| Background and ObjectivesEsophageal stricture is esophageal lumen narrowing disease that caused by a variety of reasons.It can cause patients with dysphagia,vomiting,aspiration pneumonia,weight loss,decreased immunity,and even lead to death,seriously affecting the quality of life.Most esophageal strictures are malignant and benign esophageal strictures are uncommon.Common causes of esophageal strictures include esophageal and gastric surgery,long-term gastroesophageal reflux stimulation,acid-base intake cauterization,radiofrequency ablation,chest radiotherapy or eosinophilic esophagitis,etc.Although there are many ways to treat benign esophageal stricture,there is a very high tendency for recurrence and complications after any mechanical treatment.This study is carried out to evaluate the types of benign esophageal stricture patients in Henan Province.The safety,long-term patency and clinical efficacy of benign esophageal stricture after balloon angioplastry,stent placement and anti-reflux surgery are studied by comparing the treatment of different etiologies of clinical experience in our department.Materials and Methodology1.Related etiology and characteristics of benign esophageal stricture in Henan ProvinceAccording to 312 patients’ medical history,multi-slice spiral CT(MSCT),upper gastrointestinal imaging and gastroscopy,the type of esophageal stricture,stricture of the location,length and extent were determined.Using digital subtraction angiography(DSA)or endoscopic biopsy to confirm the nature of the lesion.2.The efficacy analysis of interventional therapy on benign esophageal stricture488 cases of the benign esophageal stricture were enrolled in our department from January 2013 to December 2016.Analysis of all patients admitted to hospital symptoms,vitals,with or without complications.Using balloon dilation angioplasty or combined removable self-expandable metal stent implantation to treat benign esophageal stricture.The perioperative complications and follow-up efficacy of the benign esophageal stricture after treatment were monitored.3.The efficacy analysis of interventional surgery combined with anti-reflux surgery in the treatment of reflux-related esophageal strictureA total of 66 patients of reflux-related benign esophageal were treated with interventional surgery(balloon dilatation or combined self-expandable metal stent)and anti-reflux surgery treatment from January 2013 to December 2016,of which 38 patients were treated with interventional surgery,and 28 patients interventional surgery and anti-reflux surgery.The general condition,symptoms and complications of the two groups were analyzed.The perioperative complications and follow-up of efficacy after surgery were also observed in two groups.4.Preoperative medical examinationAll enrolled patients needed to be undergo MS CT scan,upper gastrointestinal angiography and gastroscopy to confirm the diagnosis of benign esophageal stricture.According to the test results,and then decided the classification of stricture,length and diameters.MSCT conducted a multi-stage enhanced scan to observe esophageal stricture with or without enhanced and mediastinal infection,initially determine the site of esophageal stricture,nature and severity.Upper gastrointestinal contrast imaging using iodine contrast agent,not only to determine the location of esophageal stenosis,length,stricture diameter,but also to observe whether the presence of esophageal fistula and hiatal hernia and so on.Gastroscopy could obtain accurate the location of esophageal stricture,and nature,and to determine whether cardia relaxation.Based on medical examination,diagnosis,analysis,and measurement of esophageal stricture were performed.The stricture location,length and diameter were calculated.When reflux-related esophageal stenosis released one month later and there was no recurrence,esophageal high-resolution manometry and 24h pH-impedance monitoring test were performed.Esophageal manometry can understand the pressure levels of esophageal structures(upper esophageal sphincter,esophageal body and lower esophageal sphincter)during rest and swallowing,as well as the presence of hiatal hernia.24h pH-impedance monitoring test parameters includes DeMeester score(DMS),number of refluxes for which pH was<4,and,total time of pH<4,time percentage of upright position pH<4,time percentage of supine position pH<4 and the number of pH<4.5.The balloon angioplasty for benign esophageal stricturePatients lied supine on DSA bed,head to the right,oxygen,ECG monitoring,shop towels.Oral contrast media angiography to identify stricture location,extent and length.5F vertebral artery catheter and stiffening guide wire went through the narrow esophagus to the stomach cavity,then along the stiffening guide wire exchanged 10,12,15,20,25 or 30mm balloon catheter.Esophageal stricture ring was located in the middle of the balloon for the best,slowly pressurized the balloon.If the patient could not tolerate balloon dilatation,or after balloon dilatation esophageal stricture was still exist,esophageal stent placement could be selected.6.Removable self-expandable metal stent implantation for benign esophageal strictureFasting for 12 hours before surgery.Patients lied supine on DSA bed.Again oral contrast media angiography to identify stricture location,extent and length.Setting up to open the mouth,under the guidance of the guide wire and catheter,went through pharynx,esophagus,into the stomach.Extensions along the guide wire exchanged suitable models of esophageal stent.Esophageal stents of 13-22mm in diameter and 80-140mm in length were options for stricture segments.After the stent completely released,oral contrast was perfomed again to evaluate how the position of self-expanding stent,whether esophageal patency,with or without fistula.7.Laparoscopic anti-reflux surgeryLaparoscopic anti-reflux surgery used laparoscopic Toupet fundoplication or combined with esophageal hiatal hernia repair.Under general anesthesia,the patient lied supine on the operating table,lower extremity outreach position,upper body height 30 degree.The surgeon stood between the patient’s legs.Establish pneumoperitoneum,pneumoperitoneum pressure was set to 12-15mmHg.There were five trocars in the upper abdomen,including two 1.0 cm and three 0.5 cm size trocars.Patients with hiatal hernia first reset the contents.First using ultrasonic knife to open the parsflaccida of the lesser omentum,followed by dissection the diaphragm pillars(first on the right,then on he left).Our goal was to dissect the herniated stomach and allow a 3-5cm of esophageal reposition intra-abdominally.Both sides of diaphragmatic feet intermittent sutured with 2-0 silk and reduced esophageal hiatus.Using stomach bottom 270 degree wrapped in the lower esophagus,then intermittent sutured 2 to 3 needles with 2-0 silk,a width of 2.0 to 3.0cm,at least 2 needles in the esophageal suture layer.Patients gastrointestinal motility recover after surgery began to enter the liquid diet,and gradually transitioned to the general diet.8.Statistical analysisStatistical analysis was performed using the SPSS 17.0(Chicago,IL,USA).The data was reported as maximum,minimum,mean and standard deviation(SD)for quantitative data.T test was appropriate choice when the date was normally distributed.Mann-Whitney nonparametric test andwilcoxon rank sum test were used when the data was not normally distributed.Odds ratios(OR)were analyzed by Logistic regression.All statistical tests were considered significant when two-tailed P values were<0.05.Results1.Characteristics of benign esophageal stricture in Henan ProvinceAmong 312 patients with benign esophageal stricture,there were 246 cases(78.8%)of esophageal or cardiac resection of anastomotic stricture,32 cases(10.3%)of gastroesophageal reflux-related ulcer stricture,20 cases(6.4%)of esophageal caustic stricture caused by strong acid and alkali,14(4.5%)of radiation-related esophageal stricture.According to the length of esophageal stricture,262 cases(84.0%)had short segment stricture(<2cm),which was more common in anastomotic stricture;50 cases(16.0%)were long segment stricture(>2cm),which were more common in corrosive stenosis of chemical substances.2.The efficacy analysis of interventional therapy on benign esophageal strictureA total of 488 cases of benign esophageal stricture were enrolled using balloon dilatation and removable self-expandable metal stent implantation.Among them,368 cases of esophageal anastomotic stricture were pre-dilated ball,300 cases are treated with large balloon dilation of 25mm or 30mm diameter.360 cases of balloon dilation surgery was successful,the success rate was 97.8%.66 cases of reflux-related esophageal stricture were successfully used 25mm or 30mm balloon dilation.35 cases of chemically corrosive esophageal stricture,30 cases first jejunal feeding tube into.After 1 month,12mm or 15mm balloon dilatation was used again.28 cases of balloon dilatation surgery were successful.The success rate was 80%.19 cases of radiotherapy esophageal stricture were successfully used 25mm or 30mm balloon dilation.When the strictures were still recurrence after repeated balloon dilatation,esophageal stent placement was appropriate choice.62 patients with anastomotic stricture,6 cases of reflux-related esophageal stricture,15 cases of chemically corrosive esophageal stricture and 3 cases of radiotherapy esophageal stricture were successfully were successfully placed metal stent.Patients were followed up for an average of 10.5± 2.9 months.The clinical cure rates in patients with anastomotic stricture,reflux-related esophageal stricture,chemically corrosive esophageal stricture and radiotherapy esophageal stricture were 88.3%,24.3%,74.2%and 77.8%,respectively.The cure rate of reflux-related esophageal stricture group was significantly lower than the other three groups(P<0.05).The overall patency of esophageal stricture in the short term was no significant difference between the four groups.However,in the long-term follow-up we found that the patency rate in reflux-related esophageal stricture group(62.2%)was significantly lower than the anastomotic stricture group(90.4%),chemically corrosive esophageal stricture group(87.1%)and radiotherapy esophageal stricture group(88.9%).3.The efficacy analysis of interventional surgery combined with anti-reflux surgery in the treatment of reflux-related esophageal strictureA total of 66 cases of reflux-related benign esophageal stricture were treated with interventional surgery(balloon dilatation or combined self-expandable metal stent)and anti-reflux surgery treatment.Of these,38 cases were treated with interventional surgery,including 24 cases of male and 14 female,with an average age 60.16±9.82;28 cases were treated with interventional surgery and anti-reflux surgery,including 20 cases of male and 8 female,with an average age 57.32±10.35.In the interventional treatment group,one case lost to follow-up,9 cases(24.3%)were clinically cured,20(51.4%)were effective,9(24.3%)were ineffective,and the total effective rate was 75.7%;In interventional surgery combined with anti-reflux surgery group,14 cases(50%)were cured,13 cases(46.4%)were effective,1 case(3.6%)was ineffective and the total effective rate was 96.4%.The total effective rate of interventional therapy combined with anti-reflux surgery group was significantly higher than that of interventional treatment group(P<0.05).Conclusions1.In Henan Province,most patients with benign esophageal stricture are esophageal and gastric surgery anastomotic stricture.The incidence of gastroesophageal reflux-related esophageal stricture should not be ignored.2.The treatment of benign esophageal stricture using balloon dilatation or combined esophageal stent is a safe and effective method,and with less surgical complications.However,different causes of esophageal stricture have different clinical effects.The clinical efficacy and patency rate are significantly lower in gastroesophageal reflux-related esophageal stricture group than other causes of esophageal stricture.3.The treatment of gastroesophageal reflux-related benign esophageal stricture using interventional surgery combined with anti-reflux surgery is safe,effective,and with less surgical complications.The postoperative patency rate of esophagus is significantly higher than that of interventional surgery alone group.Relieve esophageal stenosis at the same time,anti-reflux surgery to repair the anti-reflux barrier is a reliable and optional method.This can fundamentally cure the etiology. |
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