Oesophageal Stenosis Dilatation Through Retrograde Trans-gastrostomal Approach in a Patient with Systemic Scleroderma
D. Șerban, C. Brănescu, M. Comandaşu, A.M. Dascălu, D. Dumitrescu, H. Bumbea, B. Braticievici,C. ȘavlovschiClinical case, no. 3, 2014
Aim: The paper presents the surgical solving of anoesophageal stenosis, using a device of pneumatic dilatationwith trans-gastrostomal approach, in a patient with multipledisabling handicaps, secondary severe malnutrition andpreviously diagnosed with scleroderma.Materials and method: The patient was admitted with severecachexia (37 kg, 170 cm), characteristic byzantine face withmicrostomy, distal phalanges resorption in both superior limbsand complete dysphagia, with limitation of mouth opening.The Barium swallow test revealed distal oesophageal stenosis,with an important dilation of the oesophagus above. Results: A gastrostoma was placed to allow nutrition (Gavriliuprocedure), under general anaesthesia with trans-tracheostomalintubation. After 3 years, with her metabolic status improved(59 kg), the patient returned to our clinic asking for a solutionfor natural feeding. The technical difficulties in solving thiscase were determined by the limited mouth opening, whichmade anterograde oro-oesophageal balloon dilatation orbougienage impossible, as well as oro-tracheal intubation.Making use of the presence of the gastrostomal orifice,knowing von Hacker's mechanical dilation procedure andusing the metallic Key Med kit with balls offered thepossibility of the tactics and strategy of guiding a metallicguidewire introduced via the gastrostoma, then trans-stenoticand pulled out through the oral orifice. A modified Foleycatheter (personal procedure) was attached to the initialcatheter. The trans-stenotic retrograde traction of the Foleyballoon was the pneumatic dilator factor that later allowedeasy dilatation with the metallic dilator of the Key Med, tothe maximum size. The follow-up showed good results, thepatient returned to natural nutrition.Conclusions: The device of oesophageal pneumatic dilatationallows, using the presented surgical technique, a gentle plastydone under radiological supervision and lowers the frequencyof accidents. The dilation permits the following use of KeyMed kit. The novelty consists in adapting a well-knowntechnique to a new patented device of pneumatic dilationwith bidirectional approach under radiological control, forsolving this atypical case.
