A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patient's hypopharynx. Using transillumination from the optical device, the patient's neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Pseudoachalasia: not only esophago-gastric cancer.

Pseudoachalasia is a rare clinical entity which has clinical, radiographic and manometric features often indistinguishable from achalasia. A small primary adenocarcinoma arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes. Rarely, processes other than esophagogastric cancers may lead to the development of pseudoachalasia. We present three cases of pseudoachalasia in which the primary cause of the disease was not an esophagogastric cancer. The causes were a pancreatic carcinoma, a breast cancer and an histiocytosis X. Aspects of these three patients' diagnostic and therapeutic course are discussed in detail.

Minimally invasive enucleation of esophageal leiomyoma.

BACKGROUND: Leiomyoma accounts for 70% of all benign tumors of the esophagus. Open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have recently emerged as interesting alternatives. To date, only case reports or very small series of such techniques have been reported. The authors report their experience over the past decade. METHODS: Between January 1999 and August 2005, 11 patients (6 men and 5 women; median age, 44 years) underwent surgery after presenting with dysphagia, chest pain, or heartburn. The surgical approaches included right video-assisted thoracoscopy (n = 7) for tumors of the middle lower third of the esophagus and laparoscopy (n = 4) for tumors within 4 to 5 cm of the lower esophageal sphincter or located at the gastroesophageal junction (GEJ). Intraoperative endoscopy with air insufflation during enucleation was used to confirm mucosal integrity and safeguard against esophageal perforation. Reapproximation of the muscle layers was performed after tumor enucleation to prevent the development of a pseudodiverticulum. A Nissen or Toupet fundoplication was added for patients undergoing laparoscopic enucleation of the leiomyoma. RESULTS: The median operative time was 150 min. All tumors were benign leiomyomas (median size, 4.5 cm). One leiomyoma located at the gastroesophageal junction required intraoperative mucosal repair with three stitches for an esophageal perforation (preoperative biopsies had been taken). There were no major morbidities, including deaths or postoperative leaks. The median postoperative hospital stay was 6 days. All the patients were free of dysphagia during a median followup period of 27 months. One patient had a small (< 2 cm) asymptomatic pseudodiverticulum at the 6-month follow-up endoscopy. CONCLUSIONS: Video-assisted enucleation of esophageal leiomyoma can be performed effectively and safely with no mortality and low morbidity. Thoracoscopic and laparoscopic techniques for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with minimally invasive surgery.

Single-band mucosectomy for granular cell tumor of the esophagus: safe and easy technique.

BACKGROUND: Mucosectomy involves resection of a digestive wall fragment that frequently removes a part or even all of the submucosal mass. The single-band mucosectomy technique was used to remove a granular cell tumor (GCT) of the esophagus. Only 3% of GCTs, which are relatively uncommon neoplasms, arise in the esophagus. Ultrasonography has allowed for more frequent recognition and better definition of this disease. Until recently, surgical resection of the esophagus has been the only treatment alternative to endoscopic surveillance. Endoscopic techniques such as mucosal resection (EMR), laser, and argon plasma have been proposed as safe and effective alternatives to surgery. However, to date, only a few reports of these endoscopic techniques have been published. This study aimed to evaluate the safety and feasibility of single-band mucosectomy for removing a GCT of the esophagus. METHODS: Six patients (1 man and 5 women; mean age, 45 years) with a GCT were studied between January 2000 and May 2004. They underwent EMR after endoscopic ultrasonography. RESULTS: The EMR was performed with a diathermic loop after injection of saline solution into the esophageal wall. Only one session was necessary for removal of the tumor from all 6 patients, and no complication was observed. During a mean clinical endoscopic follow-up period of 36 months, no recurrences, scars, or stenoses were observed. CONCLUSIONS: These findings show EMR to be a safe and effective technique that allows complete removal of GCTs. Furthermore, this technique provides tissue for a definitive pathologic diagnosis, which laser and argon plasma do not provide. We recommend EMR as the treatment of choice for GCTs after an accurate ultrasonographic evaluation.

Endoscopic treatment of pseudosarcomatous squamous carcinoma of the esophagus: case report and personal experience.

Spindle cell (or pseudosarcomatous) squamous carcinoma (PSC) is a rare malignant neoplasm of the esophagus, potentially capable of causing lymph node and distant metastases. Indications for surgery are the same as for squamous cell carcinoma (SCC) of the esophagus. The aims of this paper were to report a case of endoscopically treated PSC and to review our experience of surgically-treated patients with PSC in order to identify patients potentially suitable for endoscopic treatment. In our series of 4,460 patients with carcinoma of the esophagus observed between 1980 and 2003, 28 (0.6%) had the histological features of PSC. One had a PSC histologically confirmed (8cm-long polyp with a 3cm-large base) and endoscopically treated for high surgical risk. The patient had a close follow-up with endoscopic biopsies and ultrasonography with no local recurrence at 3 years. The overall survival rate was 22% for PSC and 17% for SCC (P = n.s.); after 5 years, the survival rates were 22% and 13%, respectively (P = n.s.). In our opinion the limited tendency to parietal infiltration and the good chance of disclosure in an early stage with endoscopic ultrasonography, justify non-surgical solutions in patients with a high surgical risk, possibly associated with adjuvant chemo- and radiotherapy since lymph node involvement is reported in 50% of cases. The limited number of patients with PSC involved in the present series prevent any significant statistical comparisons between the different groups, but the survival rates were roughly the same in the nonsurgical curative therapy as in the curative resection group, while the chances of survival were significantly lower in patients given palliative surgery and or non-curative treatments (P < 0.05).