| BackgroundAlthough the morbidity of anastomotic stenosis associated with esophagectomy or gastrectomy is not high,obstruction of anastomotic site most commonly present with dysphagia,vomiting,etc.,which could reduce the patients' quality of life,even result in severe malnutrition and death.To resolve the stricture and restore the ability to eat,endoscopic therapy or surgery repair are needed.Primary principle of such stenosis is to expand the narrowed luminal to effective diameters and prevent restenosis.Endoscopic balloon dilatation is a commonly used and first-line treatment for benign anastomotic stenosis,associated with high rate of immediate success and few complications.However,this technique requires good compliance for patients owing to the reality that half of them need multiple dilatations to achieve better clinical effect.As a salvage treatment,stent insertion is increasingly reported for benign esophageal stricture that failed for endoscopic balloon dilatation,whereas,studies and samples on stents insertion for benign anastomotic stenosis after esophagectomy or gastrectomy are rare,especially for its' initial treatment,and the results of them are different.Besides,various stent types(fully covered or partially covered stents;metallic stents or non-metallic stents)were used in the reported studies,which could influence the consistency of results.Moreover,compared with high radial force for only a short time delivered by balloon dilators,stents could offer more consistent and lower radial force in anastomotic fibrosis,therefore,stents insertion could obtain a better clinical efficiency theoretically.Part?: Clinical efficacy and safety of fully covered self-expandable metallic stent insertion for benign anastomotic stenosis after esophagectomy or gastrectomy AimsEvaluate the efficacy and safety of fully covered self-expandable metallic stent for benign anastomotic stenosis after esophagectomy or gastrectomy in large samples.MethodsPatients who between January 2010 and December 2015 underwent fully covered self-expandable metallic stent(FCSEMS)placement for management of benign anastomotic stenosis after esophagectomy or gastrectomy were included in this retrospective analysis.The primary outcomes were the recurrence of stricture,clinical success and technical success.The secondary outcomes were stent-related complications and the risk factors related to stent migration.ResultsIn total,102 FCSEMSs were placed in 75 patients,technical success was achieved in 98% of stents(100/102).The recurrence of stricture and clinical success occurred in 69.3%(52/75)and 48%(36/75)of patients with a median follow-up time of 23.5 months(0.9-88.4 months).Total adverse events after insertion occurred in 93.1%(95/102)of stents and included retrosternal pain(44.1%),nausea and vomiting(13.7%),odynophagia(10.8%),etc.Adverse events(per stent event)during stents indwelling periods occurred in 91.2%(93/102),including 43.1% of migration,25.5% of tissue overgrowth,10.8% of ulcer,7.8% of fistulae,3.0% of upper gastrointestinal hemorrhage and 1.0% of unexplained expiratory dyspnea.Strictures less than 2cm(HR 2.787,95%CI 1.324-5.864,P=0.007)was significant risk factors for stent migration,while location of stenosis,anastomotic type,luminal diameter and stent diameter were uncorrelated with stent migration.ConclusionsFCSEMS insertion is a feasible and effective option for the management of benign anastomotic strictures after esophagectomy or gastrectomy,which could avoid secondary surgery in a proportion of patients.However,stents related adverse events should be highly concerned.Stricture less than 2cm was significant risk factors for stent migration.Part?: Endoscopic balloon dilatation vs.fully covered self-expandable metallic stent for the initial treatment of benign anastomotic stenosis after esophagectomy or gastrectomy AimsCompare the clinical efficiency of endoscopic balloon dilatation(EBD)and fully covered self-expandable metallic stent(FCSEMS)for initially treating of benign anastomotic stenosis after esophagectomy or gastrectomy.MethodsPatients who between January 2010 and December 2015 underwent EBD or FCSEMS insertion for management of benign anastomotic stenosis after esophagectomy or gastrectomy were included in this retrospective analysis and were divided into EBD or FCSEMS group according to their first therapy.The primary outcomes were the technical success and recurrence of stricture.The secondary outcomes were the risk factors related to stricture recurrence.Results101 patients presented with benign anastomotic stenosis after esophagectomy or gastrectomy were included in this retrospective study.Among them,53 patients for EBD group,48 patients for FCSEMS group.Technical success and dysphagia resolution were compatible between the two groups(98.1% vs.100%,P=1.000;96.2% vs.93.8%,P=0.666,respectively).However,the recurrence of stricture,average duration of hospitalization and average cost in FCSEMS group was significantly higher than EBD group(72.9% vs.52.8%,P=0.037;7d vs.5.5d,P=0.027;24276 ?vs.15387?,P=0.000,respectively).History of occurrence with postoperative anastomotic fistula(HR 2.250,95%CI 1.264-4.005,P=0.006)and luminal diameter(HR 0.140,95%CI 0.027-0.726,P=0.019)were risk factors for stricture recurrence.ConclusionsThe clinical efficiency of FCSEMS insertion for the initial treatment of benign anastomotic stenosis after esophagectomy or gastrectomy was not better than that of EBD.In addition,FCSEMS group had a longer duration of hospitalization,higher cost and more adverse events(shown in first part)than EBD group.Therefore,we strongly recommend against the insertion of FCSEMS for the initial treatment of benign anastomotic stenosis after esophagectomy or gastrectomy.Postoperative anastomotic fistula and luminal diameters were risk factors for stricture recurrence. |
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