Esophageal dilation

Esophageal dilatation is mainly used for esophageal stricture and esophageal achalasia. As early as 1674, the British willis described the expansion of the esophagus with a whale bone to make the symptoms relieved. There are various types of expansion probes, such as the Hurst probe without a guide wire, the Maloney probe, and the EdeI-PLtest with a guide wire. Ow dilator, Savary-alliard or (2elesl, in dilator. Since 1981, London et al. under the X-ray will be guided by a balloon dilator with a guide wire to achieve significant effect of esophageal stenosis, followed by a variety of endoscopic A balloon dilator that expands the esophageal stricture (without a guidewire), such as a RegiflexTTS balloon catheter dilator. Treatment of diseases: esophageal stenosis, esophageal achalasia Indication 1. Esophageal chemical burn stenosis, digestive stenosis caused by reflux esophagitis, anastomotic stenosis after surgery, congenital stenosis (esophageal fistula) and other organic stenosis. It is better to have a narrower degree of stenosis and a limited range. 2. Functional stenosis such as pharyngeal achalasia, achalasia, and diffuse esophageal fistula (DEs). 3. Esophageal cancer after radiotherapy stenosis, advanced esophageal cancer or relapse after treatment of esophageal stent placement before surgery. Contraindications 1. Patients with esophagitis are not suitable for this operation. Because of the inflammatory inflammation of the mucosa during esophagitis, the tissue is brittle and easily torn and cause perforation. Therefore, it is safer to use the internal medicine to control inflammation after esophagitis. 2, the degree of stenosis is severe, a wide range, when conditions are available, you can ask for surgical consultation, consider the intestinal esophagectomy to improve eating. 3, known or suspected to have esophageal perforation should be cautious. 4, obstruction caused by malignant lesions such as esophageal cancer and cardia cancer should not be simply dilated, otherwise it may aggravate obstruction due to inflammation and edema. Anastomotic stenosis within 3 weeks after esophageal reconstruction, mostly caused by inflammation and no scar formation. Preoperative preparation 1. Preoperative examination of esophageal X-ray barium should be made to determine the location, extent and extent of the stenosis in order to select the expansion method and surgical instruments. 2, fasting 4-6h before surgery to avoid vomiting. The esophagus can be cleaned, the esophagus can be cleaned with a thick stomach tube, and the residual food can be sucked out to avoid aspiration during surgery and easy to observe. 3. Give Atolu and appropriate sedatives and analgesics before surgery. Surgical procedure (1) Hard dilator expansion 1. Equipment (1) Non-guidewire rigid dilator: through a metal esophagoscope, a dilator with a rigid dilator (elastic, metal or other material) expands through the stenosis, using these methods to perforate concurrency The incidence of symptoms is high and the patient is suffering and is currently rarely used. (2) with a guidewire rigid dilator: This type of dilator mainly has two types of Eder-nlestow dilator and savary_Gilliard (or (elestin) dilator. In the 1950s Eder-PLlestow designed "metal olive head" The front end of the dilator has a tight spiral spring head to protect the esophagus and the stomach wall tissue from being pierced, and the inside of the dilator can be connected to the flexible expansion rod through the guide wire and in a detachable manner, and the operation rod and the spring are asked. Loading and unloading is a replaceable stainless steel expansion head (an olive head) with an olive head 4 cm long and a diameter of 7 (21 FG) to 18 mm (54 FG), gradually increasing the diameter of the olive head and gradually expanding the stenosis. The savary_Gilliard dilator was used in the 1980s. Clinically, the dilator system consists of a metal guide wire with a spring probe at the front end and 10 silicone expansion strips with a conical shape at the front end (length '70cm, diameter 5, 7, 9, 11, 12.8, 14, 15, 16 17, 18rnm), the expansion strip is tough, bendable, and has appropriate hardness, is not easy to age, the tip gradually expands to a fixed diameter, and the center has a small hole through the guide wire. 2. Operation process 30 minutes before surgery, pharyngeal surface anesthesia, intramuscular injection of pethidine l ~ 2mg / kg (or stability 10mg), atropine 0.5mg satin j esophageal stricture expansion and stenting (or 654-210 ~ 20mg) Systemic intravenous anesthesia can also be used. Non-cooperative children can be given intramuscular injection of ketamine 6mg / k, after the additional dose according to the need for surgery, the total amount can reach 15mg. Operation steps: Firstly, the position of the esophageal stenosis and the degree of stenosis are examined in detail under the endoscope. The guide wire is delivered to the esophageal stricture through the endoscopic biopsy hole and exits the endoscope, leaving the guide wire in the esophageal lumen. The size of the expansion strip is selected according to the degree of esophageal stenosis, the guide wire is inserted into the central channel at the front end of the expansion strip, and the expansion strip is pushed along the guide wire to the narrow portion for expansion, from small to large. The expandable maximum diameter expansion strip is placed in the narrow esophageal lumen for 5 to 10 minutes, and finally it is pulled out together with the guide wire. For those who need multiple expansions, the interval between two expansions should be 1 to 2 weeks, and the follow-up time should be at least 3 months after the last expansion. (two) non-hard dilator Applied in the early 20th century, it is a rubber dilator with mercury. It has been used for esophageal dilation for a long time. It is safe and effective. It is commonly used in Hust dilators and Ma [oney dilators. The maximum diameter of this type of dilator is up to 20 ram, but the patient is more painful during the expansion process, and the effect is too poor for the tightness of the stenosis. With the wide application of the dilator with a guide wire and the balloon dilator, the current application is more less. (C) balloon dilator The balloon of the early balloon dilator was made of polyethylene or latex. With the development of the polymer material industry, the materials used in the clinical balloon dilator balloon are mostly made of polytetrafluoroethylene, polyurethane, etc. The surface is low in viscosity and can withstand pressures of 2 to 4 atmospheres up to 6 atmospheres. Commonly used balloons are inelastic. When the balloon is full, it will continue to pressurize. It will only increase the pressure inside the balloon (the hardness of the balloon) without increasing the diameter. When the pressure inside the balloon is too large, the balloon will be longitudinal. The axial direction is broken and it is not easy to cause perforation of the esophagus. The diameter ranges from 6 to 40 mm and the length is 6 to 8 cm. It can be used for esophageal stenosis of different ages and different causes. According to the different catheter design, it is divided into two types: balloon dilator and endoscopic balloon dilator. The catheter has a guide wire hole in the center of the catheter, and another hole passes through the balloon for inflation. The diameter of the catheter is about 2 mm. The catheter has a radiolabel at the proximal and distal ends of the balloon for positioning under the X-ray. The latter is only in the center of the catheter. There is a hole through the balloon, the catheter is thin, and the hole can be biopsy through the fiber esophagus. In recent years, Micr0-Vasive has designed a controlled radial balloon dilator (CRE) that controls the diameter of the balloon by pressure. A balloon dilator has three different diameters under controlled pressure, such as 15- 16.5-18mm CRE dilator, at 3, 4.5, 7 atmospheres, the diameter of the balloon is 15, 16.5, 18mm, respectively, which can reduce the esophageal trauma caused by the replacement of the balloon dilator during the stepwise expansion. complication A small number of perforation and hemorrhage, often a small amount of bleeding, clinical manifestations of hematemesis or melena, aspiration and gastroesophageal reflux (often occurs after repeated expansion). The most serious complication is perforation of the esophagus, with an incidence of about 3%. According to the appearance of perforation, it can be divided into acute perforation and subacute perforation. Immediately after acute perforation, according to experience, if the persistent pain does not relieve or even worse after 1h, it should be highly alert to the possibility of perforation. No gas short and subcutaneous emphysema, and take chest X-ray, if found with a longitudinal gas and subcutaneous emphysema, and take a chest film, if found with mediastinal emphysema or liquid pneumothorax, the diagnosis can be established, swallow contrast agent, see outside A leak can confirm the diagnosis. Once the diagnosis is confirmed, the surgical repair should be performed immediately. Generally, the perforation is on the posterior side wall of the lower end of the esophagus. After the esophagus is removed, the leak is repaired. After the repair of the perforation, the swollen muscle is incision on the side wall of the leak to avoid postoperative secondary resection. In rheumatoid esophagitis, anti-reflux surgery can be applied at the same time. Subacute esophageal perforation was found late, more cases of mediastinal perforation or esophageal angiography confirmed that the perforation was found late, and more mediastinal abscess or empyema had occurred, requiring drainage. In the case of suspected occult perforation or perforation, more often, mediastinal abscess or empyema has occurred, and drainage is needed. In the case of suspected occult perforation or transesophageal angiography confirmed by perforation without the formation of empyema or abscess, antibiotics, fasting infusion and placement of gastric tube nasal feeding and other positive conservative treatment. After one week, asymptomatic or angiographically confirmed perforation healing, oral feeding can be resumed.