Bougienage of esophagus in critical burn strictures

Bougienage was made in 625 patients with burn strictures of the esophague which made up 59.4% of all patients (1053) who have undergone treatment since 1966 to October 1977 in Research Center of Surgery. Indications and contraindications for bougienage are discussed. In patients with short strictures (146) good effect was obtained in 83.1% of cases, in long strictures (803) the bougienage was effective in 61.1% of patients, in total strictures (104) good and favourable results were obtained in 26.2% of cases. Bougienage is an important method of treatment for patients with burn strictures of the esophagus, as well as a method of preoperative preparation.     

Vibration bouginage in the cicatricial strictures of esophagus

In 66 patients for the dilation of the cicatricial stricture of the esophagus vibration method was used. In 48 patients the vibrator was attached to proximal end of the bouge, in 18 patients the vibration device was introduced directly in the area of the stricture. The suggested method provided an easy and fast dilation of the stricture in 63 patients. In 3 cases surgical treatment was carried out because multiple strictures in separate areas resulted in complete obliteration of the esophagus. There were no complications due to the vibrobouginage. For the treatment of inflammatory disorders of the esophagus and for prophylaxis of the scar formation in the area of stricture in 29 patients the therapeutic laser irradiation was used. This treatment has ensured promising results.     

The endoscopic therapy of benign stenoses of the esophagus and cardioesophageal junction using Eder-Puestow instrumentation

The results of palliative endoscopic treatment by bougienage using Eder-Puestow instrumentation, performed in a limited contingent of patients presenting benign esophageal strictures, are analyzed. It is underscored that the method is readily carried out and effective, and seldom leads to noteworthy complications, such as esophageal perforations--one patient alone presenting cicatricial stricture out of the total of 42 cases given treatment with bougienage over a 10-year period. The commonest cause of benign strictures of the esophagus in the series being examined is reflux (peptic) esophagitis against the background of hiatus hernia.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Surgical treatment of intraoperative injuries and cicatricial strictures of extrahepatic bile ducts

The analysis of 70 cases of surgical treatment for intraoperative injuries and cicatricial strictures of extrahepatic bile ducts was carried out. In 25 patients surgical procedure was restorative and in 45--reconstructiver. Most common causes of corrective operations were: iatrogenic injuries of extrahepatic bile ducts (14) and cicatricial strictures of hepaticocholedochal duct due to intraoperative trauma (31). The problems of operative technique in performing biliobilio-, hepato-hepatico and hepatico-jejuno-anastomoses are considered. There were three deaths in the early postoperative period: 2 patients died of hepatic failure, pyogenic cholangiogenic intoxication caused by cholangioectasies and intrahepatic abscesses, and 1-due to generalyzed peritonitis caused by acute gastric ulcer perforation. Special attention is paid to the choice of the method of prolonged drainage used in reconstructive as well as in restorative operations.     

The NHS--taking a look back

The article summarizes 11 years' experience (1986-1997) of endoscopical treatment for scar strictures of esophageal anastomoses in 13 patients after various types of esophagoplasty. In 65% of patients the diameter of the anastomosis did not exceed 5 mm. For distension of the anastomoses bouginage, balloon dilation and both of them were used. All sorts of dilators were introduced through an endoscopically inserted guide. In one patient introduction of the guide was a failure. Endoscopical procedures were performed in 112 patients. The diameter of the anastomosis 14 mm and more was achieved in 40 (35.7%) patients, 10-13 mm--56 (50,0%), less than 10 mm--in 18 (14.3%). In one half of the patients restenosis developed 1-3 months after the treatment. As a prophylactic measure it is necessary to maintain regular treatment in outpatient clinic with increasing interval during 3-6 months using any available dilators of a large diameter.     

Psychopathology as adaptive development along distinctive pathways

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.     

Role of preoperative sonourethrography in bulbar urethral reconstruction

PURPOSE: The accuracy of sonourethrography for the evaluation of bulbar urethral strictures has been well documented. Thus, we sought to define the role of preoperative sonourethrography in establishing objective criteria for procedure selection during bulbar urethral reconstruction. MATERIALS AND METHODS: Sonourethrography was performed preoperatively, just before incision, in 67 men selected for bulbar urethroplasty. All patients had strictures 25 mm. or less in length on preoperative radiographic retrograde urethrography, thus potentially amenable to resection and end-to-end anastomosis. Ultrasonic measurements were prospectively recorded, compared with those on preoperative retrograde urethrography, and used to guide the selection of urethroplasty technique. RESULTS: Overall, a significant trend for retrograde urethrography to underestimate stricture length was demonstrated (r = 0.678, p < 0.0001). Indeed, sonographic measurements were frequently twice those of retrograde urethrography, occasionally more. All 26 patients with short strictures on retrograde urethrography (10 mm. or less) were successfully treated by resection and end-to-end anastomosis, and sonographic assessment did not alter management. However, ultrasonic measurement changed the reconstructive procedure selected in 15 of 41 patients (37%, 3 penile flaps, 12 graft procedures) with bulbar strictures of intermediate length on retrograde urethrography (11 to 25 mm.). CONCLUSIONS: Sonourethrography has a major influence on selection of therapy in patients with bulbar strictures of intermediate length. By prospectively identifying strictures too long for resection and end-to-end anastomosis, sonourethrography enables quantitative criteria for selection of patients who may be more appropriately treated by flap or graft procedures. We advocate excisional therapy for strictures appearing sonographically to be 25 mm. or less, and substitution urethroplasty for longer strictures.     

The role of ceramide in the cellular response to cytotoxic agents

STUDY AIM: The aim of this study was to report the results of pharyngoesophageal reconstruction in extensive corrosive strictures and to describe an original conception concerning extensive chemical burns of the pharynx with involvement of the epiglottis, oro-hypopharyngeal junction and cricopharyngeal pinchcock. PATIENTS AND METHODS: A personal series of 253 esophageal reconstructions using the colon and ileum is reported. In 124 patients, the cervical anastomosis of the graft was performed at the level of the pharynx, and these cases with extensive pharyngeal lesions were the basis of this study. The anastomosis was performed with the hypopharynx in 27 patients, with the oropharynx in nine and a total reconstruction of the pharynx or "pharyngoplasty" was carried out in 69 patients. The pharyngoplasty was classified according to the approach, in anterior, posterior, lateral, superior (transmandibular) and inferior. In high strictures with epiglottic injury, epiglottectomy was necessary in order to prevent recurrence. A visceral pharyngoplasty was performed in 61 patients, using the colon in 42 and the ileum in 19, a skin reconstruction in six patients and a myocutaneous flap in two. RESULTS: The global postoperative mortality rate was 4.7%. Stenosis of the cervical anastomosis occurred in 4.9% of the whole series. With a follow-up from 6 months to 10 years, 70% of the patients resumed a normal oral diet, 21% had mild symptoms and 7% had poor results (patients with tracheostomy and gastrostomy). CONCLUSION: Extensive chemical burns of the pharynx are very severe and their treatment very difficult. For the author, total visceral pharyngeal reconstruction is considered to be the procedure of choice, using ileopharyngoplasty with realization of an ileal pouch. Good results were obtained in 70% of the patients with extensive corrosive strictures.     

The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures

During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.     

Comparison of vacuum extraction delivery between the conventional metal cup and the new soft rubber cup

The authors present a safe, conservative method of endless-loop bougienage (ELB) through the oral cavity and esophagus to a gastrostomy without general anesthesia in three children with corrosive esophageal burns treated since 1966. Esophagogastroscopy was performed to evaluate for esophagitis at an early phase after ingestion of the caustic substance. When esophageal stricture formation was recognized after subsequent conservative treatment, a feeding gastrostomy was made. A continuous string loop with plummets of progressively larger size was positioned to pass through the patient's oral cavity and esophagus to the gastrostomy. Strictures were found in the upper esophagus in two patients and in the middle and lower esophagus in one. The gastrostomy was performed 15 months, 20 days, and 2 months after the injury, respectively, and the periods of ELB were 3, 5, and 2(1/2) years, respectively. The patients were able to start eating at 26, 42, and 29 months after injury, respectively. They are now 30, 18, and 17 years old, and slight dysphagia remains in patients 1 and 2. No patient developed esophageal carcinoma at the site of the corrosive stricture. Our method of ELB through the patient's oral cavity and esophagus to the gastrostomy appears to be safe, reliable, and useful. We believe that most caustic esophageal strictures in children can be treated by this conservative measure.     

Iatrogenic esophageal injuries and their treatment

In our Department 22 patients were treated due to esophagus perforations in the years 1990-1996. Most of them (16) occurred after endoscopic examinations: diagnostic-3, after strictures dilatation-10, endoscopic intubation-2, sclerotherapy-1, transesophageal cardioversion-1. There were 5 intraoperative perforations: 3-after cardiomyotomy, 2-after intubation. The following treatment was performed: oesophageal suture and drainage-5 patients, subtotal oesophagectomy with oesophagogastrostomy-3 patients, oesophagectomy with salivary fistula and oesophago-gastro or -colostomy in second operation--9 patients, perforation covered with gastric fundus--3, intubation--1 patient, conservative treatment--1 patient. Four (18%) patient died.     

Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP)

BACKGROUND AND STUDY AIMS: The clinical importance of magnetic resonance cholangiopancreatography (MRCP) as a noninvasive diagnostic modality for investigation of the biliary tree and pancreatic duct system is under debate. Using endoscopic retrograde cholangiopancreatography (ERCP) as the gold standard, this study determined in a prospective, blinded fashion the sensitivity and further statistic values of MRCP findings for evaluation of the biliary and pancreatic tract. PATIENTS AND METHODS: Seventy-eight patients referred for ERCP were studied prospectively with MRCP and ERCP during a 12-month period. All images were interpreted on a blinded basis by two radiologists. Any dilations, strictures, and intraductal abnormalities were recorded and correlated with the clinical diagnoses. RESULTS: MRCP images of diagnostic quality were obtained in 76 of the 78 patients (97%). Magnetic resonance cholangiography (MRC) showed sensitivities (and positive predictive values) of 71% (62%) for recognition of normal bile ducts, 83% (91%) for recognition of dilation, 85% (100%) for recognition of strictures, 77% (91%) for correct stricture location, and 80% (100%) for diagnosing bile duct calculi. In addition, the sensitivity of MRC in classifying benign and malignant strictures was 50% and 80%, respectively. The statistical values (sensitivity and positive predictive value) for magnetic resonance pancreatography findings were determined for the recognition of normal pancreatic ducts (33% and 50%), recognition of dilation (62% and 100%), recognition of strictures (76% and 87%) and correct location (66% and 100%), diagnosis of benign strictures (87% and 87%) and malignant strictures (60% and 75%), and for diagnosing pancreatic duct stones (60% and 100%). CONCLUSIONS: MRCP is capable of providing diagnostic information equivalent to ERCP in many patients, and should be applied whenever established techniques provide no results, or inadequate results.     

Combination of diathermy and argon plasma coagulation in treatment of cicatricial esophageal stenoses

Scar stenoses of the esophagus are caused by peptic reflux or following surgery of the upper gastrointestinal tract. Short scar cicatricial stenoses are difficult to treat and have a high recurrence rate. Pneumatic dilatations show a short term success. We treated 5 patients with a short scar esophageal stenosis after esophagogastrostomy (n = 3) and after esophagojejunostomy (n = 2). The main symptom was dysphagia. X-ray shows the length of the stenosis (max. 1.5 cm). The stenosis was cutted by diathermy in a starshape. In all 5 cases it was possible to achieve the wide lumen. There were no complications. The combination of diathermy and argon-plasma-coagulation is a safe method, rare of complications in the treatment of short scar stenosis of the esophagus.     

Endoscopically guided balloon dilatation of benign esophageal strictures in 6 cats and 7 dogs

Benign esophageal strictures in 6 cats and 7 dogs were treated with endoscopically guided balloon dilatation. Six of 13 had a history of anesthesia within 3 weeks prior to the onset of signs; 8 animals had a single stricture, and 5 had multiple strictures, for a total of 19 strictures. Four of the 19 strictures were in the upper esophagus, 11 were in the middle esophagus, and 4 were in the lower esophagus. The luminal diameters ranged from 1 to 18 mm, with a mean of 5.1 mm. Twelve animals survived the immediate postprocedure period and had a total of 50 dilatation procedures performed; the mean number of procedures per animal was 4.2 (range, 2 to 8). Complications included mild bleeding and tearing (11 of 13), moderate bleeding (1 of 13), and esophageal perforation (1 of 13). The cat with the perforation was subsequently euthanized. Follow-up information was available on the 12 remaining animals; 9 were known to be alive 6 to 59 months (mean, 28.2 months) after dilatation. Two were euthanized, 1 for persistence of signs and the other for unrelated causes. One animal died of possible aspiration pneumonia. Three of 13 animals had complete and 9 had partial resolution of signs. Of the 9 animals with partial resolution, 7 were substantially better with dietary modification, 1 was moderately better, and 1 had minimal improvement. Eleven of 13 animals (85%) had a successful outcome with moderate to complete resolution of signs. Thus, it is concluded that endoscopically guided balloon dilatation is an effective and relatively safe treatment for benign esophageal strictures in dogs and cats.     

Recurrent parotitis in children and HIV infection. Apropos of 4 cases]

Over a 2-year period at our institution, 6 patients underwent metallic stent treatment, 5 for malignant conditions and 1 for a benign condition of the esophagus. The use of expandable metallic stents for benign strictures has paralleled malignant indications but is limited and less understood from a clinical standpoint. A review of current literature in the treatment of benign strictures is presented. Treatment of benign strictures is associated with high morbidity and mortality as demonstrated by the cumulative experience of 21 patients. Migration, hyperplastic tissue obstruction at the terminal ends, reflux, and complications of perforation occur at a prohibitive rate. We conclude that expandable metallic stents should be reserved for palliative treatment of esophageal malignant obstructions and tracheoesophageal fistulas. Pharmacological management, necessary dilatations and operative corrections (antireflux procedures, esophagectomy) are recommended treatments for benign strictures.     

MPK38 expression is upregulated in immature T cells activated by concanavalin A

Between 1974 and 1994, 25 colonic interposition procedures were performed for esophageal replacement in 23 cases of esophageal atresia (EA) and 2 corrosive strictures. Nine patients had one-stage and 16 had two-stage reconstructions. The transthoracic route was used in 16 cases (64%) and the retrosternal route in 9 (36%). Average age at the time of operation in EA patients was 17 months (range 12-33), and the children with corrosive injuries were 3 and 6 years old. Mean age at follow-up was 11.8 years (2.3-20.5 years). There was no mortality in the series. One patient developed full-graft necrosis and had a gastric pull-up procedure later. One child had partial graft necrosis (3 cm at the cervical end), however, enough colon was available for reconstruction. Ten patients developed a leak from the cervical anastomosis (40%) and 7 developed a stricture at the cervical esophago-colonic anastomosis (28%). The strictures were treated by repeated esophageal dilatation, and 3 patients required revision of the anastomosis (12%). Other complications included acid reflux in 2 cases (8%), small-intestinal obstruction in 1 (4%), redundancy of the colon in 1 (4%), and chest infections in 2 (8%). Follow-up included assessment of the patient's symptoms, serial growth measurements (height and weight), and where relevant, endoscopy and a contrast swallow or meal. There was a 52% improvement in weight and height percentiles post-operatively. Each of the 19 patients who had barium swallows showed rapid transit and emptying without any significant delay or hold-up. Overall long-term results were excellent in 13 patients (52%), good in 7 (28%), and fair in 5 (20%). The colon conduit thus provides an excellent substitute esophagus in pediatric patients.     

Primary biliary stones: diagnosis and management

To review the results of treatment of primary biliary stones, 96 consecutive patients managed from 1991 to 1996 were studied retrospectively. Acute cholangitis and abdominal pain were the presenting symptoms in 57 patients (59%) and 29 patients (30%), respectively. Fifty-four patients (56%) had a history of biliary surgery. Endoscopic retrograde cholangiopancreatography, ultrasonography, and computed tomography were frequently employed for diagnosis of primary biliary stones and were performed on 84 patients (88%), 90 patients (94%), and 89 patients (93%), respectively. Intrahepatic stones were identified in 91 patients (95%) and biliary strictures in 34 patients (35%). Concomitant cholangiocarcinoma occurred in 15 patients (16%). Hepatic resection was required in 55 patients (57%) for removal of an atrophic liver lobe or a segment related to repeated infection, biliary strictures, liver abscesses, or cholangiocarcinoma. Intraoperative choledochoscopy was routinely performed in all patients to detect, remove, or confirm clearance of biliary stones. A hepaticocutaneous jejunostomy (HCJ) was constructed in 70 patients (73%) to facilitate postoperative choledochoscopic examination or biliary stone extraction. Twenty-two patients (23%) had residual stones and required postoperative choledochoscopic extraction. Complete eradication of residual stones was achieved in all patients. Postoperative morbidity occurred in 28 patients (29%), and there was one hospital death (a patient with cholangiocarcinoma). With a median follow-up of 26 months (range 2-62 months), stones recurred in three patients. In conclusion, the early results of treatment of primary biliary stones were satisfactory owing to a systematic, aggressive approach that consisted of hepatic resection, frequent construction of an HCJ, and postoperative choledochoscopy.     

Modified ileocolonic bladder: 5 years of experience

A total of 25 patients 17 to 78 years old (mean age 61 years) underwent bladder replacement with a modified ileocolonic bladder: 20 underwent construction of the neobladder following cystoprostatectomy for invasive bladder tumor, 4 after cystectomy for severe interstitial cystitis and 1 for undiversion. There were 21 men and 4 women. Followup ranged from 3 to 66 months. There were no perioperative deaths. The early complication (perioperative 3 months) and late complication rates were 18% and 16%, respectively. Complications included ureterocolonic anastomotic strictures in 4 ureters (3 were treated via endoscopic retrograde balloon dilation and 1 with endourological antegrade dilation), urethral strictures in 2 patients, treated by urethral dilation, pancreatitis 2 weeks postoperatively in 1 and mild hypercholoremia without concomitant acidosis in 2. One patient presented 3 years postoperatively with a left mid ureteral stone that was managed by ureteroscopic extraction. Three patients died of recurrent carcinoma (none with urethral recurrence). The daytime continence rate was 100% and the nighttime continence rate was 92%. The ureters in this modified ileocolonic bladder were placed in an anatomically correct position to resemble a trigone near the mouth of the neobladder with the left ureter uncrossed. This placement provided easy visualization and instrumentation of the upper urinary tract. No patient had vesicoureteral reflux.     

Subcycling-PCR for multiplex long-distance amplification of regions with high and low GC content: application to the inversion hotspot in the factor VIII gene

OBJECTIVE: Treatment of long or multiple anterior urethral stricture(s) when Monseur technique is not applicable. Our technique entails augmentation of the dorsally slit open stenosed urethra using pedicled non-hair bearing penile skin. PATIENTS AND METHODS: Between June 1991 and May 1996, 26 men (median age 34 years) with anterior urethral strictures underwent roofing urethroplasty. Nine patients had long stricture (average 3.2 cm) and 17 had multiple short segment strictures (average 7 cm). All patients were circumcised, and dorsal urethral augmentation was performed using transversely oriented non-hair bearing penile skin pedicled flap. RESULTS: Median follow-up was 38 months (range 3-50). A successful outcome with no recurrent stricture as evidenced by normal retrograde urethrography and voiding history was achieved in 23 of 26 men (88%). Two patients had fistula in early postoperative period; one of them needed surgical closure. CONCLUSION: Roofing urethroplasty is a practical alternative for repair of long anterior urethral stricture(s) when Monseur technique cannot be applied.