Özofagusun Selim Darlıkları

Özofagus darlığının tedavisi için bilinen en eski yöntem, bugünkü dilatatörlere benzeyen balina kılçığı ile yapılan itme işlemidir. Yazılı ilk kayıt 17. yüzyılda bir Cezayir şehri olan Bejaia'da yaşayan İtalyan anatomist Fabricius ab Aquapendente'nin balmumunu rijid dilatatör olarak kullanmasıdır. Özofagus striktürlerinin dilatasyonu için bujinaj yöntemi ilk kez 1821 yılında yayınlanmıştır. Normal özofagus lümen çapı 20-30 mm arasında olup, 12 mm'den daha dar olduğunda disfaji ortaya çıkmaya başlar. Semptomatik iyileşme için en az 15 mm olması gerekir. Darlık sebebi olarak sık olarak peptik özofajit , anastomoz darlıkları, travma, radyasyon tedavisi, koroziv yanıklar sayılmaktadır. Fizik muayene, sıklıkla disfajinin nedenine ilişkin bir ipucu sağlamaz. Hastanın beslenme durumunun tayin edilmesi önemlidir. Tanısal amaçla baryumlu özofagus pasaj grafisi endoskopik bulgular ile tamamlanmalıdır; tedavi sıralamasında darlık derecesine göre önce agresif proton pompa inhibitör (PIP) tedavisi, daha sonra buji veya balon dilatasyon, tedaviye dirençli olgularda kortikosteroid enjeksiyonu, yine de devam etmesi halinde ise genişleyebilen stent yerleştirme işlemleri yapılabilir. Stentler asla ilk tedavi basamağı olarak kullanılmamalı ve birçok kez uygulanacak dilatasyon seanslarının sonrasına bırakılmalıdır. Basit darlıklar agresif bir PIP tedavisine veya 2-3 seans buji dilatasyonuna iyi cevap verirken, kompleks olanlar özellikle proksimal kılavuz telin ilerlemediği durumlarda PEG yapılır ve retrograd olarak striktüre müdahale edilir. Dilatasyon komplikasyonları; %0,1-0,3 oranında perfotasyon, %0,2'den az oranda kanama riski vardır. Zor darlıklarda kendiliğinden genişleyen kaplanmış veya kaplanmamış metalik stentler veya metalik olmayan stentler kullanılır. Dikkatle seçilmiş hastalara uygulanmış olmasına karşın, stent migrasyonu, ciddi göğüs ağrısı, kanama, perforasyon, gastroözofageal reflü, stent tıkanması ve fistül komplikasyonları gözlenmiştir. Zor darlıklarda alternatif tedavi işlemleri endoskopik striktüroplasti ve en son olarak cerrahi rezeksiyon uygulanmaktadır. Birçok çalışmada, peptik darlıklar için progresif şekilde 40-60F çapa kadar dilatasyon uygulanmasının, düşük bir komplikasyon oranı ile %85 hastada disfajiyi rahatlattığı gösterilmiştir. Buna karşın, yaklaşık %30 hastada 1 yıl içerisinde dilatasyon tekrarı gerekli olmuş ve anti-sekretuar ilaç desteği olmayanlarda bu oran %60 olarak belirlenmiştir. Cerrahi uygulamanın başarısı, cerrahın deneyimi ve merkezin özofagus darlıklı hasta kapasitesine bağlı olarak değişmekte olup, genelde %77 civarındadır. Cerrahi sonrasında dilatasyon gereksinimi %1-43 hastada ortaya çıkar ve genellikle 1-2 seansa ihtiyaç duyulur.

The Benign Strictures of the Esophagus

The old procedure known as the treatment of esophageal stricture is the pushing of "string of whale" similar to a modern dilatator. The first written record is from the 17th century by an Italian anatomist Fabricius ab Aquapendente who lived in Bejaia, a city in Algeria; he used a wax bougie in place of a dilatator. The first bougienage procedure in esophageal strictures was published in 1821. The normal esophageal diameter is between 20-30 mm, and if the diameter is less than 12 mm, the dysphagia symptom becomes evident. The symptoms disappear when the diameter becomes larger than 15 mm. Peptic esophagitis (70%-80%), anastomotic strictures, trauma, radiation treatment, and caustic burn were the frequent causes of stricture. The physical examination did not offer a clue in terms of cause of stricture. It is important to evaluate the nutrition status of a patient. The barium contrast passage completed by endoscopic evaluation are important in diagnostics; by a sequence in the function of grading of stricture, an initial treatment with aggressive proton pump inhibitor (PIP) is preferred. After the bougie and balloon dilatation and in cases with persistent strictures, corticosteroid injection and self-expanded stents will be used. The expanding stents will never be used as the fırst option and will be used only after multiple dilatations. Although PIP and bougie dilatations are used with good results in simple strictures, the complex strictures, particurarly in which the guiding wire does not progress through strictures, a percutaneous gastrostomy (PEG) is performed and the stricture is retrogradely aborted. The complications of dilatation procedure are up to 0.1%-0.3% perforation and bleeding of less than 0.2%. In difficult strictures, covered and uncovered metallic or nonmetallic stents are used. Despite careful indications, there are many complications such as stent migration, severe thoracic pain, bleeding, perforation, gastroesophageal reflux, stent obstruction, and fistula development. Endoscopic stricturoplasty and surgical resection are alternative treatments in the treatment of diffıcult strictures. In many studies, the progressive dilatation up to 40-60 F is with less complication, and 85% of the patients improved; however, 30% of these patients were recurrent, and 60% of the patients without anti-secretory treatment were recurrent after one year of follow-up. The success of surgical resection is related to the experience of surgical center and is generally approximately up to 77%. The requirement of dilatation after surgery is between 1% and 43%, and one to two sessions are needed.

Kaynakça

Kelly HD. Origins of oesophagology. Proc R Soc Med 1969; 62: 781- 6.

Hildreth CH. Stricture of the esophagus. N Engl J Med Surg 1821; 10: 235.

Goyal RK, Bauer JL, Spiro HM. The nature and location of lower esophageal ring. N Engl J Med 1971; 284: 1175-80. [CrossRef]

Lewis MI, McKenna RJ (eds). Medical Management of the Thoracic Surgery Patients. Soukiasian HJ, Luketich JD. Benign Esophageal Disease, Saunders-Elsevier, Philadelphia, Chapter 57, 2010.

Mukherjee S, Katz J. Esophageal stricture, Jan 4 2012, Available from: http://emedicine.medscape.com/article/175098-overview

Siersema PD. Treatment options of esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008; 5: 142-52. [CrossRef]

Baron TH. Management of Benign Esophageal Strictures. Gastroen- terol Hepatol (N Y) 2011; 7: 46-9.

Pines G, Klein Y, Melzer E, Idelevich E, Buyeviz V, Machlenkin S, et al. One hundred transhiatal esophagectomies: a single-institution experience. Isr Med Assoc J 2011; 13: 428-33.

Yendamuri S, Gutierrez L, Oni A, Mashtare T, Khushalani N, Yang G, et al. Does circular stapled esophagogastric anastomotic size affect the incidence of postoperative strictures? J Surg Res 2011; 165: 1-4. [CrossRef]

Lawson JD, Otto K, Grist W, Johnstone PA. Frequency of esophage- al stenosis after simultaneous modulated accelerated radiation the- rapy and chemotherapy for head and neck cancer. Am J Otolaryngol 2008; 29: 13-9. [CrossRef]

Umsawasdi T, Valdivieso M, Barkley HT Jr, Booser DJ, Chiuten DF, Murphy WK, et al. Esophageal complications from combined che- motherapy (cyclophosphamide + adriamycin + cisplatin + xrt) in the treatment of non-small cell lung cancer. Int J Radiat Oncol Biol Phys 1985; 11: 511-9. [CrossRef]

Wang KK, Lutzke L, Borkenhagen L, Westra W, Song MW, Prasad G, et al. Photodynamic therapy for Barrett's esophagus: does light still have a role? Endoscopy 2008; 40: 1021-5. [CrossRef]

Wijburg FA, Heymans HS, Urbanus NA. Caustic Esophageal lesions in childhood: Prevention of stricture formation. J Pediatr Surg 1989; 24: 171-3. [CrossRef]

Coln D, Chang JH. Experience with esophageal stenting for caustic burns in children. J Pediatr Surg 1986; 21: 588-91. [CrossRef]

Bulut T. Selim özofagus striktürleri, Available from: http://www.ooci- ties.org/turkerbulut/trSelim.html

Ono S, Fujishiro M, Niimi K, Goto O, Kodashima S, Yamamichi N, et al. Predictors of postoperative stricture after esophageal endosco- pic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41: 661-5. [CrossRef]

Valentine R, Gangloff J, MacGillivray D. Supraclavicular approach for the simultaneous treatment of dysphagia lusoria and thoracic outlet syndorme. Ann Vasc Surg 1988; 2: 378-80. [CrossRef]

Pace F, Antinori S, Repici A. What is new in esophageal injury (infec- tion, drug-induced, caustic, stricture, perforation)? Curr Opin Gast- roenterol 2009; 25: 372-9. [CrossRef]

Dolar ME, Boyacioglu AS, Ates KB, Caner ME, Hilmioglu F, Sahin B. Esophageal strictures after endoscopic injection sclerotherapy. En- doscopy 1994; 26: 370. [CrossRef]

Ahtaridis G, Snape WJ, Cohen S. Clinical and manometric findings in benign peptic strictures of the esophagus. Dig Dis Sci 1979; 24: 858-61. [CrossRef]

Swarbrick ET, Gough AL, Foster CS. Prevention of recurrence of oe- sophageal stricture, a comparison of lansoprazole and high-dose ranitidine. Eur J Gastroenterol Hepatol 1996; 8: 431-8.

McLean GK, LeVeen RF. Shear stress in the performance of esopha- geal dilation: comparison of balloon dilation and bougienage. Radi- ology 1989; 172: 983. [CrossRef]

Dakkak M, Hoare RC, Maslin SC. Oesophagitis is as important as oesophageal stricture diameter in determining dysphagia. Gut 1993; 34: 152-5. [CrossRef]

Smith PM, Kerr GD, Cockel R. A comparison of omeprazole and rani- tidine in the prevention of recurrence of benign esophageal strictu- re. Restore Investigator Group. Gastroenterology 1994; 107: 1312-8. [CrossRef]

Silvis SE, Farahmand M, Johnson JA. A randomized blinded compa- rison of omeprazole and ranitidine in the treatment of chronic esop- hageal stricture secondary to acid peptic esophagitis. Gastrointest Endosc 1996; 43: 216-21. [CrossRef]

Marks RD, Richter JE, Rizzo J. Omeprazole versus H2-receptor an- tagonists in treating patients with peptic stricture and esophagitis. Gastroenterology 1994; 106: 907-15.

Moayyedi P, Leontiadis GI. The risks of PPI therapy. Nat Rev Gastro- enterol Hepatol 2012; 9: 132-9. [CrossRef]

Jones MP, Bratten JR, McClave SA. The Optical Dilator: a clear, over- the-scope bougie with sequential dilating segments. Gastrointest Endosc 2006; 63: 840-5. [CrossRef]

Guelrud M, Saltzman JR, Travis AC. Management of benign esophage- al strictures. UpToDate, 24 Agus 2011, Available from: http://www.upto- date.com/contents/management-of-benign-esophageal-strictures

Kozarek RA, Patterson DJ, Ball TJ, Gelfand MG, Jiranek GE, Bred- feldt JE, et al. Esophageal dilation can be done safely using selec- tive fluoroscopy and single dilating sessions. J Clin Gastroenterol 1995; 20: 184-9. [CrossRef]

Ho SB, Cass O, Katsman RJ, Lipschultz EM, Metzger RJ, Onstad GR, et al. Fluoroscopy is not necessary for Maloney dilation of chronic esop- hageal strictures. Gastrointest Endosc 1995; 41: 11-4. [CrossRef]

Bueno R, Swansos SJ, Jaklitsch MT, Lukanich JM, Mentzer SJ, Su- garbaker DJ. Combined antegrade and retrograde dilation: A new endoscopic technique in the management of complex esophageal obstruction. Gastrointest Endosc 2001; 54: 368-72. [CrossRef]

Kozarek RA. To stretch or to shear: a perspective on balloon dilators. Gastrointest Endosc 1987; 33: 459-61. [CrossRef]

Wesdorp IC, Bartelsman JF, den Hartog Jager FC, Huibregtse K, Tytgat GN. Results of conservative treatment of benign esophageal strictures: a follow-up study in 100 patients. Gastroenterology 1982; 82: 487-93.

Tulman AB, Boyce HW Jr. Complications of esophageal dilation and guidelines for their prevention. Gastrointest Endosc 1981; 27: 229- 34. [CrossRef]

Bakken JC, Wong Kee Song LM, de Groen PC, Baron TH. Use of a fully covered self-expandable metal stent for the treatment of be- nign esophageal diseases. Gastrointest Endosc 2010; 72: 712-20. [CrossRef]

Barkin JS, Taub S, Rogers AI. The safety of combined endoscopy, bi- opsy and dilation in esophageal strictures. Am J Gastroenterol 1981; 76: 23-6.

Zein NN, Greseth JM, Perrault J. Endoscopic intralesional steroid injections in the management of refractory esophageal strictures. Gastrointest Endosc 1995; 41: 596-8. [CrossRef]

Ramage JI Jr, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murray JA, et al. A prospective, randomized, double-blind, place- bo-controlled trial of endoscopic steroid injection therapy for recal- citrant esophageal peptic strictures. Am J Gastroenterol 2005; 100: 2419-25. [CrossRef]

Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002; 56: 829-34. [CrossRef]

Dunne DP, Rupp T, Rex DK, Lehman GA. Five year follow-up of pros- pective randomized trial of Savary dilation with or without intra-lesi- onal steroids for benign gastroesophageal reflux strictures. Gastro- enterology 1999; 116: 152.

Cwikiel W, Willen R, Stridbeck H, Lillo-Gil R, von Holstein CS. Sel- fexpanding stent in the treatment of benign esophageal strictures: Experimental study in pigs and presentation of clinical cases. Radio- logy 1993; 187: 667-71. [CrossRef]

Evrard S, Le Moine O, Lazaraki G, Dormann A, El Nakadi I, Devière J. Self-expanding plastic stents for benign esophageal lesions. Gastro- intest Endosc 2004; 60: 894-900. [CrossRef]

Song HY, Jung HY, Park SI, Kim SB, Lee DH, Kang SG, et al. Cove- red retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience. Radiology 2000; 217: 551-7. [CrossRef]

Oh YS, Kochman ML, Ahmad NA, Ginsberg GG. Clinical outcomes after self-expanding plastic stent placement for refractory benign esophageal strictures. Dig Dis Sci 2010; 55: 1344-8. [CrossRef]

Fry SW, Fleischer DE. Management of a refractory benign esopha- geal stricture with a new biodegradable stent. Gastrointest Endosc 1997; 45: 179-82. [CrossRef]

Eloubeidi MA, Lopes TL. Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of re- moval, and tissue response in humans. Am J Gastroenterol 2009; 104: 1374-81. [CrossRef]

Bakken JC, Wong Kee Song LM, de Groen PC, Baron TH. Use of a fully covered self-expandable metal stent for the treatment of be- nign esophageal diseases. Gastrointest Endosc 2010; 72: 712-20. [CrossRef]

Thorsen G, Rosseland AR. Endoscopic incision of postoperative ste- noses in the upper gastrointestinal tract. Gastrointest Endosc 1983; 29: 26-9. [CrossRef]

Tang SJ, Singh S, Truelson JM. Endotherapy for severe and comp- lete pharyngo-esophageal post-radiation stenosis using wires, bal- loons and pharyngo-esophageal puncture (PEP) (with videos). Surg Endosc 2010; 24: 210-4. [CrossRef]

Kaynak Göster