Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease

BACKGROUND/AIMS: Benign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients. METHODS: Patients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms. RESULTS: Forty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period. CONCLUSIONS: The experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.

Research progress in endoscopic incision in treating gastrointestinal benign stricture / 中南大学学报(医学版)

Gastrointestinal benign stricture is a common disease with symptoms of dysphagia,abdominal pain and difficult defecation,which severely impair the quality of life for patients.Endoscopic intervention is the first-line treatment,and the available methods include balloon dilation,local drug injection and stent insertion,etc.Endoscopic incision was first used for the treatment of Schatzki's rings,and later it was used for the treatment of other gastrointestinal benign strictures,and the promising results were achieved.

Experiencia colangioscopia peroral monoperador (SPYGLASS) en patología biliar en un centro privado de tercer nivel en Venezuela / Experience colangioscopia peroral single operator (SPYGLASS) in biliary pathology in a center deprived of the third level in Venezuela.

Spyglass es un colangioscopio peroral mono operador desechable que ha estado disponible desde principios de 2007 para patología biliar. Objetivo: Demostrar la experiencia en Venezuela usando sistema Spyglass en pacientes con patología biliar. Pacientes y Métodos: Estudio prospectivo (febrero2012-mayo2015), Policlínica Metropolitana.50 spyglass fueron realizados, representando 7,7% del volumen de CPRE biliares en el mismo período (50/650). Se incluyeron 46 pacientes (45 hombres, 1 mujer), edad media 62,6 años (24-92 años). Indicaciones: coledocolitiasis (20), estenosis (23), tumor (2), descarte Neo entre 2 prótesis (1), prótesis trans stent (1). Un mono operador a través de un duodenoscopio terapéutico realizó colangioscopia spyglass. Sedación por anestesiología en quirófano y antibiótico profiláctico fue administrada. Resultados: Spyglass fue realizada en 46 pacientes (50 procedimientos).Hallazgos: litiasis (20 pacientes), estenosis benigna (10), estenosis maligna (13), colangitis esclerosante (1), prótesis trans stent (1). De los pacientes con litiasis, el clearance ductal posterior a litotripsia holmiun láser se logró en el 85% después de una sesión, y el 15 % en un segundo intento.Spyglass confirmó el diagnóstico de malignidad en 13/21 (62%), el diagnóstico se estableció por combinación de características visuales y biopsias directas.En 7/21 (33,33%) cambio diagnóstico: benigno (6), colangitis esclerosante (1) y en uno no se pudo establecer diagnóstico. La sospecha de benignidad se confirmó en 3/4 pacientes. Pancreatitis, microperforación retroperitoneal y fístula pancreática se reportó en un paciente (2,17%) resuelto con tratamiento médico y quirúrgico. Conclusiones: Spyglass es una técnica útil en estenosis sospechosa de benignidad o malignidad, difirió el diagnóstico, modificando la conducta. Es una técnica adyuvante de la CPRE en el manejo de cálculos.

Spyglass is a disposable peroral cholangioscope monoperator that has been available since early 2007 for biliary disease. Objective: To demonstrate the experience in Venezuela using Spyglass system in patients with biliary disease. Patients and Methods: Prospective study (february2012-may2015), Polyclinic Metropolitana.50 spyglass were performed, representing 7.7% of the volume of bile ERCP in the same period (50/650). 46 patients (45 males, 1 female), mean age 62.6 years (24-92 years) were included. Indications: choledocholithiasis (20), stenosis (23), tumor (2), dicard neo between two prothesis (1), trans prosthesis stent (1) .A monoperator through a therapeutic duodenoscope made cholangioscopy spyglass. Sedation for anesthesiology and prophylactic antibiotic was administered. Results: Spyglass was performed in 46 patients (50 procedures) .Findings: lithiasis (20 patients), benign stricture (10), malignant stricture (13), sclerosing cholangitis (1), trans prosthesis stent (1). Of patients with stone disease, ductal clearance holmium laser after lithotripsy was achieved in 85% after a session, and 15% in a second attempt.Spyglass confirmed the diagnosis of malignancy in 13/21 (62%), the diagnosis was established by combination of visual features and directs biopsies.En 7/21 (33.33%) change diagnosis: benign (6), sclerosing cholangitis (1) and one diagnosis could not be established. The suspicion was confirmed benignity in 3/4 patients. Pancreatitis, retroperitoneal microperforation and pancreatic fistula was reported in one patient (2.17%) resolved with medical and surgical treatment. Conclusions: Spyglass is a useful technique for suspected benign or malignant stricture, diagnosis differed modifying behavior. Spyglass is a useful adjuvant to ERCP in the management of difficult stone disease.

Development of a Swine Benign Biliary Stricture Model Using Endoscopic Biliary Radiofrequency Ablation

The large animal model with benign biliary stricture (BBS) is essential to undergo experiment on developing new devices and endoscopic treatment. This study conducted to establish a clinically relevant porcine BBS model by means of endobiliary radiofrequency ablation (RFA). Endoscopic retrograde cholangiography (ERC) was performed on 12 swine. The animals were allocated to three groups (60, 80, and 100 W) according to the electrical power level of RFA electrode. Endobiliary RFA was applied to the common bile duct for 60 seconds using an RFA catheter that was endoscopically inserted. ERC was repeated two and four weeks, respectively, after the RFA to identify BBS. After the strictures were identified, histologic evaluations were performed. On the follow-up ERC two weeks after the procedure, a segmental bile duct stricture was observed in all animals. On microscopic examination, severe periductal fibrosis and luminal obliteration with transmural inflammation were demonstrated. Bile duct perforations occurred in two pigs (100 W, n = 1; 80 W, n = 1) but there were no major complications in the 60 W group. The application of endobiliary RFA with 60 W electrical power resulted in a safe and reproducible swine model of BBS.

Efficacy of endoscopic radial incision (ERI) for benign stricture of upper digestive system / 中国内镜杂志

Objective To evaluate the safety and efficacy of endoscopic radial incision (ERI) for benign stricture of upper digestive system. Methods Patients with benign esophageal or gastric stricture (including anastomotic stricture, stricture after ESD and caustic stricture) were enrolled in this study. The stage of stricture, length of the lesion and the thickness of the scar were recorded. ERI (maybe associated with balloon dilatation) were performed. Post-opera-tive symptoms, complications and follow-up were also recorded. Results 7 patients were enrolled and all received ERI, and 4 additional balloon dilatation were done. Dysphagia in all patients relieved. 1 case with hemorrhage oc-curred and relieved with conservative treatment. Majority of the patients got long-term remission after 1~2 times of ERI. Conclusion ERI is safe and effective for benign stricture of upper digestive system. It may prolong the dyspha-gia-free period, worth clinical promotion.

Efficacy of Retrievable Metallic Stent with Fixation String for Benign Stricture after Upper Gastrointestinal Surgery

OBJECTIVE: To determine the efficacy of retrievable metallic stent with fixation string for benign anastomotic stricture after upper gastrointestinal (UGI) surgery. MATERIALS AND METHODS: From June 2009 to May 2015, a total of 56 retrievable metallic stents with fixation string were placed under fluoroscopy guidance in 42 patients who were diagnosed with benign anastomotic stricture after UGI surgery. Clinical success was defined as achieving normal regular diet (NRD). RESULTS: The clinical success rate after the first stent placement was 57.1% (24/42). After repeated stent placement and/or balloon dilation, the clinical success rate was increased to 83.3% (35/42). Six (14.3%) patients required surgical revision to achieve NRD. One (2.4%) patient failed to achieve NRD. Stent migration occurred in 60.7% (34/56) of patients. Successful rate of removing the stent using fixation string and angiocatheter was 94.6% (53/56). Distal migration occurred in 12 stents. Of the 12 stents, 10 (83.3%) were successfully removed whereas 2 could not be removed. No complication occurred regarding distal migration. CONCLUSION: Using retrievable metallic stent with a fixation string is a feasible option for managing early benign anastomotic stricture after UGI surgery. It can reduce complications caused by distal migration of the stent.

Surface anesthesia and assisted balloon dilatation to treat dysphagia caused by radiotherapy for nasopharyngeal carcinoma / 中华物理医学与康复杂志

Objective To investigate the effects of surface anesthesia on assisted balloon dilatation when treating dysphagia caused by radiotherapy for nasopharyngeal carcinoma.Methods Fifty-four patients with dysphagia after radiotherapy were divided randomly into an anesthesia group and a non-anesthesia group.The anesthesia group received anesthetics before treatment while the non-anesthesia group did not.All of the patients were treated with low-frequency electrical stimulation and assisted balloon dilatation for 3 weeks.They were then assessed using videofluoroscopy and self-reports of difficulty in swallowing before and after the treatment.Results After the treatment, significant improvement was observed in pharyngeal delay time, in cricopharyngeal opening, and in laryngeal elevation and forwardness.There was also a significant decrease in self-reported swallowing difficulty and failed swallows in both groups compared with before the treatment.The improvements in the non-anesthesia group were significantly greater than in the anesthesia group.After the treatment, the average aspiration rate of the anesthesia group was significantly higher than before treatment and higher than that of the non-anesthesia group.The improvement in oral intake of the non-anesthesia group was significantly better than that of the anesthesia group.Conclusion Balloon dilatation and low-frequency electrical stimulation have a synergistic effect and can improve patients' swallowing after radiation-induced cranial nerve damage, thus promoting survival.Assisted balloon dilatation without anesthesia has a better effect than when surface anesthesia is used.

Endoscopic dilation combined with intramuscular injection of mitomycin C for benign esophageal strictures / 中华消化内镜杂志

Objective To evaluate the safety and efficacy of an endoscopic dilation in association with the intramuscular injection of either mitomycin C for benign esophageal strictures. Methods A total of 89 patients with benign esophageal strictures were retrospectively divided into 3 groups, including 30 cases of dilation combined with mitomycin C injection (mitomycin C group) , 29 of dilation combined with dexamethasone injection (dexamethasone group) and 30 of dilation with saline injection (dilation group). The successful rate, complications and the clinical effect in the 3 groups were compared. Results The 89 patients all successfully received the procedure, with the endoscopic and clinical release. No massive hemorrhage occurred. In mitomycin C group, 1 case with major complication (perforation) and 7 minor complication occurred;9 and 7 cases with minor complication occurred in dexamethasone group and dilation group, respectively. There were no significant difference of the complications in the 3 groups (P<0. 05). The mean dysphagia-free period was 5. 25±1. 18 months in the mitomycin C group, 4. 46±1. 53 months in the dexamethasone group, and 3. 03±1. 62 months in the dilation group (P<0. 05). Conclusion Endo-scopic dilation with or without the intramuscular injection of either mitomycin C or dexamethasone are safe and effective. Dilation combined with drug injection may prolong the esophageal dysphagia-free period. Furthermore, mitomycin C injection may have the dominant effect.

Clinical Efficacy of Endoscopic Treatment for Benign Colorectal Stricture: Balloon Dilatation versus Stenting

BACKGROUND/AIMS: There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes. METHODS: Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed. RESULTS: Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5+/-13.3 months vs. 2.0+/-0.6 months, p=0.031). CONCLUSIONS: Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.

The Experiment Research of Plastic Anastomosis in Treatment of Benign Stricture of Hilar Bile Duct / 昆明医科大学学报

Objective To explore a new technique to treat the benign stricture at hilar bile duct of plastic anastomosis, so as to obtain the theoretical basis and the feasibilities of practical application in treating the benign stricture at hilar bile duct with plastic anastomosis through the animal experiments. Methods 30 miniature pigs were randomly divided into three groups. Group A (control group):2 centimeters of the bile duct above the duodenum was isolated;Group B:The same separation of bile duct with group A, then making physical injury on it with the clamps and electric heat;Group C:Making bile duct injury model in group C as group B,and then monitoring of the diet, feces, urine, ALT, AST and bilirubin etc. When the bile duct stricture was formed, taking the plastic anastomosis operation in this group. After all the operations, we observed the diet, mental state and the color of the urine of animals in all the three groups, and tested ALT,AST,T-BIL and D-BIL levels on the pre- and post-day and every 7 days after surgery respectively. After three months of the surgery,we executed all the pigs,picked up part of the liver tissue,then preserved them by liquid nitrogen for pathological examination. Results From the day before operative-day to the 30 days after operation, there was no significant change in ALT, AST, T-BIL and D-BIL in group A,while the relative indicators of group B and C had obvious changes ( <0.05) . The indicators of group B were significantly increased 21 days after surgery, compared with pre-operation and 14 days after operation respectively ( <0.05) . In group C, the indicators were significantly declined 14 to 21 days after the plastic anastomosis compared with pre-operation (<0.05) . Conclusions Treating benign stricture at hilar bile duct of miniature pigs by plastic anastomosis is feasible and practicable. This study provides an experimental basis for clinical application of plastic anastomosis in treatment of benign stricture at hilar bile duct.

Clinical effect analysis of painless endoscopic pneumatic balloon dilation in the treatment of the stricture of esophagus and cardia / 中国基层医药

Objective To exlpore the effect and safety of endoscopic pneumatic dilation in the treatment of the benign stricture of esophagus and carclia.Methods 35 patients with the benign stricture of esophagus,eardia and anastomosis were treated with painless endoscopic pneumatic balloon dilation.Results The rate of stricture improvement was 100％,and the entire anastomosis diameter was extended over 12 am,at the first time,difficulty in swallowing was obviously relieved.Following up three months,the total effecttive percentage of stricture improvement was 88.6％,and no serious complication occurred in all cases.Conclusion Endoscopic pneumatic balloon dilation is effective and safe to treat the benign stricture of esophagus and cardia

Role of Fully Covered Self-Expandable Metal Stent for Treatment of Benign Biliary Strictures and Bile Leaks

Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.

Temporary Placement of Stent Grafts in Postsurgical Benign Biliary Strictures: a Single Center Experience

OBJECTIVE: To evaluate the effect of temporary stent graft placement in the treatment of benign anastomotic biliary strictures. MATERIALS AND METHODS: Nine patients, five women and four men, 22-64 years old (mean, 47.5 years), with chronic benign biliary anastomotic strictures, refractory to repeated balloon dilations, were treated by prolonged, temporary placement of stent-grafts. Four patients had strictures following a liver transplantation; three of them in bilio-enteric anastomoses and one in a choledocho-choledochostomy. Four of the other five patients had strictures at bilio-enteric anastomoses, which developed after complications following laparoscopic cholecystectomies and in one after a Whipple procedure for duodenal carcinoma. In eight patients, balloon-expandable stent-grafts were placed and one patient was treated by insertion of a self-expanding stent-graft. RESULTS: In the transplant group, treatment of patients with bilio-enteric anastomoses was unsuccessful (mean stent duration, 30 days). The patient treated for stenosis in the choledocho-choledochostomy responded well to consecutive self-expanding stent-graft placement (total placement duration, 112 days). All patients with bilio-enteric anastomoses in the non-transplant group were treated successfully with stent-grafts (mean placement duration, 37 days). CONCLUSION: Treatment of benign biliary strictures with temporary placement of stent-grafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant.

Self-Expandable Metallic Stent Therapy for a Gastrointestinal Benign Stricture / 대한소화기내시경학회지

BACKGROUND/AIMS: It is well known that self-expandable metallic stents are useful for the treatment of malignant strictures. Balloon and bougie dilation have received significant attention as a useful treatments for a gastriointestinal benign stricture, but the use of stents has some complications, including perforation and bleeding. We evaluated the clinical effectiveness and procedure- related complications of the use of self-expandable metallic stent therapy in gastrointestinal benign strictures. METHODS: We inserted self-expandable metallic stents in 11 patients with benign strictures during the period from January 2003 to May 2007. Eleven patients were included in this study (six males; mean age, 50.9 years). We observed clinical improvement, as well as complications and restenosis during follow-up. We defined "recurrence" as the return of symptoms. RESULTS: The causes of strictures were peptic ulcers (eight cases), corrosive esophagitis (two cases) and an anastomosis site stricture (one case). Three stents migrated within two weeks after placement. The mean length of time of a stent staying in a stricture was 16.1 days (3~35 days). After stent dilation, none of the patients had dysphagia to solid food or procedure- related complications. During a mean follow-up period of 12.8 months (3~35 months), the rate of restenosis was 36.4% (4/11 cases). All restenosis cases (two cases of peptic ulcer and two cases of corrosive esophagitis) occurred within three months after stent placement. CONCLUSIONS: We conclude that the use of self-expandable metallic stent therapy can be effective and safe for patients with gastrointestinal benign strictures. Restenosis (36.4%) occurred within three months. Future research on the management of gastrointestinal benign strictures is recommended.

Benign Stricture of Esophagojejunostomy after Radical Total Gastrectomy

PURPOSE: Benign anastomotic stricture after an esophagojejunostomy using EEA stapler following a radical total gastrectomy is one of the most serious complications. The purpose of this study is to evaluate the incidence, risk factors, and treatment associated with benign stricture. MATERIALS AND METHODS: From March 1998 to February 2001, 436 patients underwent an esophagojejunostomy with Roux-en-Y anastomosis using an EEA stapler followed by an endoscopy. Thirty three of the 436 patients (5.5%) developed an anastomotic stricture; included 24 of the 33 patients had a benign stricture. Nine patients with a malignant stricture were excluded. RESULTS: The median age of the 436 patients was 57 years (23~85 years). Two hundred ninety two patients were male, and 144 patients were female. The median time to diagnosing the stricture was 1.5 months (0.5~6 months). There was no statistical significance in any of the risk factors, including the diameter of the stapling device, the status of adjuvant treatment, the status of reflux esophagitis, and a clinical history of diabetes and hypertension. The strictured patients were treated with balloon dilatation, one to three times, with symptom relief. CONCLUSION: There were no statistically significant risk factors. However, further study of the vascularity of anastomoses and benign strictures needs to be considered. In the anastomotic strictured patients, endoscopic balloon dilatation appeared to be the first line of treatment.

Endoscopic ballon dilatation for benign colorectal anastomosis strictures / 中华消化内镜杂志

Objective To study the effeciency of endoscopic balloon dilat ation(EBD) for benign structures of colorectal anastomosis. Methods Fifteen cas es with benign stenosis of colorectal anastomosis(BCAS) were treated with endosc opic balloon dilatation,of which sigmoidectomy was performed in one case,and ant erior resection was performed in 14 case;stapler was used in 13 case,and hand su tura was used in 2 cases.Diameters and lengths of strictures were ranging from 0 .2～ 0.7 cm and 0.5～ 2.0 cm respectively. Results Strictures of all 15 patients were dilated successfully.There were no complications in this series.Follow－ u p has been from 3～ 30 months without recurrence of symptoms. Conclusion EBD is safe,efficient and well tolerated,and should be considered as the first choice o f treatment of BCAS.

A Case of Esophageal Stricture by Lye that Treated with Esophageal Endoscopic Endoprosthesis / 대한소화기내시경학회지

Swallowing caustic materials may produce full-thickness burn and loss of esophageal function. Caustics, both acid and alkalis, can corrode and destroy living tissue. Full-thickness burn of esophiageal epithelium causes severe stricture which frequently requires surgical repair. Recently, non-operative dilatation of luminal stenosis has been utilized. Esophageal endoscopic endoprosthesis has been used widely in malignant esophageal stricture but not in benign stricture. In recurrent benign esophageal stricture following repetitive balloon dilatation, we experienced a case of an 18-year-old woman with severe stricture which was successfully managed by esophageal endoprosthesia So we report this case with the review of the literature.

A Case of Esophageal Stricture by Lye that Treated with Esophageal Endoscopic Endoprosthesis / 대한소화기내시경학회지

Swallowing caustic materials may produce full-thickness burn and loss of esophageal function. Caustics, both acid and alkalis, can corrode and destroy living tissue. Full-thickness burn of esophiageal epithelium causes severe stricture which frequently requires surgical repair. Recently, non-operative dilatation of luminal stenosis has been utilized. Esophageal endoscopic endoprosthesis has been used widely in malignant esophageal stricture but not in benign stricture. In recurrent benign esophageal stricture following repetitive balloon dilatation, we experienced a case of an 18-year-old woman with severe stricture which was successfully managed by esophageal endoprosthesia So we report this case with the review of the literature.