Endoscopic Dilatation

The efficacy of endoscopic dilatation for palliation of dysphagia is short term, but occasionally the effects are prolonged. More importantly, esophageal dilatation allows a more comprehensive evaluation of a malignant lesion where the distal margin cannot be assessed because the tumor is impassable even using miniscopes. Endoscopic dilatation can also be used for radiation-induced esophageal strictures, anastomotic strictures, and anastomotic tumor recurrence. In addition, dilatation is often used in conjunction with other palliative modalities, such as endoscopic injection, APC, laser ablation, and stent placement. Dilatation can be performed either with Savary-Gilliard dilators over a stiff wire or with balloon dilators introduced over a wire through the scope under direct endoscopic vision. The use of fluoroscopy is recommended to ensure safe passage of the Savary wire in each technique. In some very tight strictures that cannot be maneuvered by miniscopes, guide wires with a hydrophilic coating (Terumo type) may be used, usually under fluoroscopic guidance. Complications associated with dilatation include perforation risk (around 4%), chest pain, bleeding, and bacteremia. The risk of perforation is slightly increased when dilatation is used in conjunction with other endoscopic palliative measures.

under fluoroscopic guidance, the metal markers can be placed as external skin markers to mark the proximal and distal ends of the tumor. Repositioning of the stent can be achieved by withdrawal and/or reconstraining (Wallstent) the partially deployed stents.

Different options in stent selection include plastic or metal, coated or uncoated, and the various designs offer different degrees of tensile strength, memory, and expansive radial forces. The use of rigid plastic stents has fallen significantly since the introduction of self-expandable metallic stents (SEMS), partly because of their higher complication rates (associated with preplacement dilatation), and partly because metallic stents are easier to use and deploy and tend to cause less pain. In one randomized study comparing plastic stents to SEMS, there was no significant difference in complications or mortality rate between the two groups (O'Donnell et al, 2002). The SEMS demonstrated advantages in terms of quality of life, survival, and cost effectiveness after 4 weeks. If a patient's expected survival is relatively short and the cost of the stent is an issue, a covered plastic stent, such as a Polyflex esophageal stent (Willy Rusch, Kernen, Germany) (Figure 22-5), should be considered over the SEMS in the palliation of EC.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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