Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent

PURPOSE: To evaluate the clinical effectiveness of a polyurethane-covered, retrievable, self-expandable metallic stent and hook catheter in the treatment of esophageal strictures. MATERIALS AND METHODS: Stents were constructed of 0.4-mm stainless steel wire in a cylindric zig-zag configuration of six to nine bends. Four to eight stents were connected in tandem by dipping in a polyurethane solution. A nylon loop was hooked inside to each bend of the proximal portion of the stent and strung with a thread. Under fluoroscopic guidance, 22 stents were placed in 16 patients with a malignant stricture and five patients with a benign stricture. The stent was removed with a hook catheter 2 months after placement in patients with a benign stricture and when complications occurred in patients with a malignant stricture. All patients had dysphagia with ingestion of soft foods or liquids. RESULTS: Stent placement was technically successful and well tolerated in 20 patients. In one patient, the stent was misplaced but relocated successfully. After stent placement, all patients were able to ingest solid and/or soft foods without dysphagia. After stent removal, strictures showed improvement but recurred in two patients. CONCLUSION: Use of polyurethane-covered, retrievable expandable stents seems to be a feasible and effective method of treatment of benign and malignant esophageal strictures.     

Management of acid-peptic esophageal strictures

A new, nontoxic material extracted from Aspergillus fumigatus, is described with complement-depletion capacity both in vivo and in vitro. Extracts of the mycelium of A. fumigatus were found to haemolyse sheep red blood cells, to be lethal for mice and to convert C3 into its faster electrophoretic form when incubated with normal human serum. Conversion did not take place when purified C3 was used, suggesting that serum factors were required in the reaction. Adsorption of the extracts with activated carbon or heating at 100 degrees C for 30 min yielded detoxified materials devoid of both toxic and haemolytic properties but still capable of converting serum C3. In guinea pigs, administration of detoxified extracts was followed by complement depletion lasting not less than 48 h. Heating (100 degrees C for 30 min) extracts which had been previously detoxified by carbon adsorption resulted in a partial loss (40%) of their complement-inhibitory capacity indicating that part of the anticomplementarity of AFE was due to a heat-stable substance.     

Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

Contribution of B.A. Petrov to development of methods for surgical treatment of postburn esophageal strictures

The article in historical aspect presents more than 40-year experience in improvement of methods for surgical treatment of esophagus and stomach burn aftereffects in N.V. Sklifossovsky Research Institute of Emergency Care. Great role in development of this problem of B.A. Petrov is stressed, who, as a follower of S.S. Yudin, has perfected a method of intestinal plastics, developed and applied in practice a technique of retrosternal esophagoplasty from ileocolon and has laid the foundation of reconstructive surgery on an artificial esophagus. The authors autline their own experience of the last two decades: 158 total isoperistaltic retrosternal esophagoplasties from the colon with lethality 3.1%. To present cancer, in 115 patients cicatricised esophagus was removed, lethality being 2.6%. Attention was paid to the physiological aspects of esophagoplasty, especially in the light of long-term results.     

Inhibition of experimental esophageal lye strictures by penicillamine

We describe a new experimental model for the study of caustic stenosis of the esophagus in the rat. Sixty-five Wistar rats were given a standard esophageal lye burn. Animals were divided into two groups: (1) a control group and (2) a treatment group that received penicillamine from the day after the esophageal lye burn. Stenosis developed in only two of the 23 treated rats. Our conclusion is that penicillamine-induced lathyrism inhibits the onset of stenosis in the rat. Double-blind controlled studies of the effect of penicillamine in the prevention of corrosive strictures of the esophagus in man seem warranted.     

Medical therapy of gastroesophageal reflux and management of esophageal strictures

The goals of modern medical therapy for gastroesophageal reflux disease are threefold: first, eliminate symptoms; second, heal injured esophageal mucosa; third, manage and/or prevent complications. Selection of a particular medical regimen depends on the severity of the disease, effectiveness of the therapy, cost, and convenience of the medical regimen. An accurate diagnosis needs to be made in patients suspected with esophageal strictures. If there is a treatable underlying disease, specific therapy is essential. The goal of dilation therapy should be established and set about to accomplish in a timely, but unhurried fashion. Fluoroscopy and wire-guided dilators should be used liberally, especially for difficult strictures.     

Clinical technique and success of the esophageal stent to prevent corrosive strictures

Membrane potential, Vm, and K+ (86Rb+) fluxes have been measured simultaneously on individual cells of Acetabularia mediterranea. During resting state (resting potential approx. -170 mV) the K+ influx amounts to 0.24-0.6 pmol-cm-2-s-1 and the K+ efflux to 0.2-1.5 pmol-cm-2s-1. According to the K+ concentrations inside and outside the cell (40:1) the voltage dependent K+ flux (zero at Vm = EK = -90 mV) is stimulated approx. 40-fold for Vm more positive than EK. It is calculated that during one action potential (temporary depolarization to Vm more positive than EK) a cell looses the same amount of K+, which leaks in during 10-20 min in the resting state (Vm = -170 mV). Since action potentials occur spontaneously in Acetabularia, they are therefore suggested to have a significant function for the K+ balance of this alga.     

Nonthermal ablation of malignant esophageal strictures. Photodynamic therapy, endoscopic intratumoral injections, and novel modalities

Several novel nonthermal ablative modalities for the palliation of malignant esophageal stenoses have been developed over the past decade. In this article, the authors review techniques and clinical experience with photodynamic therapy as well as the intratumoral injection of alcohol, cytotoxins, and immunomodulators.     

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.     

Diagnosis and evaluation of esophageal varices

Increasingly, the ability to respond to society's needs is becoming a guiding principle for educational institutions. This concept will, in difficult financial times, take on even greater significance when all programs will have to justify their survival by preparing graduates that can work in areas where there is a demonstrable need. The implications of this approach are far-reaching and require years of planning to adjust the current focus of a program to meet the new goals. In this article, a dental program that set out to broaden the scope of its curriculum in order to respond to societal needs will be reviewed.     

Malignant mesothelioma. Diagnosis and treatment

In over 90% of cases, mesothelioma initially presents as a banal pleural effusion, contributing no orientation to the diagnosis. The pleural fluid can even disappear after initial puncture. For early diagnosis, simple puncture, with or without biopsy, does not suffice. Thoracoscopy is 98% diagnostic. The course depends on the stage, the histological type and the general status. A new international TNM classification has been proposed to allow comparison of series and to choose a treatment appropriate to the stade: at stage I, intrapleural, local immuno-chemotherapy treatment gives good results; at stages II and III, surgery followed by radiation therapy are indicated; at stage IV, symptomatic treatment alone is justified.     

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.