Modification of the Standard Esophageal Dilation Technique Improves Efficacy in the Treatment of Schatzki Rings and Strictures

Abstract

Purpose: Historically, Schatzki Rings and strictures at the gastroesophageal junction have been managed with a variety of techniques that include Maloney Bouigenage, Savory dilation and balloon dilation. Balloon dilation has become the preferred technique by experienced endoscopists with or without adjuvant Endoincision. Some dilation procedures result in a single deep tear that prevents further dilation while allowing the majority of the ring to remain intact. This paper describes a modification on the current technique of 3 stage controlled radial expansion (CRE) balloon dilatation. Methods: 20 patients (17 with Schatzki Rings and 3 with strictures) had initial dilations that resulted in deep submucosal tears that prevented further dilatation. None of the patients had experienced relief of dysphagia from these procedures and returned to the endoscopy suites for a second procedure. All patients underwent a second dilation with a Microvasive CRE Balloon® (Boston Scientific). Rather than dilating at the traditional 3 stages based on measurements in French or millimeters, a modified technique was carried out where balloon pressure was increased by 0.5 ATM (stopping at each 0.5 ATM stage for 1 minute). Results: Using the slow dilation technique, all patients averaged 3 adequate tears (range 2-5), without the need to stop prematurely. All patients had a greater percentage of their ring or stricture disrupted with this technique. 16 patients had an increase in the circumference of the balloon by 9 French and 4 by 6 French as compared to their initial dilation using the traditional technique. Mean follow-up time was 9 months (range 6-18 months). The only recurrence was in a patient with Scleroderma Esophagus with refractory Grade D esophagitis. Conclusion: 1) The slow dilation techniques improve the end-result in patients experiencing early deep-tears and premature cessation of the procedure. 2) 95% had lasting success and the only failure was a Scleroderma Esophagus with persistent esophagitis. 3) All patients had greater ring destruction and future studies may prove the slow dilation method to be the preferred method in all patients.