ORIGINAL ARTICLE
Endoscopic Balloon Dilatation as an Effective Treatment for Lower and Upper Benign Gastrointestinal System Anastomotic Stenosis Cevher Akarsu, MD, Mustafa Gokhan Unsal, MD, Ahmet Cem Dural, MD, Osman Kones, MD, Ali Kocatas, MD, Mehmet Karabulut, MD, Burak Kankaya, MD, Mustafa Ates, MD, and Halil Alis, MD
Objective: Endoscopic balloon dilatation (EBD) is currently accepted as an effective, safe, and first-line treatment of postoperative benign gastrointestinal anastomosis stenosis (BGAS); however, a limited number of publications on the subject exist in the literature. The aim of the study was to retrospectively evaluate the efficiency of endoscopic dilatation in patients with postoperative intestinal anastomotic stenoses at a single surgical center. Methods: Patients with postoperative BGAS treated by EBD at our institution from February 2008 to 2012 were included. The dilatations were all performed using through-the-scope balloons. The balloon was introduced into the stricture using a guidewire under radiologic guidance. Each dilatation session consisted of 2 to 3 twominute multistep inflations of the balloon until adequate dilatation was achieved. Results: Of the 48 patients included in the study, 44 patients (91.7%) fully recovered and 4 (8.3%) did not respond to treatment. The mean follow-up period was 24 months (range, 3 to 57 mo). Four patients who did not respond to the procedure were treated surgically. Two patients (4.1%) with intestinal perforation during EBD were treated conservatively with a stent. Conclusions: EBD has a low rate of complications and a high success rate, is well tolerated, and avoids further surgical procedures for BGAS. Therefore, EBD should be the first choice of treatment for postoperative anastomotic stenoses. Key Words: anastomosis, stenosis, dilatation, balloon, stent
(Surg Laparosc Endosc Percutan Tech 2015;25:138–142)
P
ostoperative benign gastrointestinal anastomotic stenosis (BGAS) is seen as an early or late complication in 2% to 30% of cases who undergo surgery.1–5 Bleeding, ischemia,6,7 leakage,8,9 radiotherapy,10 and anastomotic surgery11,12 are held responsible in the etiology of anastomotic stenoses. In addition, increased use of the stapler closure technique rather than sutures to close an anastomosis has been associated with an increase in the incidence of anastomotic stenoses.4,11 The stenoses are mostly seen between postoperative days 50 and 60.12–15 Although most stenoses recover spontaneously, 2% to 5% of cases do not regress and become symptomatic.16 Received for publication January 17, 2014; accepted July 9, 2014. From the Department of General Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey. The authors declare no conflicts of interest. Reprints: Cevher Akarsu, MD, Cumhuriyet Mah Ebabil Cad No: 8/15, Kucuk cekmece, Istanbul, Turkey (e-mail: cevher.akarsu@hotmail. com). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
138 | www.surgical-laparoscopy.com
BGAS can be treated surgically or nonsurgically. Along with technical challenges—narrow segment excision and reanastomosis—the surgical technique carries higher mortality and morbidity risks and rates.3 Recently, the preferred alternative method has been endoscopic balloon dilatation (EBD).17,18 EBD has a high rate of success and low complication and mortality rates. A recent systematic review estimated the immediate success rate of EBD as approximately 86%, with a long-term clinical efficacy rate of 58%.17 High success rates for EBD have been reported in the literature. However, different opinions exist for certain types of cases, such as long-segment stenoses, for which the success rate of EBD is reduced.19 Although EBD has been accepted as an effective, safe, and first-line treatment of the postoperative BGAS, few publications have focused on the subject.3,20,21 The aim of this retrospective study was to evaluate the efficiency of endoscopic dilatation in patients with postoperative BGAS at a single-surgical center.
PATIENTS AND METHODS The medical records of patients who developed BGAS after digestive tract surgery and were treated with balloon dilatation between October 2008 and 2013 in the Bakirkoy Dr Sadi Konuk Training and Research Hospital, Department of General Surgery, were investigated retrospectively. The study protocol was approved by the Ethics Committee of our institute. The current study included patients who developed gastrointestinal obstruction following digestive tract surgery, were diagnosed with intestinal anastomotic stenosis based on physical examination and radiographs, and who had a stricture that prevented endoscopic evaluation. Patients with recurrent tumors, fistulas, or abscessation of the anastomosis were excluded from this study.
Endoscopic Technique Endoscopy and dilatation were performed under conscious sedation using intravenous diazepam or flunitrazepam, after informed consent was obtained from all patients. Dilatation was performed using a standard gastrointestinal scope of 9.4 mm in diameter (Fujinon Corporation, Saitama, Japan) for upper gastrointestinal strictures, whereas a standard colonoscope 12.8 mm in diameter was used for lower gastrointestinal strictures. The dilatations were performed using through-the-scope balloons (Balton, Endoscopic Balloon Dilatation Catheter; Balton sp.z.o.o., Warszawa, Poland) with inflated diameters of 8 to 20 mm and lengths of 30 to 80 mm. The balloon
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
was introduced into the stricture using a guidewire under radiologic guidance (Fig. 1). Each dilatation session consisted of 2 to 3 two-minute multistep inflations of the balloon until adequate dilatation was achieved. Passage of the scope through the stricture was attempted in all patients and was used to define primary therapeutic success. After successful dilatation, patients were followed up in our hospital as outpatients. Repeat dilatations were performed in patients with obstructive symptoms in whom restenosis was confirmed radiologically or through endoscopy. The success of the procedure was evaluated based on improvement of symptoms after the procedure. Those with no symptoms after the procedure were reevaluated with endoscopy at the third week and the third month. Postoperative occurrence time of stenosis, demographic features, complications, and mortality and morbidity rates of the procedure were evaluated.
Statistical Analysis Statistical analysis was performed using the statistical package SPSS 17.0 (SPSS Inc., Chicago, IL). Statistical analysis involved the use of Student t test or the MannWhitney U test for continuous variables, depending on which assumption was made. Descriptive statistics were reported as the means ± SD. A P-value of
Endoscopic Balloon Dilatation as an Effective Treatment for Lower and Upper Benign Gastrointestinal System Anastomotic Stenosis Cevher Akarsu, MD, Mustafa Gokhan Unsal, MD, Ahmet Cem Dural, MD, Osman Kones, MD, Ali Kocatas, MD, Mehmet Karabulut, MD, Burak Kankaya, MD, Mustafa Ates, MD, and Halil Alis, MD
Objective: Endoscopic balloon dilatation (EBD) is currently accepted as an effective, safe, and first-line treatment of postoperative benign gastrointestinal anastomosis stenosis (BGAS); however, a limited number of publications on the subject exist in the literature. The aim of the study was to retrospectively evaluate the efficiency of endoscopic dilatation in patients with postoperative intestinal anastomotic stenoses at a single surgical center. Methods: Patients with postoperative BGAS treated by EBD at our institution from February 2008 to 2012 were included. The dilatations were all performed using through-the-scope balloons. The balloon was introduced into the stricture using a guidewire under radiologic guidance. Each dilatation session consisted of 2 to 3 twominute multistep inflations of the balloon until adequate dilatation was achieved. Results: Of the 48 patients included in the study, 44 patients (91.7%) fully recovered and 4 (8.3%) did not respond to treatment. The mean follow-up period was 24 months (range, 3 to 57 mo). Four patients who did not respond to the procedure were treated surgically. Two patients (4.1%) with intestinal perforation during EBD were treated conservatively with a stent. Conclusions: EBD has a low rate of complications and a high success rate, is well tolerated, and avoids further surgical procedures for BGAS. Therefore, EBD should be the first choice of treatment for postoperative anastomotic stenoses. Key Words: anastomosis, stenosis, dilatation, balloon, stent
(Surg Laparosc Endosc Percutan Tech 2015;25:138–142)
P
ostoperative benign gastrointestinal anastomotic stenosis (BGAS) is seen as an early or late complication in 2% to 30% of cases who undergo surgery.1–5 Bleeding, ischemia,6,7 leakage,8,9 radiotherapy,10 and anastomotic surgery11,12 are held responsible in the etiology of anastomotic stenoses. In addition, increased use of the stapler closure technique rather than sutures to close an anastomosis has been associated with an increase in the incidence of anastomotic stenoses.4,11 The stenoses are mostly seen between postoperative days 50 and 60.12–15 Although most stenoses recover spontaneously, 2% to 5% of cases do not regress and become symptomatic.16 Received for publication January 17, 2014; accepted July 9, 2014. From the Department of General Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey. The authors declare no conflicts of interest. Reprints: Cevher Akarsu, MD, Cumhuriyet Mah Ebabil Cad No: 8/15, Kucuk cekmece, Istanbul, Turkey (e-mail: cevher.akarsu@hotmail. com). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
138 | www.surgical-laparoscopy.com
BGAS can be treated surgically or nonsurgically. Along with technical challenges—narrow segment excision and reanastomosis—the surgical technique carries higher mortality and morbidity risks and rates.3 Recently, the preferred alternative method has been endoscopic balloon dilatation (EBD).17,18 EBD has a high rate of success and low complication and mortality rates. A recent systematic review estimated the immediate success rate of EBD as approximately 86%, with a long-term clinical efficacy rate of 58%.17 High success rates for EBD have been reported in the literature. However, different opinions exist for certain types of cases, such as long-segment stenoses, for which the success rate of EBD is reduced.19 Although EBD has been accepted as an effective, safe, and first-line treatment of the postoperative BGAS, few publications have focused on the subject.3,20,21 The aim of this retrospective study was to evaluate the efficiency of endoscopic dilatation in patients with postoperative BGAS at a single-surgical center.
PATIENTS AND METHODS The medical records of patients who developed BGAS after digestive tract surgery and were treated with balloon dilatation between October 2008 and 2013 in the Bakirkoy Dr Sadi Konuk Training and Research Hospital, Department of General Surgery, were investigated retrospectively. The study protocol was approved by the Ethics Committee of our institute. The current study included patients who developed gastrointestinal obstruction following digestive tract surgery, were diagnosed with intestinal anastomotic stenosis based on physical examination and radiographs, and who had a stricture that prevented endoscopic evaluation. Patients with recurrent tumors, fistulas, or abscessation of the anastomosis were excluded from this study.
Endoscopic Technique Endoscopy and dilatation were performed under conscious sedation using intravenous diazepam or flunitrazepam, after informed consent was obtained from all patients. Dilatation was performed using a standard gastrointestinal scope of 9.4 mm in diameter (Fujinon Corporation, Saitama, Japan) for upper gastrointestinal strictures, whereas a standard colonoscope 12.8 mm in diameter was used for lower gastrointestinal strictures. The dilatations were performed using through-the-scope balloons (Balton, Endoscopic Balloon Dilatation Catheter; Balton sp.z.o.o., Warszawa, Poland) with inflated diameters of 8 to 20 mm and lengths of 30 to 80 mm. The balloon
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 2, April 2015
was introduced into the stricture using a guidewire under radiologic guidance (Fig. 1). Each dilatation session consisted of 2 to 3 two-minute multistep inflations of the balloon until adequate dilatation was achieved. Passage of the scope through the stricture was attempted in all patients and was used to define primary therapeutic success. After successful dilatation, patients were followed up in our hospital as outpatients. Repeat dilatations were performed in patients with obstructive symptoms in whom restenosis was confirmed radiologically or through endoscopy. The success of the procedure was evaluated based on improvement of symptoms after the procedure. Those with no symptoms after the procedure were reevaluated with endoscopy at the third week and the third month. Postoperative occurrence time of stenosis, demographic features, complications, and mortality and morbidity rates of the procedure were evaluated.
Statistical Analysis Statistical analysis was performed using the statistical package SPSS 17.0 (SPSS Inc., Chicago, IL). Statistical analysis involved the use of Student t test or the MannWhitney U test for continuous variables, depending on which assumption was made. Descriptive statistics were reported as the means ± SD. A P-value of
