Dilation Of Esophageal Strictures Research Articles

Safety of a systematic endoscopic biopsy protocol in patients with Barrett’s esophagus

OBJECTIVE: Widespread implementation of rigorous, systematic endoscopic biopsy protocols for patients with Barrett’s esophagus may be hindered by concerns about their safety. This report describes the safety experience of a large series of patients with gastroesophageal reflux disease and Barrett’s esophagus who underwent such procedures. METHODS: Patients in the Seattle Barrett’s Esophagus Project undergo biopsy surveillance in a research-based clinical setting, using large channel endoscopes and “jumbo” biopsy forceps. After visual inspection, multiple biopsies are obtained from lesions and at 1- to 2-cm intervals throughout the Barrett’s esophageal segment. RESULTS: From 1983 to 1997, 1,458 consecutive endoscopies were performed on 705 patients and 50,833 biopsies (average, 35; maximum, 120 per procedure) were taken. Procedures lasted from 15 to 90 min during which one to two biopsies were obtained per minute. Eleven patients experienced 18 significant adverse events, five of which led to overnight hospitalizations: two for bleeding attributed to concomitant esophageal stricture dilation; two for cardiac dysrhythmias; and one for respiratory arrest. Events managed in outpatient settings included chest pain during seven endoscopies (all accounted for by two patients), chest or epigastric pain developing after five endoscopies, and one tonsillar abrasion. All patients recovered completely, and no deaths, perforations, aspiration, or esophageal stricturing resulted from the procedures. CONCLUSIONS: A rigorous, systematic endoscopic biopsy protocol in patients with Barrett’s esophagus does not produce esophageal perforation or bleeding when performed by an experienced team of physicians, nurses, and technicians.

3506 COMPARISON OF CONTROLLED RADIAL EXPANSION BALLOON DILATORS TO CONVENTIONAL BALLOON DILATORS IN PATIENTS WITH BENIGN ESOPHAGEAL STRICTURES.

BACKGROUND: The current treatment of benign esophageal strictures often relies on the use of successively larger reusable Savary dilators or disposable balloon catheters. Recently, a new balloon catheter has been designed in which the balloon material has been preprogrammed to reach three successively larger sizes, depending upon the inflation pressure. This allows one balloon to provide dilatation to three different diameters (CRETM balloon, Microvasive). AIM: To provide a prospective, multi-center, randomized comparison of the CRETM balloon to a standard balloon dilator with regards to ease of use, complications, and effectiveness in patients with benign esophageal strictures. METHODS: A total of 60 patients were studied. Forty men and 20 women, mean age of 67 (range 24-87), with benign esophageal strictures were randomized based on stricture severity. At the time of entry, the two groups were comparable with regards to age, gender, history of previous dilatation, presence of esophagitis, use of antireflux medication, severity of dysphagia, and stricture severity. The mean lumen diameter prior to dilatation was 12.3 mm in the CRETM group and the standard group was 12.7 mm. RESULTS: In comparing the effectiveness of the two groups, the dysphagia score within the first day was reduced by 3.5 in the CRETM group vs. 2.6 in the standard group, p=0.07. Maximum dilatation obtained was 17.3 mm in the CRETM group versus 17.1 mm in the standard group. Dilatation time was comparable, although the CRETM balloon deflated more quickly than the standard, 6 versus 28 seconds. A slightly smaller number of CRETM balloons were used per case than standard dilators, 1.2 versus 1.4. There was a trend in favor of the CRETM balloon in regards to effectiveness at one month with an improvement in dysphagia score of 2.8 vs. 1.9 (p=0.07). CONCLUSIONS: The CRETM balloon works at least as well as the standard balloon in dilatation of benign esophageal strictures. The CRETM balloon allows dilatation to progressively larger diameters using a single catheter. There is a trend that suggests the CRETM balloon might allow more effective dilatation with an increase in lumen size and reduction of symptoms. These trends should be explored in the context of a larger-scale randomized trial. BACKGROUND: The current treatment of benign esophageal strictures often relies on the use of successively larger reusable Savary dilators or disposable balloon catheters. Recently, a new balloon catheter has been designed in which the balloon material has been preprogrammed to reach three successively larger sizes, depending upon the inflation pressure. This allows one balloon to provide dilatation to three different diameters (CRETM balloon, Microvasive). AIM: To provide a prospective, multi-center, randomized comparison of the CRETM balloon to a standard balloon dilator with regards to ease of use, complications, and effectiveness in patients with benign esophageal strictures. METHODS: A total of 60 patients were studied. Forty men and 20 women, mean age of 67 (range 24-87), with benign esophageal strictures were randomized based on stricture severity. At the time of entry, the two groups were comparable with regards to age, gender, history of previous dilatation, presence of esophagitis, use of antireflux medication, severity of dysphagia, and stricture severity. The mean lumen diameter prior to dilatation was 12.3 mm in the CRETM group and the standard group was 12.7 mm. RESULTS: In comparing the effectiveness of the two groups, the dysphagia score within the first day was reduced by 3.5 in the CRETM group vs. 2.6 in the standard group, p=0.07. Maximum dilatation obtained was 17.3 mm in the CRETM group versus 17.1 mm in the standard group. Dilatation time was comparable, although the CRETM balloon deflated more quickly than the standard, 6 versus 28 seconds. A slightly smaller number of CRETM balloons were used per case than standard dilators, 1.2 versus 1.4. There was a trend in favor of the CRETM balloon in regards to effectiveness at one month with an improvement in dysphagia score of 2.8 vs. 1.9 (p=0.07). CONCLUSIONS: The CRETM balloon works at least as well as the standard balloon in dilatation of benign esophageal strictures. The CRETM balloon allows dilatation to progressively larger diameters using a single catheter. There is a trend that suggests the CRETM balloon might allow more effective dilatation with an increase in lumen size and reduction of symptoms. These trends should be explored in the context of a larger-scale randomized trial.

Intralesional steroids augment the effects of endoscopic dilation in benign esophageal strictures

Intralesional steroids augment the effects of endoscopic dilation in benign esophageal strictures

3493 Endoscopic dilation of postcricoid esophageal strictures following head and neck cancer treatment- new techniques for safe access to pces.

Introduction/Aim: Management options for PCES following H&N cancer surgery & radiotherapy include endoscopic dilation, surgical reconstruction, or continued PEG feeding. The PCES anatomy makes endoscopic dilation technically challenging with a high risk of perforation. Hence, most patients undergo either reconstructive surgery or left with continued PEG feeding. We describe a novel approach to access and dilate the postcricoid strictures. Methods: From 07/98-10/99, 5 patients (mean age 64 yrs; 2M & 3F) underwent endoscopic dilation of PCES following H&N cancer treatment. The following protocol to access PCES for endoscopic dilation was used in a stepwise approach (Step 1,2,3). Endoscopic dilation techniques: <i>1) Antegrade dilation-Conventional technique:</i>In 3 patients, wire guided endoscopic dilation with Savary dilators was performed under conscious sedation. Dilation to 15 mm was achieved in 4 wks. <i>2) Antegrade dilation- Laryngeal Jack assisted technique:</i>In a 57 yr. female, the stricture opening could not be identified at endoscopy. A novel approach, the Laryngeal Jack technique (elevation of the larynx from the posterior pharyngeal wall and maintaining the position with a Dedo laryngoscope suspended in a stabilizer) was used to identify the opening of the PCES under general anesthesia with the assisance of ENT team.Wire guided endoscopic dilation of the PCES was done to 12 mm. In 2 mo, the stricture was dilated to 16 mm. <i>3) Combined approach- Laryngeal Jack technique and Retrograde Esophageal Membranotomy:</i>In a 41 yr. female with complete dysphagia (even to saliva), PCES opening could not be identified despite the Laryngeal Jack technique under general anesthesia. After the removal of PEG tube(24 Fr), a 6-mm endoscope(EG1840, Pentax)was passed into the stomach and up into the esophagus. A complete esophageal membranous obstruction was noted. After transillumination from above through the laryngoscope, the thinnest portion of the membrane was punctured with a 5-4-3 catheter, followed by wire guided balloon dilation to 8 mm. In 3 mo, the stricture was dilated to 12-mm. Outcome: All patients gained weight & their PEG tubes were removed. Complications:nil. Conclusions: PCES can be successfully managed by endoscopic dilation without significant morbidity or mortality. Special techniques like the Laryngeal Jack assistance or the combined approach can be useful in difficult cases. Reconstructive surgery can be avoided.

Comparison among the perforation rates of Maloney, balloon, and Savary dilation of esophageal strictures

Background: Traditionally, mercury-filled rubber bougies are used for dilation of simple or mild-to-moderate esophageal strictures, whereas through-the-scope balloon dilators and wire-guided polyvinyl bougies have become standard for more complex strictures. Because few comparative trials are available, the choice of dilator and technique is largely based on the training and experience of the operator. Methods: We reviewed 348 esophageal dilation procedures performed on a total of 142 patients over a 4-year period (January 1, 1993, to January 1, 1997). The location and cause of stricture, the maximum diameter of the instrument used per session, the rate of perforation, and the rate of fluoroscopy use were recorded. Results: Maloney, balloon (hydrostatic and pneumatic type), and Savary dilations were performed in 102, 156, and 90 sessions, respectively. Perforations occurred in 4 patients. All of these perforations occurred when Maloney dilators were passed blindly into complex strictures (Fisher's exact test, p = 0.011, two-tailed). Three of these four patients had undergone endoscopy with conscious sedation immediately before the dilation. The immediate outcome of surgery was good in all 4 patients with no deaths. Conclusion: Perforation was most commonly associated with the blind passage of Maloney bougies into complex strictures. (Gastrointest Endosc 2000;51:460-2.)

Endoscopic dilation of benign esophageal strictures: report on 1043 procedures

OBJECTIVE: Endoscopic dilation is considered the best treatment for most cases of benign esophageal stricture, although the best dilation technique and the kind of stricture is the most amenable to treatment is still controversial. We report on our experience on a large series of patients treated by dilation without the aid of fluoroscopy and compare the results of this therapy among patients with strictures from different causes. METHODS: Between 1992 and 1997, we performed 1043 dilation sessions on 153 patients. Treatment was considered adequate if the esophageal lumen could be dilated up to the size of a 42F catheter. If the stricture recurred after initial successful treatment, the stricture was dilated again up to a 42F catheter. RESULTS: One hundred forty patients (96 men, 44 women; mean age, 54.1 yr) were followed-up for a mean of 20.5 months (4 to 62 months). Stricture’s etiology was postsurgical in 80 patients, peptic in 37, caustic in 12, and from other causes in 11 patients. Adequate dilation was achieved in 93.5% of the patients (131 of 140). Patients with peptic strictures needed a median of three sessions to be adequately dilated during follow-up in comparison to five sessions among patients with postsurgical or caustic strictures ( p = 0.07). There were four perforations, with one death (2.8% and 0.7% per patient and 0.4% and 0.1% per session, respectively). CONCLUSIONS: Endoscopic dilation without the aid of fluoroscopy is safe and effective in relieving dysphagia caused by benign strictures of different causes, although repeated sessions are necessary because of stricture recurrence.

Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures

Background: Intralesional corticosteroid injection has been shown to be effective in refractory esophageal strictures of various etiologies. The present study was conducted to determine the efficacy of intralesional triamcinolone in augmenting results of endoscopic dilation in corrosive esophageal strictures. Methods: Seventeen patients with corrosive esophageal strictures were treated with endoscopic dilation together with injection of triamcinolone acetonide into the stricture. Fourteen patients were already undergoing dilation; 3 patients were newly recruited. The interval between dilations and frequency of dilation were calculated before and after corticosteroid injections, and periodic dilation index was calculated as number of dilations/number of months. Results: The mean age of the 17 patients (8 men and 9 women) was 30 ± 9.21 (range 13 to 52). Thirteen had strictures due to acid ingestion, four to alkali ingestion. There were 18 strictures in total, involving the upper (n = 2), middle (n = 10), and lower (n = 6) thirds of esophagus. Fourteen patients already on a dilation program had undergone 27.92 ± 28.63 (range 6 to 92) dilations over a period of 22.92 ± 30.73 months (range 2 to 96) before corticosteroid injections. Nine patients received a single injection of triamcinolone, whereas four each had two and three sessions. The dilation requirement after injections in these 14 patients was reduced to 3.57 ± 2.90 (range 0 to 10) dilations over a period of 10.5 ± 5.58 (range 4 to 21) months. The median total periodic dilation index irrespective of corticosteroid therapy was 0.33 (range 0.55 to 1.8). In 12 of the 14 patients, periodic dilation index before injections (range 0.91 to 3.0, median 1.67) was higher than the median total periodic dilation index and in all the 14 patients periodic dilation index after corticosteroid therapy (range 0 to 0.83, median 0.32) was less than the median of total periodic dilation index ( p < 0.01). In addition three patients received intralesional corticosteroid injections at the time of first dilation. These three patients could be effectively dilated with 5, 3, and 3 dilations. Conclusions: Intralesional triamcinolone injections augment the effects of endoscopic dilation in patients with corrosive esophageal strictures. (Gastrointest Endosc 1999;49:509-13.)

Viridans streptococcal bacteremia after esophageal stricture dilation

Background: The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation. Methods: Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation. Results: A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients ( p = 0.001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation. Conclusions: These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis. (Gastrointest Endosc 1998;48:568-73.)

Long-term outcomes of balloon dilation of esophageal strictures in children

The purpose of this study was to determine the long-term success of the use of angioplasty balloons for dilation of esophageal strictures in children. The authors studied 24 children who had undergone fluoroscopically guided angioplasty balloon dilation of esophageal strictures. Ten children had stricture of the anastomosis after surgical repair of esophageal atresia; five had achalasia; three had strictures due to gastroesophageal reflux; three had corrosive strictures; two had congenital stenosis; and one had stricture after radiation therapy. Success was defined as resolution of the dysphagia a year after dilation. A year after the last dilation, 15 of the 24 children had no dysphagia. Patients in whom treatment was successful included eight children with strictures after surgery for esophageal atresia, one with achalasia, three with strictures caused by gastroesophageal reflux, one with a corrosive stricture, one with congenital stenosis, and one with a stricture resulting from radiation therapy. The long-term results of balloon catheter dilation are highly successful in patients with stricture after surgical repair of esophageal atresia and stricture due to gastroesophageal reflux. Dilation is not as valuable in the treatment of esophageal strictures resulting from other causes.

Bacteremia with esophageal dilation

(GUMMI BEARS) Background: Antibiotic prophylaxis has been recommended for selected patients undergoing esophageal stricture dilation because of a reported high rate of bacteremia. The aim of this study was to determine the rate of bacteremia after esophageal dilatation in a large series and the source of the organisms recovered. Methods: Blood cultures and oral temperatures were obtained before esophageal dilation and at 5 and 30 minutes after dilation. Dilators were cultured immediately before dilation. Procedural data collected included type of dilation, number of passes, and presence of malignancy. Results: Of 100 procedures in 86 patients undergoing esophageal dilation, 22 (22%) were associated with a positive post-dilation blood culture. Bacteremia was more frequent with dilation of malignant strictures compared with benign strictures (9 of 17 [52.9%] vs. 13 of 83 [15.7%], respectively, p = 0.002) and with passage of multiple dilators compared with passage of a single dilator (16 of 46 [34.8%] versus 6 of 54 [11.1%], respectively, p = 0.007). Bacterial isolates from 22 positive blood cultures matched those from a dilator in only one episode (4.5%). Conclusion: The rate of bacteremia after esophageal dilation is 22% and is associated with dilation of malignant strictures or passage of multiple dilators. Organisms cultured from the blood are not transmitted from the dilator. (Gastrointest Endosc 1998;48:563-7.)

Balloon dilatation of oesophageal strictures in children: K. Sandgren and G. Malfors. Eur J Pediatr Surg 8:9–11, (February), 1998

Balloon dilatation of oesophageal strictures in children: K. Sandgren and G. Malfors. Eur J Pediatr Surg 8:9–11, (February), 1998

Intralesional steroids augment the effect of endoscopic dilation in corrosive-induced esophageal strictures

functional dyspepsia (5 men and 15 women, ages 20 to 55 years) with dysmotility-like dyspepsia symptoms (Rome criteria). Subjects consumed a light breakfast (4 oz. of apple juice and toast with butter or margarine) 2-3 hours before the EGG test. In the laboratory, subjects ingested water until feeling full (water load test). EGGs were recorded for 15 min. preand 30 min. post-water ingestion. The percentages of EGG total power in the bradygastria (0-2.25 cycles per min., cpm), normal (2.25-3.75 cpm), tachygastria 3.75-10 cpm) and duodenal (10.0-15 cpm) ranges were calculated. Data from control subjects were used to establish normative EGG data (mean +_ 1 SD). EGG results from each of the 20 patients were compared with the normative EGG data to determine whether a given patient's EGG fell within (normal result) or outside (abnormal result) the normal range. Results: Abnormal EGG responses to the water load test were found in 11 of 20 patients (55%). The Normal-EGG and Abnormal-EGG patient groups drank similar volumes of water (Abnormal-EGG = 395 +-41 ml, Normal-EGG = 385+-41 mi). The Abnormal-EGG group showed an increase in bradygastria and decrease in 3 cpm activity in response to the water load that was not observed the Normal-EGG group (F[3/54]=4.6, p <0.05 and F[3/54]=3.6, p < 0.05, respectively). In addition, the Abnormal-EGG group showed more tachygastria throughout the recording period compared to the Normal-EGG group (F[1/18]=5.8, p < 0.05). Conclusions: 1) In controls and patients the water load test provides a standard stimulus for evaluating gastric myoelectrical activity responses with the EGG; 2) Patients with dysmotilitylike dyspepsia may be defined in terms of normal vs. abnormal EGG responses, responses that provide an objective measure for definitions of functional dyspepsia and treatment protocols.

An Unusual Presentation of a Retained Esophageal Foreign Body

An Unusual Presentation of a Retained Esophageal Foreign Body

Balloon dilatation of oesophageal strictures in children.

During the last ten years balloon dilatation has become increasingly frequent in the therapy of oesophageal strictures, both for diagnosis and treatment. From 1983 to 1994, balloon catheterization was performed in 36 children (oesophageal atresia 28, tracheo-oesophageal fistula 3, congenital stenosis 1, acquired oesophageal stricture subsequent to gastro-oesophageal reflux 1, to caustic ingestion 3). Age at treatment varied from 2 weeks to 15 years. Thirty-nine (3 double) strictures were dilated a total of 171 times. Balloon dilatation was successful in 31 cases (79%). In two children therapy was changed to conventional bouginage and six strictures were resected. Advantages of the method may include that forces are exerted radially and that the procedure may be performed under better control since fluoroscopy is used.

Frequency of viridans streptococcal bacteremia after esophageal stricture dilation: Implications for use of antibiotic prophylaxis to prevent infective endocarditis

Frequency of viridans streptococcal bacteremia after esophageal stricture dilation: Implications for use of antibiotic prophylaxis to prevent infective endocarditis

Endoscopic dilation of esophageal strictures: Prospective analysis of 990 procedures

Endoscopic dilation of esophageal strictures: Prospective analysis of 990 procedures

Preliminary clinical experience with the new cre TM multidiameter balloon for dilatation of esophageal strictures

Preliminary clinical experience with the new cre TM multidiameter balloon for dilatation of esophageal strictures

Dilation of Peptic Esophageal Strictures

Dilation of Peptic Esophageal Strictures

Dilation of proximal esophageal strictures following therapy for head and neck cancer: experience with Savary Gilliard dilators.

There is little information on dilation of proximal strictures following surgical and/or radiation therapy for head and neck cancer. We studied the feasibility and efficacy of dilating proximal strictures following therapy for head and neck cancer using Savary Gilliard dilators. Twenty-one consecutive patients with proximal strictures resulting from surgery and/or radiation therapy of head and neck cancer were studied. Savary Gilliard dilation was performed using the standard and a modified method. Dysphagia was graded before and after dilation using a 5-point scale. Technical success, dysphagia relief, complications, and duration of relief were noted. Technical success was achieved in 20 (95%) patients. Adequate dysphagia relief was obtained in 15/20 (75%) patients, which lasted for 4-36 weeks (median 14 weeks). There were no perforations, bleeding, or deaths. Four patients required repeat dilation after a median interval of 12 weeks. Savary Gilliard dilation is a safe and effective method for dilating strictures caused by therapy for head and neck cancer.

Therapeutic gastrointestinal endoscopy.

The safety, efficacy and utility of various therapeutic gastrointestinal (GI) endoscopic procedures performed on children (January 1992 to July 1995) at a tertiary referral centre in India were studied. A total of 1,030 sessions (upper GI 972 and lower GI 58) of therapeutic GI endoscopy were performed in 162 children (mean age 7.4 +/- 4 years; upper GI 115, lower GI 47). Various upper GI endoscopic procedures done were injection sclerotherapy (EIS), endoscopic variceal ligation (EVL), bougie dilatation of oesophageal strictures, balloon dilatations of oesophageal stricture/pyloric obstruction and retrieval of foreign bodies in 75%, 6%, 9%, 4% and 12% of children respectively. Therapy for bleeding from oesophageal varices constituted the major group (75%). Repeated EIS (sessions total--876, mean 8, range 5-15) performed on 86 children resulted in control of bleeding in all and eradication of oesophageal varices in 85% of cases. Minor complications (oesophageal ulcers and oesophageal strictures) due to EIS were observed in 9% of children. EVL (10 sessions in 7 children) was effective in controlling bleeding and substantial decrease of varices in all without any complication. Oesophageal dilation either by bougie (61 sessions in 10 children) or balloon (6 sessions in 3 children) were performed for benign strictures. Balloon dilatation of pyloric obstruction was successfully done in 2 children. Foreign bodies (retained or sharp) were retrieved from upper GI tract in 14 children. No complications were observed with stricture dilatation/foreign body retrieval. Therapeutic lower GI endoscopies were performed in 47 children (colonoscopic polypectomy in 92%, anal dilatation and piles banding in 4% each). One child with juvenile polyposis coli developed sigmoid colon performation following colonoscopic polypectomy which required surgical correction. We conclude that upper and lower GI endoscopic therapeutic procedures in children are highly effective and safe. The risk of major complication is very small in experienced hands and occasional minor complications, can be managed conservatively.