:8), the sham laparotomy group; group B (n:8), the untreated group (positive control group); Group C (n:16), where the standard esophageal burn was induced and colchicine applied at a dose of 1 mg/kg i.p. in 1 ml volume, and group D (n:14), where the rats did not have any operation, but were treated with colchicine (1 mg/kg, i.p.) as in group C. In the second experiment, colchicine was applied at repeated doses of 100 μg/kg (i.p.) on the first, 7th, 14th, and 21st days. Twenty-five rats were divided into groups. Group AA (n:8), the sham laparotomy group; group BB (n:9), the untreated group (positive control group); and group CC (n:8), where the standard esophageal burn was induced and colchicine was applied at repeated doses. All the rats were killed on the 28th day and evaluated for esophageal tissue hydroxyproline content and histopathologic damage score. Results: Colchicine treatment at a dose of 1 mg/kg significantly reduced the quantity of hydroxyproline in the esophageal tissue in groups C and D compared with the positive control group B (P<0.05). However, it is associated with a mortality rate of 60%. Colchicine at repeated doses of 100 μg/kg showed no significant effect in group CC compared to the untreated group BB and in the quantity tissue of hydroxyproline content (P>0.05). Conclusion: At non-toxic doses, colchicine was not effective in the treatment of alkaline esophageal burn in rats. Colchicine-like molecules with less adverse effects or colchicine itself in titrated doses may be hopeful in preventing the development of fibrosis in the alkaline burns of the esophagus.