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To determine the safety and effectiveness of fluoroscopic guidance biopsy in the diagnosis of serve anastomotic stricture after esophagogastrostomy for esophageal carcinoma.A total of 55 patients with severe anastomotic stricture were enrolled for forceps biopsy between June 2013 and July 2017. Chest computed tomography (CT) and esophagogram were used to determine the location and extent of stricture. Specimens were collected from the site of stricture by using biopsy forceps under fluoroscopic guidance. Stooler's dysphagia score was compared before and after treatment.The technical success rate of fluoroscopic guidance biopsy was 100%, with no serious complications occurred. A total of 38 patients were diagnosed as benign stricture, of which, 2 patients were further diagnosed as cancer by further biopsy, with a missed diagnosis rate of 5.3%, and 1 patient developed squamous cell carcinoma after 5 months. Thus 20 cases were diagnosed as cancer, 3 cases were adenocarcinoma and 17 cases were squamous cell carcinoma. Balloon dilation was performed for 20 patients (33 times) of benign stricture, and 9 patients (10 times) of malignant stricture. A total of 26 esophageal covered stents were implanted for benign restenosis after repeated balloon dilation. A total of 8 esophageal covered stents were implanted for malignant stricture. After esophagus stenting, dysphagia was immediately alleviated. The dysphagia score decreased from 3.4 ± 0.1 to 0.7 ± 0.1 (P < .001) after treatment.Fluoroscopic guidance biopsy is a safe and effective procedure for directing appropriate treatment of anastomotic stricture after esophagogastrostomy, and it may be an alternative approach for patients who cannot tolerate fibergastroscopy.