- Email: [email protected]
The use of a removable self expanding metal stent in a radiation induced esophageal stricture
ESOPHAGUS 233
t"235
THE USE OF A REMOVABLE SELF EXPANDING METAL STENT IN A R A D I A T I O N I N D U C E D ESOPHAGEAL STRICTURE. Riten Sheth, lohn W. Birk. Peter P. Ells, and Gall M. Comer, Division of Gastroenterology and Hepatology. State University of New York at Stony Brook, New York, 11794. Introduction: Esophageal stricture is a late complication of radiation therapy. These strictures tend to be long and tortuous. Treatment often consist of repeated esophageal dilatation which has variable success and a high complication rate. We describe a novel therapy for radiation induced esophageal stricture using a removable self expanding metal stent. Case Report: A 48 yo white female with past medical history of schizophrenia and metastatic breast cancer who is s / p surgery to the left breast with adjuvant radiation therapy 10 years ago, presented with dysphagia. Two years ago she developed nausea and vomiting and was found to have a esophageal stricture. Endoscopic biopsy showed it to be benign. Dilatation was done with progressive Savary-Gillard dilators with symptomatic relief. One year ago her symptoms recurred. PE was unremarkable. An Upper GI series showed a 1.3 cm long mid esophageal stricture, with a lumen of 8 mm. U p p e r endoscopy showed a stricture with 9 m m opening at 30 cm. Endoscopic biopsy and cytology was benign. CT scan of thorax showed thickened esophageal wall. The stricture was dilated dProgressively with Savary dilators up to 12.8 mm. The luminal iameter could not be dilated any further on several endoscopic dilatation attempts and patient continued to complain of dysphagia. We then placed a removable self expanding, esophageal metal stent (UltraflexTM,Microvasive) to control the dysphagia. The patients symptoms improved and 2 month later the stent was removed without difficulty. On endoscopic removal the luminal diameter was increased to 16 ram. Discussion: Repeated esophageal dilatations are the usual therapy for esophageal strictures of all types. However in radiation induced esophageal stricture the success is variable. Self expanding metal stents may be an alternative therapy.
SHOULD BIOPSIESBE TAKEN FROM ECTOPIC GASTRIC MUCOSAIN THE UPPER ESOPHAGUS ? A, Sibille. Ph. Warz~e, M. Herin. Depamueat of Gastroontemlogy,Centre HospitalierNcXre-Dameet Reine Fabiola, Charleroi and lnstitut de Pathologieet de G~etiqae, Loverval, Belgium. Ectopic gastric mucesa (EGM) is oibm seen in the upper esophagusand is usually considered as a beaigu lesion. However, some pathological conditions arising from EGM have besa reported, such as admocereinoma, ulceration or 'i~.~lysuphagia. This study was designed to determine the rata of significant ological features in EGM, such as helionhactar pylori gastritis or metaplasia. Material and Methods. In 17 patients in whom an upper ~ndoscopywas needed, a lesion havingthe eadescepic appearanceof EGM was discovered in the upper esophagus. No patiem had esophageal symptoms. Biopsy samplesweretaken fromthe antrumand fromthe lesion. Results. In one patient the biopsy of the lesion revealed chr~ic esuphagitis and no ectopic or metaplastic tissue. Ammg the 16 other patients, EGM, intestinal metuplasia (IM) and a mixture of EGM and 1M were found in 13, 2 and 1 patients, respectively+ IIP was presemin the EGM of 3 patie~.s; in all three, there was a mildto moderate inflammatoryreaction Oymphoplasmocyticinfikrate), lip was pr~mt in the antrum of 9 patients, including all those whose EGM exhibited liP. Conclusion. HP gastritiswas preselxtin EGM in 17% of all p a t i ~ and in 33% oftha patiems exhibitingI-lPin the antrum. Intestinalm~,uphsiawas found in 17% ofthe upper esophaguslesions. EGM of the upper esophagusis subject to the same pathological omditims as the gastric muccea. The detection of these by biopsyc~ ha importantfi'omthe clinical point of view.
t'234 ENDOSCOPIC STENT PLACEMENT FOR PALLIATION OF INOPERABLE ESOPHAGEAL AND GASTRIC CARDIAC CANCER WITH ESOPAGEAL INVASION: PLASTIC STENTS VERSUS EXPANDIBLE METAL STENTS. Institute for Digestive Research, Department of Internal Medicine, Soon Chun Hyang University, Seoul, Korea, C.S. Shim. H.K. Bong, Y.H. Lee. Y.D. Cho, J.O. Kim, J.Y. Cho, Y.S. Kim, J.S. Lee, M.S. Lee, S.G. Hwang Background: Endoscopic implantations of stent are useful method of rapid palliation of malignant stenosis on esophageal and gastric cardiac cancer. But plastic stents have a high rate of complications. Recently, expandable metal stents have been available and lower rate of complications. Aim: We compared the clinical results of insertion of plastic stents with those of metal stents for palliation of malignant esophageal stenosis due to esophageal cancer and gastric cardiac cancer with esophageal invasion. Patients and Methods: Eighty nine patients with malignant esophageal stenosis due to esophageal cancer and gastric cardiac cancer with esophageal invasion underwent endoscopic implantation of stents(plastic stent: 49, expandable metal stent: 40). The degree of palliation and incidence of complications(early and late) were compared in both treatment groups. Results: Successful endoscopic placement was similar in both treatment groups(plastic stents :93.9% vs expandable metal stents :97.5%) and significant improvement of dysphagia scores was similar in both treatment groups. But number of dilatation in implantation of expandable metal stents was significantly less than those of plastic stents. Early complicalons(especially perforation in 6.1% with plastic stents vs 0 % with metal stents) were significantly less frequent with metal stents than with plastic stents(2.5% vs 10.2%). Late complications included food impaction(4 cases with plastic stents vs 1 cases with metal stents), tumor overgrowth(2 cases with plastic stents vs 1 cases with metal stents), migration(3 cases with plastic stents vs 5 cases, with metal stents), and tumor ingrowth only with metal stents(two cases). In 5 migrated cases of metal stents, 3 cases were inserted with membrane covered metal stent in lower esophageal cancer. There were no procedure-related death. Indwelling duration of stents was similar in both treatment groups(91.1 days vs 112.5 days). Conclusions: Metal stents seem to be more easy to be inserted, more comfortable to the patients, but more expansive than plastic stents. Expandable metal stents have a tendency of less short-term complications than plastic stents. There is a tendency of frequent stent migrations when membrare covered self-expandable stents are inserted in lower esophageal and cardiac cancer.
236 ACHALASIA AFTER SCLEROTHERAPY OF ESOPHAGEAL VARICES TREATED WITH BOTULINUM TOXIN J.M. J~tCAr,~, M.C. Zonca, Department of Gastroenterology, Henry Ford Hospital, Detroit, MI Endoscopic sclerotherapy is a common method for the acute treatment of bleeding esophageal varices and to reduce the risk of further bleeding episodes. Complications of sclerotherapy are well recognized and have been reported to occur 2% to more than 30%. Complications may include bleeding, ulceration and stricture formation. Esophageal dysmotility has been shown to result from sclerotherapy. Acute decreases in distal esophageal peristaltic waves in the distalesophagus and increases in the number of simultaneous contractions have been reported. This results in dysphagia in many patients. Esophageal mot~ity disorders secondary to sclerotherapy are usually reversible, returning to normal within four weeks of completing treatment. Most patients require no specific therapy unless a stricture forms. Persistent dysphagia longer than seventytwo hours without development of a stncture is rare. We report a patient with alcoholic cirrhosis who developed dysphagia and abnormal esophageal motility within one week of sclerotherapy of esophageal varices. Dysphagia persisted for greater than three months with the development of radiographic, endoscopic, and manometric findings suggesting achalasia. Mahgnancy and other known causes of secondary achalasla were ruled out. Manometry revealed markedly decreased distal esophageal peristaltic waves and a thilure of lower esophageal sphincter pressure to decrease to baseline in greater than fifty-percent of wet swallows. Pneumatic dilatation and surgery were felt to be too risky due to thepatient's poor medical condition and coagulopathy. Botulinum toxin 80u was injected into the lower esophageal sphincter with symptomatic improvement in dysphagia within three weeks. Repeat esophageal barium studies did demonstrate widening of the gastroesophageal junction. There are few cases reported ofachalasia after endoscopic sclerotherapy of esophageal varices. This is the first known case of the treatment of this type of achalasia with botulinum toxin.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 8 3
t"235
THE USE OF A REMOVABLE SELF EXPANDING METAL STENT IN A R A D I A T I O N I N D U C E D ESOPHAGEAL STRICTURE. Riten Sheth, lohn W. Birk. Peter P. Ells, and Gall M. Comer, Division of Gastroenterology and Hepatology. State University of New York at Stony Brook, New York, 11794. Introduction: Esophageal stricture is a late complication of radiation therapy. These strictures tend to be long and tortuous. Treatment often consist of repeated esophageal dilatation which has variable success and a high complication rate. We describe a novel therapy for radiation induced esophageal stricture using a removable self expanding metal stent. Case Report: A 48 yo white female with past medical history of schizophrenia and metastatic breast cancer who is s / p surgery to the left breast with adjuvant radiation therapy 10 years ago, presented with dysphagia. Two years ago she developed nausea and vomiting and was found to have a esophageal stricture. Endoscopic biopsy showed it to be benign. Dilatation was done with progressive Savary-Gillard dilators with symptomatic relief. One year ago her symptoms recurred. PE was unremarkable. An Upper GI series showed a 1.3 cm long mid esophageal stricture, with a lumen of 8 mm. U p p e r endoscopy showed a stricture with 9 m m opening at 30 cm. Endoscopic biopsy and cytology was benign. CT scan of thorax showed thickened esophageal wall. The stricture was dilated dProgressively with Savary dilators up to 12.8 mm. The luminal iameter could not be dilated any further on several endoscopic dilatation attempts and patient continued to complain of dysphagia. We then placed a removable self expanding, esophageal metal stent (UltraflexTM,Microvasive) to control the dysphagia. The patients symptoms improved and 2 month later the stent was removed without difficulty. On endoscopic removal the luminal diameter was increased to 16 ram. Discussion: Repeated esophageal dilatations are the usual therapy for esophageal strictures of all types. However in radiation induced esophageal stricture the success is variable. Self expanding metal stents may be an alternative therapy.
SHOULD BIOPSIESBE TAKEN FROM ECTOPIC GASTRIC MUCOSAIN THE UPPER ESOPHAGUS ? A, Sibille. Ph. Warz~e, M. Herin. Depamueat of Gastroontemlogy,Centre HospitalierNcXre-Dameet Reine Fabiola, Charleroi and lnstitut de Pathologieet de G~etiqae, Loverval, Belgium. Ectopic gastric mucesa (EGM) is oibm seen in the upper esophagusand is usually considered as a beaigu lesion. However, some pathological conditions arising from EGM have besa reported, such as admocereinoma, ulceration or 'i~.~lysuphagia. This study was designed to determine the rata of significant ological features in EGM, such as helionhactar pylori gastritis or metaplasia. Material and Methods. In 17 patients in whom an upper ~ndoscopywas needed, a lesion havingthe eadescepic appearanceof EGM was discovered in the upper esophagus. No patiem had esophageal symptoms. Biopsy samplesweretaken fromthe antrumand fromthe lesion. Results. In one patient the biopsy of the lesion revealed chr~ic esuphagitis and no ectopic or metaplastic tissue. Ammg the 16 other patients, EGM, intestinal metuplasia (IM) and a mixture of EGM and 1M were found in 13, 2 and 1 patients, respectively+ IIP was presemin the EGM of 3 patie~.s; in all three, there was a mildto moderate inflammatoryreaction Oymphoplasmocyticinfikrate), lip was pr~mt in the antrum of 9 patients, including all those whose EGM exhibited liP. Conclusion. HP gastritiswas preselxtin EGM in 17% of all p a t i ~ and in 33% oftha patiems exhibitingI-lPin the antrum. Intestinalm~,uphsiawas found in 17% ofthe upper esophaguslesions. EGM of the upper esophagusis subject to the same pathological omditims as the gastric muccea. The detection of these by biopsyc~ ha importantfi'omthe clinical point of view.
t'234 ENDOSCOPIC STENT PLACEMENT FOR PALLIATION OF INOPERABLE ESOPHAGEAL AND GASTRIC CARDIAC CANCER WITH ESOPAGEAL INVASION: PLASTIC STENTS VERSUS EXPANDIBLE METAL STENTS. Institute for Digestive Research, Department of Internal Medicine, Soon Chun Hyang University, Seoul, Korea, C.S. Shim. H.K. Bong, Y.H. Lee. Y.D. Cho, J.O. Kim, J.Y. Cho, Y.S. Kim, J.S. Lee, M.S. Lee, S.G. Hwang Background: Endoscopic implantations of stent are useful method of rapid palliation of malignant stenosis on esophageal and gastric cardiac cancer. But plastic stents have a high rate of complications. Recently, expandable metal stents have been available and lower rate of complications. Aim: We compared the clinical results of insertion of plastic stents with those of metal stents for palliation of malignant esophageal stenosis due to esophageal cancer and gastric cardiac cancer with esophageal invasion. Patients and Methods: Eighty nine patients with malignant esophageal stenosis due to esophageal cancer and gastric cardiac cancer with esophageal invasion underwent endoscopic implantation of stents(plastic stent: 49, expandable metal stent: 40). The degree of palliation and incidence of complications(early and late) were compared in both treatment groups. Results: Successful endoscopic placement was similar in both treatment groups(plastic stents :93.9% vs expandable metal stents :97.5%) and significant improvement of dysphagia scores was similar in both treatment groups. But number of dilatation in implantation of expandable metal stents was significantly less than those of plastic stents. Early complicalons(especially perforation in 6.1% with plastic stents vs 0 % with metal stents) were significantly less frequent with metal stents than with plastic stents(2.5% vs 10.2%). Late complications included food impaction(4 cases with plastic stents vs 1 cases with metal stents), tumor overgrowth(2 cases with plastic stents vs 1 cases with metal stents), migration(3 cases with plastic stents vs 5 cases, with metal stents), and tumor ingrowth only with metal stents(two cases). In 5 migrated cases of metal stents, 3 cases were inserted with membrane covered metal stent in lower esophageal cancer. There were no procedure-related death. Indwelling duration of stents was similar in both treatment groups(91.1 days vs 112.5 days). Conclusions: Metal stents seem to be more easy to be inserted, more comfortable to the patients, but more expansive than plastic stents. Expandable metal stents have a tendency of less short-term complications than plastic stents. There is a tendency of frequent stent migrations when membrare covered self-expandable stents are inserted in lower esophageal and cardiac cancer.
236 ACHALASIA AFTER SCLEROTHERAPY OF ESOPHAGEAL VARICES TREATED WITH BOTULINUM TOXIN J.M. J~tCAr,~, M.C. Zonca, Department of Gastroenterology, Henry Ford Hospital, Detroit, MI Endoscopic sclerotherapy is a common method for the acute treatment of bleeding esophageal varices and to reduce the risk of further bleeding episodes. Complications of sclerotherapy are well recognized and have been reported to occur 2% to more than 30%. Complications may include bleeding, ulceration and stricture formation. Esophageal dysmotility has been shown to result from sclerotherapy. Acute decreases in distal esophageal peristaltic waves in the distalesophagus and increases in the number of simultaneous contractions have been reported. This results in dysphagia in many patients. Esophageal mot~ity disorders secondary to sclerotherapy are usually reversible, returning to normal within four weeks of completing treatment. Most patients require no specific therapy unless a stricture forms. Persistent dysphagia longer than seventytwo hours without development of a stncture is rare. We report a patient with alcoholic cirrhosis who developed dysphagia and abnormal esophageal motility within one week of sclerotherapy of esophageal varices. Dysphagia persisted for greater than three months with the development of radiographic, endoscopic, and manometric findings suggesting achalasia. Mahgnancy and other known causes of secondary achalasla were ruled out. Manometry revealed markedly decreased distal esophageal peristaltic waves and a thilure of lower esophageal sphincter pressure to decrease to baseline in greater than fifty-percent of wet swallows. Pneumatic dilatation and surgery were felt to be too risky due to thepatient's poor medical condition and coagulopathy. Botulinum toxin 80u was injected into the lower esophageal sphincter with symptomatic improvement in dysphagia within three weeks. Repeat esophageal barium studies did demonstrate widening of the gastroesophageal junction. There are few cases reported ofachalasia after endoscopic sclerotherapy of esophageal varices. This is the first known case of the treatment of this type of achalasia with botulinum toxin.
VOLUME 45, NO. 4, 1997
GASTROINTESTINAL ENDOSCOPY A B 8 3