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Oesophageal dilatation were performed 24 times in 10 patients aged 12 months to 78 years presenting with acquired strictures of non-neoplastic origin. Tre conjunction of EDER PUESTOW'S metallic olives system with systematic use of fiberendoscopy enhances considerably the safety of the procedure and permits better functional results.
We report on a case of an 85-year-old man with dysphagia who suffered from a stenosing esophageal adenocarcinoma that could not be treated by surgery. The tumor demonstrated circumferential growth and extended from 14 to 22 cm from the incisors. There were no esophago-tracheal fistulas. The stenosis could be negotiated with the endoscope. Under fluoroscopic guidance, a self-expanding Strecker stent was placed in the stenosed area with no prior dilatation. After releasing the stent an x-ray revealed a twisted and wrinkled stent which had expanded to only half of its maximum diameter. The patient's symptoms had not improved. Four days later dysphagia resolved when the stent spontaneously corrected its position and was found to be maximally expanded. On the basis of this observation it may be concluded that, at least in some cases, self-correction of an initially unsatisfactory positioning of a Strecker stent may be expected, even after four days.
The Authors report a case of benign mucous pemphigoid. The review of the literature has confirmed the rarity of this disease. After having discussed acquired diagnostic data, the Authors show reasons to justify the endoscopic surgical treatment. Furthermore, they underline the importance of associated medical therapy as well as follow-ups which patients must periodically undergo.
From 1976 to 1988, 22 caustic burns of the esophagus in children were treated by retrograde dilatations (21 cases), by surgical resection and end-to-end anastomosis (2 cases) and by myotomy of the residual stricture after 12 to 18 months retrograde dilatations (4 cases). 3 deaths are recorded which might have been avoided; the treatment was successful in 11 cases and failed in 4 cases which led to the replacement of the esophagus; dilatations are being continued in 4 cases. In view of these results, the choice of the treatment should not be restricted either to conservative treatment continued in spite of poor results or systematic surgical replacement of the esophagus at an early stage. Furthermore, the use of an intraluminal splint has proved efficient in preventing esophageal stricture in 4 cases of caustic burns at stage III.
Recessive dystrophic epidermolysis bullosa (RDEB) is a rare, hereditary, chronic, non-inflammatory mechanobullous disease. Esophageal involvement is invariable in RDEB patients. A 15-year-old girl visited with protracted vesiculobullous skin eruptions since birth. On physical examination, bullae, atrophic scars, milia, crusts and erosions were noted primarily on the distal extremities. Loss of entire nails and syndactyly of the right fourth and fifth toes were seen. Diagnosis of RDEB was confirmed by clinical, histopathologic, immunofluorescent and electron microscopic findings. Endoscopic and esophagographic studies revealed a stenosis and several hemorrhagic bullae and erosions. She successfully underwent bougienage under endoscopic and fluoroscopic control
Oesophago-respiratory fistula in most instances in a complication of advanced malignant tumours of the oesophagus or the lung. In our patient group eleven oesophago-respiratory and one gastro-respiratory fistulas were encountered. Three patients were operated upon. In one of them with achalasia, early oesophageal carcinoma was discovered in the background of the fistula. Two patients had fistulas without of oesophageal narrowing, therefore, stent implantation into the trachea and bronchus was performed. One of them was previously managed endoscopically with lyodura plug and fibrin glue, but only temporary occlusion of the fistula was obtained. In five patients, seven conventional oesophageal prosthesis (6 Cook, 1 Rüsch) were used to close the fistulas. In one of these patients, three oesophago-respiratory fistulas developed one after the other at the level of the prosthesis funnel. They were closed with three prostheses connected with short silicone tubes. In the last two patients, Gianturco-Z stent was employed. Its advantages over the plastic prostheses include small basic and lager final luminal diameter, lesser predilatation, easier implantation, lower complication and mortality rate. The silicone coated and double funnel stent with expansile force is effective in fistulas closure. On implantation, stent shortening in minimal, allowing precise placement of the stent even in proximal malignant oesophageal stenosis with oesophago-bronchial fistula. The high price of the stent is compensated for by the lower complication rate, shorter hospitalization and subsequent reduction is hospital expenses. Therefore these metal stents should be financed by the National Health Service, at least in specialized centers for managing patients with dysphagia.
The Authors report two cases of transposed colon redundancy occurring after surgical treatment in 37 patients with caustic oesophageal strictures by retrosternal oesophagoplasty. Surgical management was required because of persistent dysphagia and weight loss in both patients. The technique performed was a resection of the redundant loop with a termino-terminal colo-colonic anastomosis via a right thoracic approach.
The authors report on their experience over a period of three years with the endoscopic treatment of benign oesophageal stenosis utilising the endoscopic balloon dilatation (EBD) technique or Savary-Gilliard cylindrical-conical dilators. They evaluate the results of the therapy with clinical and endoscopic follow-up at six-monthly intervals. The treatment proved effective, with total remission of dysphagia symptoms in approximately 95% of patients and with a low risk of complications.
The Authors study the pre- and post-operative nutritional treatment of the patients suffering from oesophageal stenosis, principally neoplastic, waiting to undergo the radical operation. Although the compensation of the nutritional situation of these patients through the enteral and parenteral nutrition results difficult to be effected, the results encourage to apply this clinical practice everywhere a demolitive operation, always long, heavy, and burdened by a high morbidity and mortality, is foreseen.
UNLABELLED: 50 patients suffering from dysphagia and oesophageal stenosis were treated in the period 1975-77. Of these 31 had renutrition of longer than two weeks and are the subject of the present study. Three nutrition systems were employed: 1) total parenteral feeding (7 patients), 2) feeding by naso-gastric tube or gastric fistula (15 patients), 3) feeding per os with semiliquid foods (9 patients). The patients were suffering from benign cicatricial stenosis (5), tumours of the cardia (7), tumours of the oesophagus (19). Short-term survival, weight behaviour and the course of certain blood parameters (Hb, GR, cholesterol, albumin, total proteins) are reported. CONCLUSIONS: --in benign cicatricial stenosis and tumours of the cardia, a normal protein-caloric amount (2000-3500 KCal., 80-120 g/24 h of proteins) is sufficient to obtain weight increase and stabilization of blood examinations. The administration route is unimportant; --in malignant stenosis, 4000-6000 KCal. and 100-130 g of protein/24 h must be provided to obtain the same result. In patients treated with total parenteral nutrition the weight loss persists. The reason for this behaviour is not known; it is likely that enzymatic blocks exist in substrate utilization; --further study is needed to improve results obtained and to clarify the reasons for such behaviour.
Of 40 patients admitted to the ENT clinic in 1984-1998 (age 18-77 years) with cicatrical esophagostenosis, 34 entered with acid or alkaline burn resulting in esophagostenosis of degree III or IV. Bouginage was a prevalent treatment. Bouginage of the lower third of the stenotic esophagus along 8-12 cm was made according to an original technique of orthograde double bouginage by two different bougies. The bouginage was successful in 8 patients with life-threatening cicatrical esophagostenosis in the lower third, with tubular stricture along two-three segments and obstruction of the degree III and IV.
On the basis of 12 cases of caustic burns of the oesophagus, the authors describe the technique of alimentation, once the acute phase of the first eight days has passed. From the 8th to the 15th days, calories and provided parenterally. An upper GI series is carried out on the 15th day: if the stomach is healthy, the authors fashion an alimentation gastrostomy, if the stomach is damaged, they carry out gastrectomy with alimentation gastrostomy or jejunostomy. In all cases, continuity is re-established by coloplasty two months later.
The results of treatment of patients with stenosis of the esophagus of unrecognized genesis are discussed. The traditional method of diagnosis, radiological and endoscopic with target biopsy, produced diverse results. The authors describe a method for bougienage of the esophagus by means of an original bougie with which dilatation of the stenosed segment can be combined with collection of bioptic material from the stenosed part and its lower pole. This made it possible to verify the diagnosis and determine the subsequent therapeutic tactics.
The article discusses the results of complex functional examination of the stomach in 41 patients with post-burn stenosis of the esophagus in different postoperative periods. Group I consisted of 21 patients with isolated chemical burns of the esophagus, group II was made up of 20 patients with combined chemical burns of the esophagus and stomach. Special new methods of examination (3-canal and endoscopic pH-metry, balloonography, radioisotope gastroscintigraphy, radioimmunological test for the hormone gastrin) were conducted to study the functional condition of the stomach which had been operated on. Objective evaluation is possible only by complex use of special methods of examination.
Dilatation in oesophageal stenosis are normally done by repeated bouginage. Based upon our constructing plans of 1978 and after the experiences in coronary dilatation procedures made by Dr Grünzig, we developed in collaboration with Schneider, Medintag Zurich, a new dilatation system. Once in place the dilatation system served as a feeding tube as well as for dilatation which was done under slight sedation as a bedside treatment. We present the technical aspects as well as one of our first patients treated with this new technique. The follow-up is now 6 months.
The authors present the case of an 81-year-old male patient with cardia adenocarcinoma. The patient underwent a surgical resection. Due to local recurrence Gianturco prosthesis implantation was performed. After 5 months of unimpeded swallowing, the patient gradually lost his ability to swallow. This was caused by tumor overgrowth. The serious condition was managed by nitinol (Ultraflex) metallic prosthesis. This reticular, compressed stent is a nickel-titanium based alloy. After implantation, as a result of the body temperature it assumes its original shape. After the twofold prosthesis implantation the patient had no complaints. The authors found the case worthy of presentation because of the new method and the originality of the new design.
OBJECTIVE: To evaluate the problems of approach, of technique and of care as a 20 years experience demonstrates. MATERIAL AND METHOD: a retrospective study including 45 operated cases where the large-bowel served as reconstructive material (in 33 cases the transverse colon and in 12 cases right ileocolon). RESULTS: Healing was obtained in 42 patients. Early postoperative evolution presented: peritonitis caused by anastomotic leakages--2 cases, hemoperitoneum--2 cases, cervical fistula --1 case, wound infection--6 cases, evisceration--1 case, acute respiratory failure--6 cases. Cervical anastomosis reconstruction for late stenosis--1 case. There were 2 postoperative deaths by haemorrhagic shock and peritonitis--mortality 4.4. DISCUSSIONS: Reconstruction by using the large-bowel was justified through anatomic argumentation (sufficient vascular supply), technic argumentation (easy anastomosis, tension free, short time of execution), functional argumentation (good compliance of large-bowel to the new function). CONCLUSION: Coloesophagoplasty is an efficient method on the condition of a strict planning: continent gastrostomy and evolvement of vascular arcades due to previous vascular "carving".
The authors have used selective angiography of the upper and lower mesenterial arteries in patients with scary constriction of the esophagus in order to obtain data of blood supply of the colon before operation of esophagus plasty and to give preliminary grounds for surgical tactics. The method was used in 37 patients operated upon. In ten of them angiography of the upper mesenterial arteries has shown contrasted veins. Coincidence of the pathway of arteries and veins was noted in 1 patient. Angiography of the lower mesenterial artery has shown coincidence of the pathway of arteries and veins in 16 cases, i.e. in all the cases where the venous phase was fulfilled.