Dilatation of benign or malignant oesophageal strictures can be performed with either endoscopic or fluoroscopic guidance. The choice depends on local expertise but screening during dilatation is advisable to reduce the risk of oesophageal perforation. Balloon dilatation is achieved by the introduction of a balloon over a guidewire under fluoroscopic guidance. Balloon dilatation has the advantage of providing a controlled radial dilating force without the longitudinal shearing forces associated with conventional oesophageal bougie dilatation, which is thought to predispose to oesophageal rupture. Obliteration of the waist of the balloon with inflation can be observed in real time and provides an indication of the likely success of the procedure.
In patients with malignant oesophageal disease, considered incurable by surgical intervention, oesophageal stent placement provides good palliation. The use of rigid plastic stents (Celestin or Atkinson tubes) has been gradually superseded by self-expanding metal stents (Fig. 2.39). Some of these are covered with plastic, minimising tumour ingrowth and sealing any associated perforation or fistula. Placement rapidly relieves symptoms, allowing the patient to return home to a relatively normal diet. These techniques are being expanded to strictures elsewhere in the gastrointestinal tract. Duodenal and colonic strictures have been satisfactorily stented although experience is currently limited and the long-term prospects for such procedures are currently unknown.
Percutaneous gastrostomy placement provides a more comfortable alternative to long-term nasogastric feeding in patients who are unable to maintain nutrition with oral intake. This is usually as a result of upper aerodigestive tract malignancy or an inability to swallow as a result of a previous cerebrovascular accident. Percutaneous placement of gastrostomy feeding tubes can be achieved using either endoscopy or fluoroscopy. The choice again largely depends on local expertise and both methods are technically satisfactory. Fluoroscopic placement is essential in patients in whom nasopharyngeal or oesophageal narrowing is such that even the smallest endoscope cannot bypass the obstruction. The fluoroscopic technique requires insufflation of the stomach with air or CO2 via a fine nasogastric tube. This renders it fluoroscopically visible and distends the stomach against the anterior abdominal wall. A puncture site is selected over the lower body of the stomach. Following guidewire placement, the track is dilated co-axially and a 12-French loop catheter finally positioned with a retention loop in the stomach. Minor complications include wound infection and tube dislodgement. Peritonitis does occasionally occur which may be minimised by gastropexy, i.e. fixation of the stomach to the anterior abdominal wall by removable sutures (Fig. 2.40).
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