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Murat Kekilli
Ankara Eğitim ve Araştırma H...
Alpaslan Tanoğlu
Sultan Abdülhamid Han Eğitim...
Tolga Düzenli
Sultan Abdülhamid Han Eğitim...
Serkan Öcal
Başkent Üniversitesi Tıp Fak...

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A New Technique for the Management of Postoperative Esophagojejunal Stricture: Balloon Dilation after Endoscopic Incision with Sphincterotomy

A New Technique for the Management of Postoperative Esophagojejunal Stricture
Articles > Internal Medicine: Gastroenterology
Submitted : 07.09.2019
Accepted : 08.11.2019
Published : 13.01.2020

Abstract

Esophagojejunal anastomotic stricture is not an uncommon situation and minimal invasive procedures can easily save patients from big surgical operations. Herein, we present a 63- year-old patient with postoperative benign esophagojejunal stricture who was managed with a new endoscopic technique. We performed four to five radial incisions parallel to the longitude of the esophagus with sphincterotomy and then dilated the esophagus by 25 mm diameter endoscopic balloon. This endoscopic technique showed that sphincterotomic incisional treatment is easy to perform, well tolerated, and safe. This technique may be useful and an effective alternative procedure in patients with esophagojejunal anastomotic strictures who are not suitable for balloon dilation and stent placement or denying surgery.

Introduction

In this era gastric cancer is globally one of the most commonly seen, highly mortal malignancy in the world. Approximately one third of the patients with gastric cancer undergo total gastrectomy (TG) with esophagojejunal anastomosis 1. In the literature, frequency of benign postoperative anastomotic strictures at the esophagojejunostomy site ranges from 1.2% to 7.9% and strictures  usually occur due to intraoperatively mechanical stapling. 2,3 Generally, benign esophagojejunal anastomotic strictures are managed by endoscopic techniques including bougie or balloon dilation, electrocautery therapy, self expanded stent placement, laser ablation, corticosteroid injection and surgery 4. In this clinical problem, endoscopic balloon dilation techniques are usually performed with good outcomes, but no one dilation method is superior to others 5. On the other hand, sometimes patients with severe anastomotic strictures are not suitable for endoscopic balloon dilation. In these cases, using new therapeutic endoscopic techniques before endoscopic balloon dilation may secure favorable consequences. Here,  we present a case of postoperative benign esophagojejunal stricture which was managed with a new endoscopic technique.

Case Report

A 63-year-old male was admitted to our gastroenterology outpatient clinic because of nausea, vomiting and weight loss. Five months ago, he underwent TG with esophagojejunal anastomosis using mechanical stapling technique. One month after TG he was admitted to another health center because of nausea and vomiting. Endoscopic intervention was performed and esophagojejunal anastomotic stricture was diagnosed. At that center, endoscopic balloon dilation was performed successfully and his symptoms were relieved. Four months after the endoscopic balloon dilation, he was referred to our outpatient clinic because of similar complaints. In our endoscopic examination severe anastomotic stricture was diagnosed (Figure 1).

Figure 1
Severe anastomotic stricture. Endoscopic balloon dilation could not be performed because of near total stricture and the case was not suitable for the endoscopic stent placement.

 

Endoscopic balloon dilation could not be performed because of near total stricture and the case was not suitable for the endoscopic stent placement. Then,  he was consulted by general surgeons and surgical management was proposed to him for his severe anastomotic stricture, but he denied surgical intervention. As there was no other therapeutic alternative, we decided to perform repeat endoscopy using a new technique for the management of this benign anastomotic  stricture. Under direct vision, four to five radial incisions parallel to the longitude of the esophagus were carefully performed with sphincterotomy and the procedure was terminated when the endoscope could easily pass through the stricture (Figure 2).

Figure 2
Four to five radial incisions parallel to the longitude of the esophagus were carefully performed with sphincterotom.

 

Olympus electrosurgical unit (UES-30 generator; Olympus, Ülke genellik ile ekleniyor) was used with a pure-cutting current at a power output setting of 50 W/s. After sphincterotomic incisions, 25 mm diameter endoscopic balloon dilation was performed successfully (Figure 3).

Figure 3
After sphincterotomic incisions, 25 mm diameter endoscopic balloon dilation was performed successfully.

 

No complication occurred during the procedure. 15 days later, control upper endoscopy was performed and esophagojejunostomy site was seen as normal.

Discussion

Esophagojejunal anastomotic stricture is not an uncommon situation and minimal invasive procedures can easily save patients from big surgical operations. Ournew endoscopic technique showed that sphincterotomic incisional therapy is easy to perform, well tolerated, and safe. This technique may be useful and an effective alternative procedure in patients with esophagojejunal anastomotic strictures who are not suitable for balloon dilation and stent placement or denying surgery.

References

  1. Smith JK, et al. National outcomes after gastric resection for neoplasm. Arch Surg.  2007; 142:387-93.
  2. Zuiki T, et al. Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy. Surg Endosc. 2013;27(10):3683-9.
  3. Kim CG, et al. Effective diameter of balloon dilation for benign esophagojejunal anastomotic stricture after total gastrectomy. Surg Endosc. 2009;23(8):1775-80.
  4. Lee TH, et al. Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture. Gastrointest Endosc. 2009;69(6):1029-33.
  5. Chiu YC, et al. Factors influencing clinical applications of endoscopic balloon dilation for benign esophageal strictures. Endoscopy.  2004;36(7):595-600.
Keywords : Endoskopik insizyon , Özofagojejunal darlık , Sfinkteratomi

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