Peptic stricture S ht ki` i Schatzki`s ring Esophageal cancer Radiation

Transcription

Sreenivasa S. Jonnalagadda, MD
Sreeni Jonnalagadda, MD., FASGE
Professor of Medicine, UMKC
Director of Interventional Endoscopy
Saint
i Luke’s
k ’ Hospital,
i l Kansas City
i








Peptic stricture
S h t ki’ ring
i
Schatzki’s
Esophageal cancer
Radiation therapy
Esophageal surgery
p
p g
Eosinophilic
esophagitis
Caustic injury
Iatrogenic – PDT, EMR, sclerotherapy
ACG Regional Postgraduate Course - St. Louis, MO
Copyright 2013 American College of Gastroenterology
1

Location

Pr im l strictures
tri tur close
l
tto UES
Proximal

Length of stricture
Cause of stricture
Extent of transmural involvement
Associated fistula
Failure of traditional therapies

Perforation 0.1% to 0.4 %







High r in m
r complex
mpl strictures
tri tur
Higher
more
Higher in radiation strictures
Endoscopist experience (500 procedures)
 Br J Surg 1995;82:530-3.
2
Gastrointestinal Endoscopy 2009; 70:1000-1012
3



First reported in 1966 in the therapy of
cutaneous scars
Intralesional steroids soften scars and keloids
Technique
 triamcinolone acetate 40 mg/ml
 Dilute 1:1 with saline
 Inject with sclerotherapy needle in aliquots of 0
0.5
5 ml in
4 quadrants
World J Gastrointest Endosc. 2010 February 16; 2(2): 61–68
4





Prospective randomized, double-blind study
comparing steroid with sham injection in
peptic strictures
Patients maintained on PPI
Phone followup at 1, 3, 6, 9 and 12 months
15 patients randomized to each group
Strictures were dilated to 15-18 mm
Am J Gastroenterol 2005;100:2419-2425



2/15 patients in steroid group and 9/15 in
sham group required repeat dilation (p =
0.0209)
Shorter time to repeat dilation in the sham
group (p = 0.01)
In patients with recalcitrant peptic strictures,
steroid injection combined with acid
suppression
i significantly
i ifi
l diminishes
di i i h need
d for
f
repeat dilation and average time to repeat
dilation compared to sham injection and acid
suppression.
Am J Gastroenterol 2005;100:2419-2425
5



Schatzki’s rings and esophagogastric
anastomosis strictures following failure of
standard therapy
Electrocautery using a a needle knife
Incise the stricture in 4 quadrants
6




Randomized trial of 62 patients with dysphagia
secondary to anastomotic stricture after
esophageal resection
Savary dilation versus incisional therapy
No difference in clinical success rates between
the two groups at 6 months
Conclusion:
incisional
can be
C
l i
i i i
l therapy
h
b
considered in refractory Schatzki’s ring and
anastomotic stricture but more studies are
required.
Gastrointest Endosc;70:849-55
7
SEPS
FcSEMS
8

Intraprocedural:
Complications of conscious sedation.
Aspiration
Aspiration.
Malposition.
Esophageal perforation.

Postprocedural:
Chest pain.
Bleeding.
Tracheal compression and respiratory arrest.

Delayed:
Stent migration.
Tracheoesophageal fistula.
GERD,
Recurrent dysphagia. Tumor ingrowth or overgrowth.
Bleeding.
Perforation and stent occlusion

Self expanding plastic stents


Fully covered self expanding metal stents





Appr
d for
f ru
b nign refractory
r fr t r strictures
tri tur
Approved
use in benign
Off label use
No assembly required
Ease of deployment
Ease of removal
Use of partially covered and uncovered stents
is not recommended
9




10 studies, 130 patients with refractory or
recurrent benign esophageal strictures treated
with SEPS
Median follow-up 13 months (range 6-23
months)
Technical success 128/130
Clinical
Cli i l success in
i 68/128 (52%)
Aliment Pharmacol Ther 2010;31:1268-1275
10





Success was lower in upper esophagus
E l stent
t t migration
i ti iin 19 (23 %)
Early
Post endoscopic reintervention in 25 (21 %)
Fatal bleed (1), tissue overgrowth (2),
perforation (3)
Relatively high migration rate and need for
reintervention!
Aliment Pharmacol Ther 2010;31:1268-1275
11




31 patients: 15 leaks, 9 refractory strictures, 4
anastomotic strictures
strictures, 3 radiation induced
strictures
30 Wallflex stents 12 Bonastent and 1 Evolution
Migration was seen 3/19 (15.8 %) stricture
patients, and overall migration in 25.6 %.
All strictures
resolved
i
l d iin this
hi retrospective
i
series.
Gastrointest Endosc 2011;74:207-211
12

214 patients with benign esophageal disease






R fr t r strictures
tri tur 49.2
49 2 %
Refractory
Fistulae 49.8 %
52 % FCSEMS; 28.6 % PCSEMS; 19.5 % SEPS
329 stent extractions
35 (10.6 %) procedure related adverse events
7 major events:
 PCSEMS: embedded, esophageal avulsion, stent
fracture, perforation (3),
 SEPS: fistula
13


Endoscopic clips
E d l i l suturing
t i
Endoluminal
14
15






18 patients underwent 21 endoscopic suturing
procedures to anchor SEMS
19 previously placed metal stents: 14 (74%)
migrated at median of 19 days.
1-5 interrupted 2-0 polypropylene sutures
Technical success rate 100 %
Despite suture fixation, stent migration
occurred in 7/21 (33%)
No association between number of sutures and
migration rate
Fujii et al. Gastrointest Endosc 2013
16

For complex strictures in patients with existing
PEG tube – consider retrograde access to allow
passage of a wire across the stricture followed
by antegrade dilation.
17


Consider size of stent being placed
A you crossing
i the
th LES?
Are



Reflux precautions
Uncovered, covered, partially covered
Antireflux valve
18




Best to use a proximal release system
D l under
d direct
di t endoscopic
d
i and
d
Deploy
fluoroscopic guidance
Airway compression
O ti
Options



remove stent
place smaller caliber stent
consult interventional pulmonologist for
simultaneous endotracheal/bronchial stent
19




Retrospective analysis of 23 patients
undergoing circumferential ESD for esophageal
cancer in Japan
Balloon dilation alone (13) or dilation plus 30
mg oral prednisoloe daily (10)
Steroid + EBD required fewer sessions ans
shorter management period :13.8 versus 33.5
P<0.001
P 0 001
Early steroid therapy may impact collangen
deposition and fibrosis which occur 3-7 days
after injury.

Two animal studies evaluating ability to
prevent esophageal stricture following
circumferential EMR and ESD



Fabricated autologous epidermal cell sheets isolated
from oral mucosa and seeded on cell culture inserts
Extracellular matrix scaffold from porcine urinary
bladders
Prevented esophageal stricture formation in the
short term
Gastroinetst Endosc 2012;76:873-880
20
21

Peptic stricture S ht ki` i Schatzki`s ring Esophageal cancer Radiation

Transcription

Similar documents

Approach to sphincter of Oddi dysfunction

course - Grand Geneva

The stomach that refuses to empty

New Orleans Restaurant Map

1-:--` -. - JPN Melaka - Kementerian Pendidikan Malaysia

昝扦઴ ࢊ痈䇂쭊⊫ş - E

Le infezioni delle vie biliari

Eliminating bad behavior

Blow molding

LA RIVISTA DI ELSA TRENTO

PKH PKM DESI - Ditjen PAUD

I RR LA PRESA scheda tecnica

00_fm_i-xxviii.indd 1 10/02/11 15.40

SISHIP PAX for Yachts

Tavola internazionale dei Pesi Atomici

Lecture 1_Structural Assessment_Dr. Lim(1).

Shift Registers

oggettistica tappeti luce objects rugs lighting

Osservatorio HR Innovation Practice del Politecnico di

oggettistica tappeti luce objects rugs lighting

Programmi - Suor Orsola Benincasa

Scarica (Apri una nuova finestra)