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Duodenal web: complications and failure of endoscopic treatment
Letters to the Editor
Figure 3. Periductal plasma cell rich infiltrate (H&E, orig. mag. ⫻40).
Santhosh Sampath Department of Nuclear Medicine Postgraduate Institute of Medical Education and Research Chandigarh, India Bhagwant R. Mittal Department of Nuclear Medicine Postgraduate Institute of Medical Education and Research Chandigarh, India Mandeep Kang Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh, India Kartar Singh Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India
REFERENCE 1. Kamisawa T, Chari ST, Giday SA, et al. Clinical profile of autoimmune pancreatitis and its histological subtypes: an international multicenter survey. Pancreas 2011;40: 809-14. doi:10.1016/j.gie.2011.12.035
Duodenal web: complications and failure of endoscopic treatment To the Editor:
Figure 4. Immunoglobulin G4 stain in plasma cell (IHC, orig. mag. ⫻40).
Surinder S. Rana, DM, FASGE Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Deepak K. Bhasin, DM, FASGE Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Chalapathi Rao Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Ritambhra Nada Department of Histopathology Postgraduate Institute of Medical Education and Research Chandigarh, India Rajesh Gupta Department of Surgery Postgraduate Institute of Medical Education and Research Chandigarh, India www.giejournal.org
Endoscopic treatment of duodenal webs in newborns and children is an alternative option to surgery, although the experience is still limited. Recently we published in this journal a successful endoscopic incision of a duodenal web in an infant.1 Later we tried to repeat the operative procedure in a 20-month-old girl with chronic vomiting and failure to thrive. Upper GI radiographs were consistent with a perforated duodenal web. The first operative endoscopy was abandoned because of mild bleeding that occurred after the partial opening of the web. The hemorrhage spontaneously resolved. An exclusive milk diet was offered, and the child did not vomit. Three weeks later, operative endoscopy was repeated successfully, reaching the second duodenal segment with a gastroscope of an outer diameter of 8.6 mm. It is of note that the previous partial incision was entirely scarred. After the procedure the girl was able tolerate a normal diet, but an upper GI series 2 months later showed no changes. Diagnostic endoscopy showed complete closure of the previous membranotomy with a little central aperture. A third operative endoscopy was then attempted, and complete incision of the web was obtained. To avoid possible closure of the opening by scars, 2 mucosal limbs of the membrane were also resected. At the end of the procedure moderate bleeding occurred, requiring intramucosal injection of adrenaline. A blood transfusion was needed. DurVolume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1123
Letters to the Editor
ing the follow-up period the girl remained asymptomatic, but radiographs showed no modifications, and she eventually underwent surgical duodenojejunostomy. As previously described,1 the first 2 operative endoscopic procedures were followed by a transitory increase of pancreatic enzymes. Our experience adds information about the endoscopic treatment of duodenal webs, alerting practitioners to the possibility of complications such as bleeding, increase of pancreatic enzymes, and failure of complete closure of the membranotomy because of scars. Exuberant fibrotic tissue formation is presumably an individual feature, and it should stop any further attempt at endoscopic management. Arrigo Barabino Serena Arrigo Paolo Gandullia Silvia Vignola Gastroenterology and Endoscopy Unit G. Gaslini Institute for Children Genoa, Italy
25G variceal needle. No complications were observed. Repeated endoscopy 6 months and 1 year later showed no residual web. For the next 2 years the patient remained free of symptoms and consumed a normal diet. To our knowledge, this is the first case of endoscopic treatment of recurrent esophageal web in PVS with a combination of dilation and intralesional mitomycin C injection. Mitomycin C has antineoplastic and antiproliferative/ antiscarring properties, and its topical application has been found to be effective in the treatment of strictures at various anatomic locations.2-6 Recurrence of a web in PVS after dilation is unusual, and its cause in our patient is unknown. We believe that intense fibrogenesis during and after the trauma induced by repeated dilation and mechanical irritation by solid food at the site of the ruptured web may have been responsible. Panagiotis Katsinelos, MD, PhD Stergios Gkagkalis, MD, PhD Grigoris Chatzimavroudis, MD, PhD Christos Zavos, MD, PhD Department of Gastroenterology Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Greece Jannis Spyridakis, MD, PhD Department of Endoscopy and Motility Unit G. Gennimatas General Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Jannis Kountouras, MD, PhD Department of Gastroenterology Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Greece
REFERENCE 1. Barabino A, Gandullia P, Arrigo S, et al. Successful endoscopic treatment of a double duodenal web in a infant. Gastrointest Endosc 2011;73:401-3. doi:10.1016/j.gie.2011.12.036
Recurrent esophageal web in Plummer-Vinson syndrome successfully treated with postdilation intralesional injection of mitomycin C To the Editor: In their article Seo et al1 reported an esophageal web resolved by endoscopic incision in a patient with PlummerVinson syndrome (PVS). We herein report an interesting case of recurrent esophageal web in a patient with PVS successfully treated with postdilation intralesional mitomycin C injection. A 54-year-old woman with an 8-year history of PVS was referred to our department for recurrent web development despite repeat bougie dilations and without recent clinical signs and laboratory findings of iron deficiency anemia. The patient underwent an upper GI endoscopy, which showed a web on the anterior wall of the esophagus, 5 cm below the upper esophageal sphincter. Endoscopic dilation with the patient under sedation was performed under fluoroscopy with a Savary-Gillard dilator 15 mm in diameter, over a superstiff hydrophilic guidewire (Jagwire, Boston Scientific, Athens). The site of the ruptured web was then injected at 4 points with aliquots of 0.5 mL mitomycin solution (1 mg mitomycin C in 2 mL sterile water) through a No. 1124 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 5 : 2012
REFERENCES 1. Seo MH, Chun HJ, Jeen YT, et al. Esophageal web resolved by endoscopic incision in a patient with a Plummer-Vinson syndrome. Gastrointest Endosc 2011;74:1142-3. 2. Hu D, Sires BS, Tong DC, et al. Effect of brief exposure to mitomycin on cultured human nasal mucosa fibroblast. Ophthal Plast Reconstr Surg 2000;16:119-25. 3. Rosseneu S, Afzal N, Yerushalmi B, et al. Topical application of mitomycin C in oesophageal strictures. J Pediatr Gastroenterol Nutr 2007;44:336-41. 4. Spier BJ, Sawma VA, Gopal DV, et al. Intralesional mitomycin C: successful treatment for benign recalcitrant esophageal stricture. Gastrointest Endosc 2009;69:152-3. 5. Gillespie MB, Day TA, Sharma AK, et al. Role of mitomycin in upper digestive tract stricture. Head Neck 2007;29:12-7. 6. Uhlen S, Fayoux P, Vachin F, et al. Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children? Endoscopy 2006;38:404-7. doi:10.1016/j.gie.2012.01.001
www.giejournal.org
Figure 3. Periductal plasma cell rich infiltrate (H&E, orig. mag. ⫻40).
Santhosh Sampath Department of Nuclear Medicine Postgraduate Institute of Medical Education and Research Chandigarh, India Bhagwant R. Mittal Department of Nuclear Medicine Postgraduate Institute of Medical Education and Research Chandigarh, India Mandeep Kang Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh, India Kartar Singh Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India
REFERENCE 1. Kamisawa T, Chari ST, Giday SA, et al. Clinical profile of autoimmune pancreatitis and its histological subtypes: an international multicenter survey. Pancreas 2011;40: 809-14. doi:10.1016/j.gie.2011.12.035
Duodenal web: complications and failure of endoscopic treatment To the Editor:
Figure 4. Immunoglobulin G4 stain in plasma cell (IHC, orig. mag. ⫻40).
Surinder S. Rana, DM, FASGE Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Deepak K. Bhasin, DM, FASGE Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Chalapathi Rao Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh, India Ritambhra Nada Department of Histopathology Postgraduate Institute of Medical Education and Research Chandigarh, India Rajesh Gupta Department of Surgery Postgraduate Institute of Medical Education and Research Chandigarh, India www.giejournal.org
Endoscopic treatment of duodenal webs in newborns and children is an alternative option to surgery, although the experience is still limited. Recently we published in this journal a successful endoscopic incision of a duodenal web in an infant.1 Later we tried to repeat the operative procedure in a 20-month-old girl with chronic vomiting and failure to thrive. Upper GI radiographs were consistent with a perforated duodenal web. The first operative endoscopy was abandoned because of mild bleeding that occurred after the partial opening of the web. The hemorrhage spontaneously resolved. An exclusive milk diet was offered, and the child did not vomit. Three weeks later, operative endoscopy was repeated successfully, reaching the second duodenal segment with a gastroscope of an outer diameter of 8.6 mm. It is of note that the previous partial incision was entirely scarred. After the procedure the girl was able tolerate a normal diet, but an upper GI series 2 months later showed no changes. Diagnostic endoscopy showed complete closure of the previous membranotomy with a little central aperture. A third operative endoscopy was then attempted, and complete incision of the web was obtained. To avoid possible closure of the opening by scars, 2 mucosal limbs of the membrane were also resected. At the end of the procedure moderate bleeding occurred, requiring intramucosal injection of adrenaline. A blood transfusion was needed. DurVolume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1123
Letters to the Editor
ing the follow-up period the girl remained asymptomatic, but radiographs showed no modifications, and she eventually underwent surgical duodenojejunostomy. As previously described,1 the first 2 operative endoscopic procedures were followed by a transitory increase of pancreatic enzymes. Our experience adds information about the endoscopic treatment of duodenal webs, alerting practitioners to the possibility of complications such as bleeding, increase of pancreatic enzymes, and failure of complete closure of the membranotomy because of scars. Exuberant fibrotic tissue formation is presumably an individual feature, and it should stop any further attempt at endoscopic management. Arrigo Barabino Serena Arrigo Paolo Gandullia Silvia Vignola Gastroenterology and Endoscopy Unit G. Gaslini Institute for Children Genoa, Italy
25G variceal needle. No complications were observed. Repeated endoscopy 6 months and 1 year later showed no residual web. For the next 2 years the patient remained free of symptoms and consumed a normal diet. To our knowledge, this is the first case of endoscopic treatment of recurrent esophageal web in PVS with a combination of dilation and intralesional mitomycin C injection. Mitomycin C has antineoplastic and antiproliferative/ antiscarring properties, and its topical application has been found to be effective in the treatment of strictures at various anatomic locations.2-6 Recurrence of a web in PVS after dilation is unusual, and its cause in our patient is unknown. We believe that intense fibrogenesis during and after the trauma induced by repeated dilation and mechanical irritation by solid food at the site of the ruptured web may have been responsible. Panagiotis Katsinelos, MD, PhD Stergios Gkagkalis, MD, PhD Grigoris Chatzimavroudis, MD, PhD Christos Zavos, MD, PhD Department of Gastroenterology Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Greece Jannis Spyridakis, MD, PhD Department of Endoscopy and Motility Unit G. Gennimatas General Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Jannis Kountouras, MD, PhD Department of Gastroenterology Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Greece
REFERENCE 1. Barabino A, Gandullia P, Arrigo S, et al. Successful endoscopic treatment of a double duodenal web in a infant. Gastrointest Endosc 2011;73:401-3. doi:10.1016/j.gie.2011.12.036
Recurrent esophageal web in Plummer-Vinson syndrome successfully treated with postdilation intralesional injection of mitomycin C To the Editor: In their article Seo et al1 reported an esophageal web resolved by endoscopic incision in a patient with PlummerVinson syndrome (PVS). We herein report an interesting case of recurrent esophageal web in a patient with PVS successfully treated with postdilation intralesional mitomycin C injection. A 54-year-old woman with an 8-year history of PVS was referred to our department for recurrent web development despite repeat bougie dilations and without recent clinical signs and laboratory findings of iron deficiency anemia. The patient underwent an upper GI endoscopy, which showed a web on the anterior wall of the esophagus, 5 cm below the upper esophageal sphincter. Endoscopic dilation with the patient under sedation was performed under fluoroscopy with a Savary-Gillard dilator 15 mm in diameter, over a superstiff hydrophilic guidewire (Jagwire, Boston Scientific, Athens). The site of the ruptured web was then injected at 4 points with aliquots of 0.5 mL mitomycin solution (1 mg mitomycin C in 2 mL sterile water) through a No. 1124 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 5 : 2012
REFERENCES 1. Seo MH, Chun HJ, Jeen YT, et al. Esophageal web resolved by endoscopic incision in a patient with a Plummer-Vinson syndrome. Gastrointest Endosc 2011;74:1142-3. 2. Hu D, Sires BS, Tong DC, et al. Effect of brief exposure to mitomycin on cultured human nasal mucosa fibroblast. Ophthal Plast Reconstr Surg 2000;16:119-25. 3. Rosseneu S, Afzal N, Yerushalmi B, et al. Topical application of mitomycin C in oesophageal strictures. J Pediatr Gastroenterol Nutr 2007;44:336-41. 4. Spier BJ, Sawma VA, Gopal DV, et al. Intralesional mitomycin C: successful treatment for benign recalcitrant esophageal stricture. Gastrointest Endosc 2009;69:152-3. 5. Gillespie MB, Day TA, Sharma AK, et al. Role of mitomycin in upper digestive tract stricture. Head Neck 2007;29:12-7. 6. Uhlen S, Fayoux P, Vachin F, et al. Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children? Endoscopy 2006;38:404-7. doi:10.1016/j.gie.2012.01.001
www.giejournal.org