Long-term results of balloon catheter dilation for benign gastric outlet stenosis.

BACKGROUND AND STUDY AIMS: In 1981, the authors introduced balloon catheter dilation for postoperative gastric outlet stenosis and later for peptic, corrosive and postvagotomy gastric outlet stenosis. This retrospective study evaluates the effectiveness, safety and outcome of balloon catheter dilation in these various indications. PATIENTS AND METHODS: Between September 1981 and September 2001, 177 balloon catheter dilation procedures were carried out in 72 patients with benign stenoses. Double-lumen or single-lumen balloon catheters with a mean diameter of 18 mm (range 12-25 mm) were used. Endoscopic check-up examinations were carried out 1-3 weeks later, and then after three, six and 12 months, or if symptoms returned. The mean follow-up period for patients who did not undergo surgery was 98 months (range 12-240 months). RESULTS: Symptomatic relief was obtained immediately in 80 % and after 3 months or more in 70% of the patients. The mean diameter of the stenoses was 6 mm (2.0-9.5 mm) before dilation and 16 mm (10-20 mm) afterwards. Gastric retention was observed in 49 patients (68%) before dilation and in 19 patients (26.4%) afterward. Sixteen patients had recurrent stenosis 1-18 months after the first dilation. All of the 18 postoperative strictures, 21 (70%) of the 30 peptic stenoses, six (35%) of the 17 patients with corrosive strictures, and five of the six patients with postvagotomy functional stenosis were successfully treated with dilation. Pyloric perforation occurred in two cases, and arterial hemorrhage was observed in one case after dilation. CONCLUSIONS: Balloon catheter dilation is an important and effective diagnostic and therapeutic method; depending on the causative factor, it can make surgery unnecessary in nearly 70% of patients with benign gastric outlet stenosis.

Primary cricopharyngeal dysfunction: treatment with balloon catheter dilatation.

BACKGROUND: Primary cricopharyngeal dysfunction (PCD) is a rare, idiopathic, functional disorder of the upper esophageal sphincter, characterized by dysphagia, frequent aspiration, and functional narrowing at the level of the upper esophageal sphincter. METHODS: Five of 29 patients with oropharyngeal dysphagia were found to have PCD. Patients presented with severe dysphagia and predisposition to aspiration. Radiography demonstrated narrowing at the level of the upper esophageal sphincter and aspiration. An endoscope could be introduced into the esophagus in only 2 patients before dilation. OBSERVATIONS: In contrast to organic stenoses, these functional upper esophageal sphincter stenoses were dilated without difficulty with a balloon catheter. After low-pressure (1.5-2 atm) progressive balloon dilation (to 20 mm), superficial mucosal injury was observed only in one patient. After dilatation, symptoms resolved and barium swallow demonstrated normal passage through the upper esophageal sphincter. During a mean follow-up of 21 months (7-33), redilation was necessary in only 1 case. CONCLUSIONS: Balloon catheter dilatation of PCD is minimally invasive and provides both important diagnostic information and effective therapy. It should be the first choice of therapy for PCD.

[Primary cricopharyngeal achalasia and its dilatation with balloon catheter]. / Primer cricopharyngealis achalasia és ballonkatéteres tágító kezelése.

The primary cricopharyngealis achalasia (PCA) is a very uncommon functional disorder of the upper oesophageal sphincter (UES) characterized by dysphagia, frequent aspiration, and impaired relaxation of the UES. It should be differentiated from diseases of neuromuscular and ENT origin, from organic causes and other types of cricopharyngeal dysfunction. On suspected oesophageal inlet stenosis, swallow x-ray studies using water-soluble contrast material is performed, followed by oesophagoscopy. If the endoscope cannot pass into the oesophagus, balloon dilatation is performed to reach a diameter of 12-15 mm. This facilitates the passing of the endoscope and helps ruling out organic causes. If the stenotic segment dilates easily, the mucosa is intact, and no mechanical obstruction is discovered, then UES manometry is performed to differentiate from other motility disorders. Extraluminal causes are excluded using endosonography and CT. If PCA is diagnosed, low-pressure (1-1.5 atm) balloon dilatation is continued under fluoroscopic control until a lumen diameter of 18-20 mm is obtained. Efficacy of dilatation is assured clinically as well as with endoscopical, barium swallow and manometric studies. Five out of 28 patients with pharyngo-oesophageal dysphagia were found to have PCA. Patients presented with severe dysphagia and a predisposition to aspiration. The radiographic examination demonstrated stenosis at the UES level, and aspiration. It was possible to introduce the endoscope into the oesophagus only two of the five patients before the dilatation. The manometry was not pathognomonic, its value did not achieve the expectations. In contrast with organic stenoses, UES dilated easily using balloon catheter. Thereafter, the endoscope passed smoothly through the UES in each of cases. Following progressive dilatation--with low pressure (1.5-2 atm) up to 20 mm in diameter-, superficial mucosal damage was observed in one patient only. Patients' complaints ceased after treatment, and the barium swallow showed normal passage. Redilatation was necessary only in one case after following 21 (7-33) months. The authors supposed that the gastrooesophageal reflux plays role in the pathogenesis of PCA. Balloon catheter dilatation is an important diagnostic and at the same time effective, first choice, minimal invasive therapeutic method in PCA.

[Balloon dilatation in the management of gastric outlet stenoses: long-term results]. / A gyomorkimenet szúkületeinek ballonkatéteres tágításával elért hosszú távú eredmények.

The authors introduced dilatation of postoperative gastric outlet stenoses in 1981 and later in peptic, corrosive and postvagotomic gastric outlet stenoses. They performed gastric outlet stenoses dilatation with balloon catheter 153 times on 66 patients between September 1981-1999. On three of 8 malignant cases--who had dilatation because of recidive inoperable tumor--metal prosthesis implantation had been performed and others underwent surgery. On 58 patients who suffered from benign stenoses 144 balloon catheter dilatation had been done. After dilatation during the follow up time at 39/58 cases (67.2%) there was no need for operation. The stenoses of anastomosis after antrectomy and pyloric preserving pancreatoduodenectomy at 15 cases had been cured by dilatation. At pyloric and bulbus stenoses two third of the patients, 14 from 21 (67%) and at the cases of corrosive gastric outlet stenoses 6 of 17 (35%) had been treated successfully by dilatation. At postvagotomic functional stenoses 80% of the patients were treated successfully by 23 mm diameter balloon catheter. The dilatation has no long-term effect in malignant stenoses so it was used just for diagnosis or in rare inoperable cases for the preparation of prosthesis implantation. After dilatation therapy they detected one case of artery hemorrhage and two cases of perforation. The balloon catheter dilatation of the gastric outlet stenoses is a very important diagnostic and endoscopic therapeutic method which--depending on the cause--makes operation avoidable in 66% (35-100) of the benign stenoses.

[The role of endoscopic ligation in the management of esophageal varices and rupture]. / Endoszkópos gumigyürüzés szerepe a nyelöcsö-varicositas, -ruptura kezelésében.

In the last two decades sclerotherapy has became one of the most widespread procedures in the palliative therapy of esophageal varicosity and rupture. Beside many of its advantages, there are high numbers of local and general complications. The new ligation method is very effective, but less invasive and free from side effects. The single shot method in spite of using overtube is slower, unpleasant and not free from risks. The new six shooter system, which uses 6 rubber-bands eliminates these disadvantages. This technique was introduced the first time in Hungary by the authors. They performed ligations between June 1997 and June 1999 on 39 random patients, 55 times. 41 times due to rupture of varices, 8 times in no-bleeding periods for eradication of varices, 6 times for prophylaxis. The average age was 51 (27-75), 32 men and 7 women participating. The cause of esophageal varicosity was thrombosis of vena portae in 1 patient and cirrhosis in others. The background of the cirrhosis was alcohol in all cases except for one which was due to alcohol and hepatitis C in addition. Altogether 346 rubber-bands were applied. The average ligation was 6.3 (3-17) per patient and 4.5 (3-6) per session. The 41 ruptures of the 32 patients were treated with 80 units of blood, not including one patient given 29 units of blood who had mortal haemorrhage. It means 2.5 units of blood per patient and 2 units per varix rupture. After ligation patients had no complaints except for retrosternal discomfort in some patients. There were no complications observed. The mortality rate was 5 out of 32 one patient died due to bleeding. The follow up of the ligation was carried out by endoscopy and in the 4 dead patients by pathological procedures. The ligation method which was applied by the authors is effective, faster and has less complications in varix irradications than sclerotherapy. The prophylactic therapy of high risk patients and other therapeutic indications can contribute to its wider utilization.

[Malignant esophageal-respiratory fistula and esophageal stenosis treated with a Gianturco-Z-stent]. / Malignus oesophagorespiratoricus fistula és nyelöcsöstenosis kezelése Gianturco-Z-stenttel.

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 use of Wallstent in malignant constrictions of the gastrointestinal tract]. / Wallstent alkalmazása a felsó gastrointestinalis rendszer malignus szúkületeiben.

Prosthesis implantation in malignant oesophageal stenosis, postoperative gastric outlet obstruction and jejunal stenosis is a quick and efficient method. The expansile metal stents are a new alternative to conventional plastic prosthesis. The Wallstent is made of surgical steel alloy elements braided in tubular fashion. The Wallstent is delivered in a small diameter device, but it expands to a much larger size after placement than the inner diameter of plastic stent. The small predilatations diameter makes implantation of the Wallstent less prone to cause complications or severe discomfort to the patient. The authors implanted seven Wallstents in six patients. One patient had oesophageal cancer, one ischaemic jejunal stenosis and four jejunal stenosis due to extraluminal tumour recurrences following total gastrectomy for cancer. The authors discuss in detail the usefulness of the Wallstent implantation in two cases with malignant disease of the oesophagus and jejunum. They remained symptoms free for 7 and 10 months after Wallstent implantation until death. Despite their higher initial cost, the metal stents are cost effective because of the absence of early and severe complications and the decrease in the hospitalization.

Postoperative ischemic jejunal stenosis treated with balloon catheter dilation and Wallstent implantation.

Ischemic stenosis of the jejunum is rare. For technical, anatomical, and pathological reasons, ischemic stenosis of the jejunal segment used for the replacement of the esophagus or the stomach, or both, represents a special entity. The present study reports a case of balloon catheter dilation of ischemic strictures of the jejunal segment, used for substitution after gastrectomy. In this patient, an occlusion of the blood vessels supplying the affected segment was observed at its aortic origin, and a Wallstent was implanted. A rare late complication, aortoesophageal fistula, appeared one year after placement of the Wallstent. The case presented in this study suggests that using balloon catheters and implanting a Wallstent may be a useful approach to the management of postoperative ischemic strictures of the jejunum in selected cases. The minimally invasive technique with special indications used here has not previously been described. The rare complication mentioned, however, requires special attention.

[Management of postoperative ischemic jejunal stenosis using balloon dilatation and/or Wallstent implant]. / Postoperativ ischaemiás jejunalis stenosis kezelése ballonkatéteres tágítással vagy/és Wallstent implantatióval.

Ischaemic stenosis of the jejunum is rare. For technical, anatomical, and pathological reasons ischemic stenosis of the jejunal segment used for the replacement of the stomach and oesophagus requires a special approach. The present study reports two cases of dilation of ischaemic strictures of the jejunal loop by balloon catheter, used for replacement after oesophagogastrectomy and gastrectomy. In the later case, in which the occlusion of the blood vessels supplying the affected segment was observed right at the level of the aorta, Wallstent was implanted. The advantages and disadvantages of metal stents are discussed and oesophaogoaortic fistula, a rare complication, which appeared a year after Wallstent placement, is described. The two cases presented in this study give evidence that using balloon catheters and implanting Wallstent-in selected cases-may give good results in the management of postoperative ischaemic strictures of the jejunum. The minimally invasive technique with the special indications described here is not known to have been used so far. The rare complication mentioned, however, requires special attention.

[The use of a nitinol (nickel-titanium) prosthesis in the management of malignant esophageal stenosis (preliminary report)]. / Nitinol (nikkel-titanium) protesis alkalmazása malignus oesophagus stenosis áthidalására (Elözetes közlemény).

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.

[Laser therapy of malignant stricture of the gastric stump]. / A gyomorcsonk malignus szükületének lézer terápiája.

56 years old patient was operated (Billroth II) with gastric carcinoma. Two and half years after was diagnosed an inoperable recidive local tumor. Because of stomal outlet disturbances a tantalum endoprosthesis was implanted. The tumor grew through the Strecker-net. For desobliteration of stent we applied laser therapy, the gastric passage was free.

[Implantation of a Gianturco-S prosthesis in malignant esophagogastric stenosis]. / Gianturco-S prothesis implantatio oesophago-gastricus malignus stenosis áthidalására.

An 80-year-old male patient with cardia adenocarcinoma underwent a surgical resection, but the local recurrence caused stenosis at the esophagogastro-anastomosis. The surgeon did not recommend the reoperation of the aged patient. After a repeated dilation a polyethylene coated flexible metallic prosthesis equipped with a double funnel was implanted. In a couple of days the prosthesis dilated to 16 mm in diameter. The patient reported waning tensive pain in the cardial region for a week after the implantation. After 4 months, now he is symptom free. The new instrument extends the possibilities of a palliative treatment.

[Implantation of a Stecker metal prosthesis in malignant stenosis of the gastric stump]. / Strecker fémprotézis alkalmazása a gyomorcsonk kimenet recidív, malignus szükületében (Elözetes közlemény).

A 55 year old patient 3 years after gastric resection (Billroth II) has got gastric outlet stenosis. Half year ago was established a tumour recidive, that the time of reoperation was inoperable. Under endoscopic and radiological control we have introduced and placed a 19 mm diameter, 4 cm long balloon expandable tantalum stent (Strecker stent). The gastric passage has normalised and after 6 month the patient is symptom free.

[Balloon catheter for the dilatation of the urethra]. / Húgycsötágítás ballonkatéterrel.

For the first time in Hungary balloon catheter urethral dilatation have been performed in two cases. Surgical approach for the first case was contraindicated because of poor physical state and cardio-pulmonary diseases. The other patient had urethral stricture and stone incrustation (composed of hair) after he has had urethral reconstructive plastic surgery. The authors have emphasized that internal urethrotomy have been a routine surgical approach for urethral strictura for the past 10 years however, under certain circumstances balloon-urethral dilatation should be applied. The postoperative results were satisfactory. No complications observed. The authors have therefore advised the use of balloon urethral dilatation because it is easy to perform and the results are satisfactory.