LAUSR

The gastrointestinal tract is the most common site of extranodal involvement of non-Hodgkin’s lymphoma, and the small intestine is the second most common site following the stomach. Small-intestinal lymphoma is sometimes complicated by strictures, which have been usually managed with surgical resection. In recent years, balloon-assisted endoscopy has enabled the diagnosis of small-intestinal lymphoma before surgery, as well as the evaluation of tumor distribution throughout the gastrointestinal tract. There have been several reports describing the usefulness of endoscopic balloon dilation (EBD) with balloon-assisted endoscopy for small-intestinal strictures that develop during or after chemotherapy. Generally, EBD is contraindicated for strictures due to malignancies because perforation resulting from EBD has the potential to cause tumor dissemination in the peritoneal space. Chemotherapy is the first-choice treatment for small-intestinal lymphomas because the rate of initial response to chemotherapy is relatively high. Therefore, endoscopic treatment of small-intestinal strictures caused by lymphoma may be a reasonable alternative to surgery, as long as it can be performed safely. The aim of this study was to review the efficacy and safety of EBD for strictures secondary to small-intestinal lymphoma. A total of 2,081 patients underwent double-balloon endoscopy (DBE) from April 2005 to January 2017 at Jichi Medical University Hospital, and their medical records were retrospectively reviewed. Of the 2,081 patients, 55 had a histological diagnosis of small-intestinal lymphoma based on endoscopic biopsy or surgical specimens. Follow-up data were available for 41 patients. Of these 41 patients, 10 developed symptomatic small-intestinal obstruction secondary to small-intestinal lymphoma. Of the 10 patients, 9 patients had a single stricture and 1 patient had 2 episodes of small-intestinal obstruction caused by separate metachronous strictures. In all cases, the cause of intestinal obstruction was observed with DBE, and failure to pass the endoscope was defined as a stricture. The indication for DBE-assisted EBD was a stricture causing obstructive symptoms, without an apparent deep ulcer that could extend to the muscularis, without severe angulation, and with a length of <30 mm. Of 10 patients with strictures, 5 patients were treated with DBE-assisted EBD (Fig. 1). DBE-assisted EBD was carried out using a therapeutic endoscope (EN-450T5/W, EN-580T; Fujifilm, Tokyo, Japan) with a distal attachment (DH-17EN, Fujifilm). A throughthe-scope balloon catheter (CRE PRO GI wire guided; Boston Scientific, Natick, MA, USA) was inserted over a guidewire (enclosed guidewire or Revowave RWSA-3555I; Piolax Medical Devices, Yokohama, Japan) under fluoroscopic guidance. The balloon was slowly and carefully inflated with diluted contrast material and maintained in place for 1 min at the appropriate pressure under direct vision (Supplementary Video 1). The dilation diameter was increased in a stepwise manner. In patients who did not achieve complete remission after chemotherapy or in whom the diagnosis had not been confirmed, the dilation diameter was limited to 10 mm to reReceived: December 16, 2018 Revised: February 6, 2019 Accepted: March 8, 2019 Correspondence: Hironori Yamamoto Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan Tel: +81-285-58-7347, Fax: +81-285-40-6598, E-mail: [email protected] ORCID: https://orcid.org/0000-0002-3601-1153