Han Kyu Na

Benign Anastomotic Strictures After Esophagectomy: Long-Term Effectiveness of Balloon Dilation and Factors Affecting Recurrence in 155 Patients

OBJECTIVE The purpose of this article is to retrospectively evaluate the long-term clinical results of balloon dilation in the treatment of benign anastomotic strictures after esophagectomy and to identify factors associated with stricture recurrence. MATERIALS AND METHODS From January 1996 to June 2011, a total of 309 sessions of balloon dilation were performed in 155 patients with benign anastomotic strictures after esophagectomy. Long-term clinical effectiveness was assessed using the following variables: technical and clinical success, complications, and patency rates. Factors independently related to recurrence were evaluated with the Cox model. Tested variables were age, sex, operation type, postoperative anastomotic leakage, balloon size, length of stricture, time to postoperative stricture development, complications, and neoadjuvant chemoradiotherapy. RESULTS The mean follow-up period was 37 months (range, 1-159 months). Overall clinical success was achieved in 153 patients (99%) after a single (n = 78) or multiple (n = 75) balloon dilations. During follow-up, recurrence of the stricture requiring repeated dilation was seen in 77 of 155 patients (50%). Esophageal rupture (mostly intramural rupture) occurred in 22 of 155 patients (14%) and 34 of 309 balloon dilations (11%). In multivariate analysis, early development of stricture within 10 weeks after surgery (p = 0.002) and McKeown esophagectomy (p = 0.002) were independently related to recurrence after initial balloon dilation. CONCLUSION Balloon dilation under fluoroscopic guidance has encouraging long-term results in the treatment of benign anastomotic strictures after esophagectomy. However, recurrence after balloon dilation was common, with McKeown esophagectomy and development of stricture within 10 weeks after surgery associated with recurrent strictures.

Usefulness of a guiding sheath for fluoroscopic stent placement in patients with malignant gastroduodenal obstruction.

Background Self-expandable metallic stent placement is widely used to manage malignant gastroduodenal obstructions. However, there are difficulties in negotiating a guidewire (GW) and a stent delivery system (SDS). Purpose To investigate feasibility, usefulness, and safety of a guiding sheath for fluoroscopic stent placement in patients with malignant gastroduodenal obstructions. Material and Methods In July 2001 to August 2011, 726 patients with malignant gastroduodenal obstructions underwent stent placement. Guiding sheath was used in patients in whom a GW could not be passed through the obstruction and a SDS failed to reach the obstruction. Sheath usefulness was evaluated based on the ability of the sheath to successfully assist. The technical success rate and the most frequent reasons for the use of a sheath were evaluated. Results The guiding sheath was needed in 148 of 726 patients (20%). The overall technical success rate was 98% with the guiding sheath. In two of 148 patients, stent placement failed because, the GW could not be passed through the obstruction, in the other, the SDS could not be passed. A minority of patients reported mild discomfort. Patients with pancreatic cancer and duodenal obstruction were significantly more likely to require the use of guiding sheaths (P = 0.002, P < 0.001, respectively). Conclusion Using a guiding sheath for fluoroscopic stent placement appears to be feasible, useful and safe in patients with malignant gastroduodenal obstructions.

Retrospective Comparison of Internally and Externally Covered Retrievable Stent Placement for Patients With Benign Urethral Strictures Caused by Traumatic Injury

OBJECTIVE The purpose of this article is to compare the clinical effectiveness and complications of externally and internally covered stents for the treatment of benign urethral strictures. MATERIALS AND METHODS From July 2002 to June 2010, 59 retrievable self-expandable polytetrafluoroethylene-covered nitinol stents were placed in 33 men with benign urethral strictures. These included 34 internally covered stents placed in 18 patients (group I) and 25 externally covered stents in 15 patients (group E). Stents were routinely removed 4 months after placement from patients who experienced no complications. Complications, duration of stent placement, removal techniques, and maintained patency rates were compared in the two groups. RESULTS Twenty-eight complications (82.4%) occurred in 15 patients in group I, whereas 12 complications (48%) occurred in six patients in group E (p=0.005). Three (16.7%) patients in group I and nine (60%) in group E had their stents electively removed without complications (p=0.010). Stent migration was more frequent in group I (47.1%) than in group E (24.0%). No tissue ingrowth was detected in group E, whereas six cases of tissue ingrowth occurred in group I (p=0.034). The standard technique was used more frequently in group E (70.8%). The median stent indwelling period was significantly shorter in group I than in group E (51.5 vs 114 days; p=0.34). CONCLUSION Despite their relatively high complication rates, externally covered stents are more effective with fewer complications than internally covered stents in the treatment of benign urethral strictures.

IN-1233–eluting Covered Metallic Stent to Prevent Hyperplasia: Experimental Study in a Rabbit Esophageal Model

PURPOSE To investigate the efficacy of an IN-1233-eluting covered stent in preventing tissue hyperplasia in a rabbit esophageal model. MATERIALS AND METHODS The local animal research committee approved all experiments. Esophageal stents were placed in 40 male New Zealand rabbits (weight range, 2.8-3.2 kg). The drug group (D) received IN-1233-eluting covered stents (n = 20); the control group (C) received polyurethane-covered stents (n = 20). Drug loading of IN-1233-eluting covered stent was 10%. Four study groups were formed: C and D animals sacrificed at 4 (D4, C4) and 8 (D8, C8) weeks after stent placement (n = 10). Esophagography was used to assess the percentage of diameter stenosis. Histologic findings of the drug and control stents were compared. The Mann-Whitney U test was used to evaluate differences. RESULTS The mean percentage ± standard deviation of diameter stenosis was significantly lower in D groups than in C groups at both 4 (C4 = 36.15% ± 12.63, D4 = 7.83% ± 8.12 [P < .001]) and 8 (C8 = 50.21% ± 20.43, D8 = 27.78% ± 14.40 [P = .019]) weeks. Percentage of granulation tissue area (C4 = 33.07% ± 19.11, D4 = 21.59% ± 18.22 [P = .028]; C8 = 44.70% ± 21.71, D8 = 31.97% ± 22.54 [P = .131]), number of epithelial layers (C4 = 4.77 ± 1.55, D4 = 3.37 ± 1.73 [P = .002]; C8 = 5.50 ± 1.38, D8 = 4.50 ± 1.63 [P = .057]), and thickness of submucosal fibrosis (C4 = 2.42 mm ± 1.08, D4 = 1.62 mm ± 0.77 [P = .006]; C8 = 2.89 mm ± 1.00, D8 = 2.07 mm ± 0.71 [P = .007]) were lower in D than in C groups. Inflammatory cell infiltration was significantly higher in D than in C groups (C4 = 2.63 ± 0.81, D4 = 3.33 ± 1.09 [P = .032]; C8 = 2.20 ± 0.81, D8 = 3.00 ± 0.95 [P = .012]). CONCLUSION The use of an IN-1233-eluting covered stents decreased tissue hyperplasia secondary to stent placement in a rabbit esophageal model.

Safe and effective treatment of colorectal anastomotic stricture using a well-defined balloon dilation protocol.

PURPOSE To present a well-defined protocol for balloon dilation for colorectal anastomotic strictures and evaluate clinical efficacy of the dilation in 42 patients. MATERIALS AND METHODS From October 1999 to June 2010, 42 patients (32 males and 10 females with mean age 52.1 years ± 16.3) with surgical colorectal anastomotic strictures who received transanal balloon dilation using a well-defined protocol were retrospectively investigated. After the procedure, a water-soluble contrast media study was performed to detect possible complications. Stricture diameter was measured 1 month after balloon dilation. Clinical outcomes and recurrence were evaluated with a median follow-up period of 63.7 months. RESULTS There were 47 dilation sessions performed in 42 patients. Technical success and clinical success were achieved in all patients. At long-term follow-up, 36 (85.7%) patients had complete improvement. No complications were observed in any patients. Stricture diameter 1 month after the procedure was 8.85 cm ± 3.23, which was a significant increase over stricture diameter before the procedure of 5.89 cm ± 2.64 (P < .001), showing increase in diameter by 50.3%. Four (9.5%) patients experienced symptomatic recurrence. Stricture diameter of the patients with recurrence was considerably larger than stricture diameter of other patients (P = .036). CONCLUSIONS Fluoroscopically guided balloon dilation using the protocol described is safe and clinically effective for treatment of colorectal anastomotic stricture.

Bleeding after expandable nitinol stent placement in patients with esophageal and upper gastrointestinal obstruction: incidence, management, and predictors

Background Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated. Purpose To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction. Material and Methods We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement. Results Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy. Conclusion Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy.

Additional gastroduodenal stent placement: retrospective evaluation of 68 consecutive patients with malignant gastroduodenal obstruction

Background Self-expandable metallic stent placement is widely used to manage malignant gastroduodenal obstructions. However, the techniques and effectiveness of additional gastroduodenal stent placement have not been evaluated until now. Purpose To evaluate the technical feasibility, clinical effectiveness, and complications of additional gastroduodenal stent placement in patients with recurrent obstructive symptoms after primary gastroduodenal stenting. Material and Methods We retrospectively analyzed data from 68 consecutive patients who had additional gastroduodenal stents placed for recurrent obstruction. Clinical effectiveness was assessed using technical and clinical success rates, gastric outlet obstruction score improvement after primary and additional stent placement, and complications. Results Additional stent placement was technically successful in 66 of the 68 patients (97%) and symptomatic improvement was achieved in 58 (85%). The gastric outlet obstruction score improved after primary stent placement (0.3 to 1.4) and additional stent placement (0.2 to 1.4). Complications occurred in 12 of 68 patients (18%) and were caused by tumor overgrowth (n = 7), stent collapse (n = 2), food impaction (n = 1), jaundice (n = 1), and duodenal perforation (n = 1). Conclusion Additional gastroduodenal stent placement is technically feasible and clinically effective for patients with recurrent gastric outlet obstruction after stent placement.

Fluoroscopically Guided Balloon Dilation or Temporary Stent Placement for Patients With Gastric Conduit Strictures After Esophagectomy With Esophagogastrostomy

OBJECTIVE The purpose of this study was to evaluate the clinical features of patients with gastric conduit strictures after esophagectomy and to report our initial experience in the management of these strictures with fluoroscopically guided balloon dilation, temporary stent placement, or both. MATERIALS AND METHODS From January 1996 to January 2012, 12 patients with gastric conduit stricture after esophagectomy underwent fluoroscopic balloon dilation, temporary stent placement, or both. Stent placement was indicated in patients who had gastro-respiratory fistulas or recurrent symptoms within 2 weeks of balloon dilation. Technical and clinical success, complications, and length of strictures were retrospectively evaluated. RESULTS The mean length of strictures in all patients was 49 mm (range, 21-76 mm). The strictures were accompanied by gastrorespiratory fistulas in four patients. Seven patients with gastric conduit strictures without fistulas underwent 23 balloon dilations. Five patients underwent stent placement owing to gastrorespiratory fistula formation (n = 4) and frequent recurrent symptoms after balloon dilation (n = 1). During a mean follow-up period of 8 months (range, 2-28 months), clinical success was achieved in 11 patients (91.6%) after a single balloon dilation (n = 1), multiple balloon dilations (n = 5), or stent placement (n = 5). Complications occurred in 3 of 10 patients (30%) after balloon dilation and in one of five patients (20%) after stent placement. CONCLUSION Gastric conduit strictures are characterized by their substantial length and tend to be accompanied by gastrorespiratory fistulas. Despite relatively high complication and recurrence rates, this study may offer a viable treatment of gastric conduit strictures by using fluoroscopically guided balloon dilation and stent placement.