Savary Dilators Research Articles

Novel Use for Maloney Dilators in the Management of Gastrostomy Stenosis

One of the most common complications of gastrostomy tube (g-tube) placement is dislodgement. Once the tube is dislodged, the stomal tract begins to close immediately as the area heals via secondary intention. Caretakers can place a small catheter into the gastrostomy to prevent complete closure but the stoma often becomes stenosed. In patients who develop stenosis, there are limited data available describing techniques to reestablish the gastrostomy tract for use. Described here is a novel technique using Maloney dilators to dilate gastrostomies. Case A 68 year old male with progressive multiple sclerosis and dysphagia presented for follow up after g-tube dislodgement and placement of a 14 Fr catheter into the stoma. Bedside exchange to a 20 Fr g-tube was unsuccessful due to stenosis. An 18 Fr g-tube was passed with moderate resistance. Days later, the patient presented with tube malfunction. The tube was found to be clogged by medications. It was determined that an 18 Fr was too small for his medications. At bedside, the 18 Fr g-tube was removed and then, starting with an 18 Fr Maloney dilator, the patient's ostomy site was dilated up to 26 Fr (Fig 1, 2). A 22 Fr g-tube was then placed without complications and utilized successfully by the patient in the following months.Figure: Small gastrostomy tube removed and Maloney dilator being lubricated prior to insertion.Figure: Maloney dilator inserted to maximal diameter.Case B 50 year old male with history of hemorrhagic CVAs with dysphagia had a 20 Fr g- tube that was dislodged and replaced with a 16 Fr catheter to prevent closure. New g-tube could not be placed as ostomy had stenosed. The ostomy was dilated using a Savary dilator and a 18 Fr g-tube was be placed. Within that same year, while attempting to replace the g-tube, a 18 Fr replacement could not be placed due to stenosis. Maloney dilators were used to dilate to 22 Fr. An 18 Fr g-tube was then placed without complications. In follow up, patient required repeat dilation after dislodgement and insertion of a 14 Fr catheter into his stoma. Subsequent dilation to 24 Fr with Maloney dilators was well tolerated. Patient required no further dilations over the following 5 year period. When gastromy stomas become stenosed, Maloney dilators can be safely used to dilate to a desired size. Without the need for wires or other devices, this can be done by a single provider and saves the patient from repeat endoscopic placement. This method is also more cost effective than other dilation methods and repeat endoscopy. This should only be attempted in patients with mature stomal tracts.

The Use of Fully Covered Lumen-Apposing Self-expandable Metallic Stents for Treatment of Benign Strictures of the Upper Gastrointestinal Tract: A Retrospective Case-Controlled Study

Introduction: The AXIOSTM stent (Boston Scientific, Massachusetts, USA) is a fully covered lumen apposing self-expandable metallic stent (fcLASEMS). The stent was developed for transenteric drainage of pancreatic pseudocysts. The dumbbell shaped stent is available in lengths of 10mm or 15mm and can be deployed with or without electrocautery. The aim of this study was to examine the efficacy of fcLASEMSs in the treatment of benign stricture disease of the foregut. Methods: A single center retrospective database of patients who underwent endoscopic treatment of benign strictures was analyzed for this study. A total of 998 endoscopic procedures were identified on these patients between January 2014 and May 2017. Of those, 15 patients underwent endoscopic fcLASEMS placement. The average number of endoscopic dilations prior to stent placement was 2.46. A control group of non-stented patients that underwent 3 or more endoscopic dilations with Savary dilators or controlled radial expansion balloon dilators (n=36) was created. The Mann-Whitney test and twotailed-t test were used to compare the total number of endoscopic interventions between the control and fcLASEMS groups. The patient and stricture characteristics were determined based on review of follow up documentation. Complications were defined as events leading to hospitalization or requiring early removal of the stent. Results: The mean number of endoscopic dilations in the control group was 5.02 (SD 3.873). Whereas the mean number of endoscopic interventions in the fcLASEMS group was 3.385 (SD 0.870). The difference between the 2 groups was statistically significant (t-test (P < 0.0001) and Mann-Whitney test (P=0.017)). The mean duration of fcLASEMS placement was approximately 105 days. fcLASEMS placement provided symptomatic relief in 73% of patients. Stent migration and post procedure complications occurred in 6.6% and 20% of patients respectively. The mean length of follow up for the fcLASEMS and control group was 282 and 225 days respectively. Conclusion: Clinicians should consider the use of fcLASEMSs in patients with recurrently symptomatic benign foregut strictures. Early intervention with an fcLASEMS appears to be a viable option for durable symptomatic relief in patients with persistent benign foregut strictures. The overall number of endoscopic interventions was lower with the use of fcLASEMSs than with standalone serial dilations in patients who required 3 or more endoscopic dilations which may be more cost effective.Table: Table. Results of Fully Covered Lumen-Apposing Self-Expandable Metallic Stents for the Treatment of Benign Strictures of the Upper Gastrointestinal Tract

Endoscopic Incision Therapy (EIT) for Benign Esophageal Strictures

Benign esophageal strictures are conventionally managed by dilation and response is based on the etiology of the stricture. Most patients often need multiple sessions of dilations. Directed mucosal incision can have the advantage of focusing on the site of narrowing and potentially decreasing the number of endoscopic therapies needed. The aim of this pilot study is to evaluate the safety and efficacy of endoscopic incision therapy for benign esophageal strictures. Five consecutive patients with benign esophageal strictures were treated with EIT. Site and etiology of the stricture is described in Table 1. These patients underwent endoscopic incision therapy with an insulated tip endoscopic submucosal dissection knife. Patient A had Savary dilation one month prior to the incision therapy. Patients B and C had no prior treatment of the strictures. Patient D had previously undergone Savary dilation and through-the-scope balloon dilation with partial response. Patient E had multiple dilations in the past including steroid injection and stent placement with recurrence of the stricture. Four of the five patients required one endoscopic incision therapy, while patient D underwent a total of three incision therapies within a period of 5 months with significant gradual improvement in symptoms. Patients A and C required one endoscopic incision therapy with complete resolution of their symptoms. Patient B had structural improvement but had persistent dysphagia due to a motility disorder. Patient D had significant structural resolution at follow up four months after the initial incision therapy with improvement in dysphagia. Patient E had structural improvement as well as significant improvement of dysphagia at the 6 week follow-up. There were no complications in this series. Our case series demonstrates that endoscopic incision therapy is effective and safe for treatment of benign esophageal strictures as either the initial form of treatment or in refractory cases. There is a potential to reduce the number of endoscopic procedures required for desired clinical efficacy. Further long-term studies are needed to establish the role of EIT.Figure

Sarcina as an Unknown Culprit of Esophageal Strictures

Sarcina ventriculi is a gram positive organism that is well known to veterinarians, however the exact pathogenicity in humans is not well delineated. Several cases of human disease have been described including emphysematous gastritis, gastric ulcers and perforation, and recently esophageal pneumatosis. Here we present a case of Sarcina-associated esophageal stricture. A 65 year old woman with metastatic breast cancer and history of Schatzki ring presented with two months of progressive dysphagia. Imaging with x-ray fluoroscopy revealed an irregularly short segment stricture at the mid to distal esophagus. Esophagogastroduodenoscopy (EGD) showed a benign appearing stenosis at 32 cm that measured 3 mm in diameter and gastric ulcers. She underwent subsequent dilation under fluoroscopy with a Savary dilator up to 12 mm and was medically managed with a proton pump inhibitor. Esophageal biopsies revealed acute and chronic inflammation with rare large tetrads of bacterial cocci, morphologically consistent with Sarcina organisms. In light of Sarcina presence, she was treated with 7 days of metronidazole and ciprofloxacin. An esophageal stent was placed after serial dilation failed to improve symptoms. Unfortunately, her hospital course was complicated by acute pulmonary embolisms, hemorrhagic gastropathy, and persistent vomiting resulting in subsequent removal of the stent. Ultimately, the patient transitioned to palliative comfort care due to overall poor prognosis. Sarcina ventriculi is a well described pathogen in veterinary medicine, but its role in human disease is not as well understood. Human presentation has varied widely from gastrointestinal symptoms of nausea, vomiting, epigastric pain to emphysematous gastritis complicated by gastric perforation. EGD findings have also varied but common themes have emerged including luminal findings of retained food residue and mucosal findings of erosion and gastric ulcers. While most reported cases of Sarcina pathology have been gastric in location, very few have been esophageal. Studies of the esophageal microbiome did not identify Sarcina in patients with normal histology, which suggests that in contrast to gastric sites the organism is more likely to be a pathogen. Compared to previous esophageal pathology reported, we report a case of Sarcina that occurred in the setting of stasis as a result of esophageal stricture. It will be important to further assess the importance of Sarcina in the pathogenesis of esophageal diseases.Figure: EGD findings of severe esophageal stricture.Figure: Purple Sarcina cocci in characteristic tetrads (long arrows) are present in the luminal aspect of this gastric biopsy. Notice the large size of the organisms in comparison to the luminal bacilli (arrowheads) in the background. There is mild acute inflammation, demonstrated by the intraepithelial neutrophils (short arrows), in the adjacent gastric epithelium. Hematoxylin and eosin (H&E) stain, original magnification 600x.Figure: Esophagus squamous mucosa with luminal Sarcina organisms (long arrows). Arrowhead points to background bacilli for size comparison. H&E 600x.

Abstract 2766: Esophageal stenting in resource-limited settings

Abstract Background: Esophageal cancer is the 6th leading cause of cancer death globally, with geographical high-risk areas in Asia, the Middle East, and eastern and southern Africa. Esophageal squamous cell carcinoma (ESCC) is the more common variant in Africa. In Kenya, its incidence is 2nd in men after prostate cancer and 3rd in women after breast and cervix-uteri cancers. Late presentation is a common occurrence in developing countries and is multifactorial due to challenges in access to health care, low socioeconomic status and delayed or missed diagnosis. A large percentage of these tumors are thus unresectable and are only eligible for palliative care via stenting. Our hospital is a 300-bed referral center in southwestern Kenya, which is a hotspot for ESCC, and we see over 400 cases of ESCC annually. Methods: We have developed a technique for placement of esophageal self-expanding metallic stents (SEMS) without fluoroscopy that is safe and easily reproducible. This is an outpatient procedure, with the majority done under conscious sedation, and routine followup is not necessary. The tumor margins are noted at time of video endoscopy, a guidewire is placed, and dilation done with Savary dilators as required. The SEMS are then loaded on the stent delivery device and deployed into the proper position based on measurements, and placement is subsequently confirmed via endoscopic visualization. Results: A total of 3000 SEMS have been placed to date at our hospital, without using fluoroscopy. The male: female ratio has been 1.5:1, and the average age has been 60.4 years. The distribution of tumor locations was 67% in the middle and distal third. The most common complications were tumor overgrowth with obstruction and stent migration. Procedure related mortality was 0.3%. Post-procedure improvement in dysphagia score was seen in over 80% , and patient satisfaction was high. Initial data puts our post stent survival time around 8 months/ 250 days Conclusions: Placement of SEMS for ESCC, without fluoroscopy, is a safe and reproducible procedure which has a low rate of adverse events. This procedure results in effective palliation of a difficult disease and can easily be done in resource-limited settings which have endoscopy capabilities. Current efforts are ongoing to increase opportunities for training endoscopists in this procedure and for provision of affordable stents in Africa. Citation Format: Michael M. Mwachiro, Robert K. Parker, Stephen Burgert, Justus Lando, Sinkeet Rankeeti, Robert Chepkwony, Emmanuel Kiniga, Sanford Dawsey, Mark Topazian, Russell E. White. Esophageal stenting in resource-limited settings [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2766. doi:10.1158/1538-7445.AM2017-2766

Savary Dilation Is Safe and Effective Treatment for Esophageal Narrowing Related to Pediatric Eosinophilic Esophagitis.

Data on management of esophageal narrowing related to eosinophilic esophagitis (EoE) in children are scanty. The aim of the present study is to assess the safety and effectiveness of esophageal dilation in pediatric EoE from the largest case series to date. Children diagnosed with EoE during 2004 to 2015 were reviewed for the presence of esophageal narrowing. Esophageal narrowing was categorized as short segment narrow caliber, long segment narrow caliber, and single short stricture. The characteristics of the narrowed esophagus, therapeutic approach, clinical outcome, and complications were reviewed. Of the 50 EoE cases diagnosed during the study period, 11 cases (9 boys; median age 9 years, range 4-12) were identified with esophageal narrowing (22%). Six had short segment narrow caliber esophagus and 5 had long segment narrow caliber esophagus (median length of the narrowing was 4 cm, range 3-20 cm). Three cases with narrow caliber esophagus also had esophageal stricture 2 to 3 cm below the upper esophageal sphincter. Nineteen dilation sessions were performed in 10 cases using Savary dilator. Esophageal size improved from median 7 mm to median 13.4 mm. Good response was obtained in all cases. Following the dilation procedure, longitudinal esophageal mucosal tear occurred in all cases without esophageal perforation or chest pain. Esophageal dilation using Savary dilator is safe and highly effective in the management of esophageal narrowing related to EoE in children. Dilation alone does not improve the inflammatory process, and hence a combination with dietary or medical intervention is required.

Schatzkiʼs Ring: Four Quadarant Disruption vs Dilation

Introduction: Effective treatment for patients with symptoms of solid food dysphagia secondary to Schatzki's ring has been a widely investigated topic. A variety of treatment options are available but the most preferred method is dilation by bougienage. This method is generally effective in short term but fails to provide long-term treatment success. The goal of our study was to determine whether patients with Schatzki's ring have long term symptomatic relief from four quadrant disruption of the ring using biopsy forceps versus Savary dilator. Methods: We performed a randomized prospective controlled study to compare the efficacy of four quadrant disruption of Schatzki ring versus Savary (rigid polyvinyl) dilator for the treatment of solid food dysphagia in patients with Schatzki ring. Patients undergoing upper endoscopy for the complaint of solid food dysphagia due to a Schatzki ring were enrolled. Exclusion criteria: contraindications to upper endoscopy or esophageal dilation, achalasia, scleroderma, or prior esophageal or gastric surgery, esophageal malignancy, severe esophagitis, or coagulopathy. The participants answered two questionnaires from which dysphagia score and diet/eating habit score was determined. Patients were then randomized into two treatment groups: Savary dilation or four quadrant disruption with biopsy forceps. They filled out two questionnaires at 1 month, 3 months, 6 months, and 12 months after the procedure. The primary end point was the patient's self-assessment of dysphagia based on the questionnaires. Statistical analysis was carried out using independent sample Mann-Whitney test for continuous variables and Fisher's exact test for categorical variables. Results: Ten patients participated in this study. Patients were followed up for 12 months. There was no difference in the demographics (Table 1) and clinical characteristics (Table 2) of the two groups. The initial dysphagia score and eating/diet habit score were similar. Both the groups demonstrated improvement in their dysphagia and diet score at 1 month (improvement in percentage). However, it was noted that the dysphagia and diet score remained improved in biopsy group at 12 months whereas it came back to baseline in the dilation group. There were no complications in either group.Table 1: Comparison of demographic and clinical characteristics between thw two groupsTable 2: Dysphagia Score after 1 month and 12 months of treatmentConclusion: Since the long term effectiveness of esophageal dialtion for Schatzki's ring is questionable, we need to look for newer innovative techniques to improve symptoms in these patient.

Outcomes of Endoscopic Therapy of Luminal Strictures in Crohnʼs Disease

Introduction: Crohn's disease (CD)-related strictures may benefit from endoscopic therapy. We sought to describe the outcomes of endoscopic therapy of luminal strictures in CD patients (pts) at a large tertiary referral center. Methods: All pts with endoscopic dilation of CD strictures were identified between 1/1/1990 and 11/30/2013. Demographics, disease characteristics including medication use and history of surgeries, details of endoscopic procedures, and long-term outcomes including complications and need for surgery were analyzed. Successful endoscopic stricture dilation was defined as ability of the endoscope to pass through the stricture after dilation or effacement of the dilating balloon. Kaplan-Meier and Cox proportional hazards analysis were used. Results: A total of 603 procedures were performed in 274 pts. Median age was 45.9 yrs (range, 14.9-92.2) and 53.6% were female. Median duration of CD was 16.9 yrs (1.1-67.9). Most pts (94.8%) were symptomatic at the time of their procedure. Most common procedures were colonoscopy/flexible sigmoidoscopy (72.5%), esophagogastroduodenoscopy (EGD) (11.9%), and pouchoscopy (6.5%). Conscious sedation was used for 442 procedures (73.8%), and fluoroscopy was used in 80 procedures (13.5%). Most common stricture locations were ileocolonic anastomosis (41.1%) and colon (13.2%). Balloon dilation was used in 548 strictures (90.9%), Savary dilation in 19 strictures (3.2%), and Hegar dilators in 33 strictures (5.1%). Mean inner diameter of all index strictures was 8.2 mm (1.0-18.0). Steroid injection into the stricture was performed in 89 cases (14.9%). Seventy-three patients (25.4%) had a medication change after the initial procedure (addition of immunomodulators or biologics). One hundred fifteen pts had a second dilation. Cumulative probability of need for a second dilation following the index procedure was 32.5% (25.8%-38.6%) at 1 year, 53.6% (45.6%-60.8%) at 3 years, and 60.7% (51.9%-68.0%) at 5 years. See Table for factors associated with second dilation. Six complications occurred after the first procedure: 4 perforations, 1 pt with bleeding, and 1 pt with abdominal pain. Conclusion: In the largest cohort of its type, endoscopic stricture dilation in Crohn's disease was safe and effective. About 30% of pts required a second dilation at 1 year after the initial dilation; younger age and smaller inner diameter of the index stricture predicted need for a second dilation.Table 1: Predictors of a Second Dilation Based on Univariate Cox Analysis

Swiss Cheese Esophagus: A Case of Esophageal Intramural Pseudodiverticulosis

Diverticula can be seen throughout the gastrointestinal tract including the Esophagus. Esophageal Intramural Pseudodiverticulosis (EIPD) is a rare condition characterized by the presence of multiple pinhead-sized outpouchings of the esophageal wall, giving the esophagus the appearance of Swiss cheese on endoscopy. We present a case of EIPD in a patient with eosinophilic esophagitis (EoE). To our knowledge, this is the first case describing EIP with concomitant EoE. A 72 year old Caucasian male presents to a gastroenterology clinic for evaluation of dysphagia. He underwent endoscopy as part of his evaluation, which revealed multiple esophageal diverticula as well as distal esophageal strictures. The patient underwent successful esophageal stricture dilation and was advised to follow up for a repeat endoscopy. He followed with another gastroenterologist for the next 3 years where he was diagnosed with Eosinophilic Esophagitis (EoE). He was treated with oral budesonide slurry but continued to have recurrent dysphagia. He presented with a complaint of “macaroni stuck” in his throat. The food bolus passed spontaneously and on endoscopy he had multiple esophageal rings as well as pseudodiverticulosis. The patient underwent Savary dilation, followed by multiple repeat stricture dilatation sessions in the following months. He subsequently had complete resolution of his dysphagia, while on budesonide, and had a satisfactory endoscopic appearance on the most recent endoscopy, except for the pseudodiverticulosis. EIPD was first described in 1960 by the British Institute of Radiology. To date a little over 200 cases of EIP have been described in the literature. Unlike colonic diverticula, the exact mechanism by which EIPD forms is unclear. It seems, however, to be affected by chronic inflammation whereby the structural integrity of the esophageal lining, especially at the excretory ducts of the submucosal glands, is compromised leading to the formation of diverticula. This rare entity represents a unique challenge, especially in the presence of other concomitant conditions. In our patient, both EoE and EIPD can lead to dysphagia and stricture formation. This raises an interesting question: Are the strictures a result of EIPD or EoE or both? Also, if EIPD is associated with chronic inflammatory states then why is it not more commonly seen with conditions such as reflux esophagitis?Figure 1

Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience.

Benign anastomotic colonic stenosis sometimes occur after surgery and usually require surgical or endoscopic dilation. Endoscopic dilation of anastomotic colonic strictures by using balloon or bougie-type dilators has been demonstrated to be safe and effective in multiple uncontrolled series. However, few data are available on safety and efficacy of endoscopic electrocautery dilation. The aim of our study was to retrospectively investigate safety and efficacy of endoscopic electrocautery dilation of postsurgical benign anastomotic colonic strictures. Sixty patients (37 women; median age 63.6 years, range 22.6-81.7) with benign anastomotic colonic or rectal strictures treated with endoscopic electrocautery dilation between June 2001 and February 2013 were included in the study. Anastomotic stricture was defined as a narrowed anastomosis through which a standard colonoscope could not be passed. Only annular anastomotic strictures were considered suitable for electrocautery dilation which consisted of radial incisions performed with a precut sphincterotome. Treatment was considered successful if the colonic anastomosis could be passed by a standard colonoscope immediately after dilation. Recurrence was defined as anastomotic stricture reappearance during follow-up. The time interval between colorectal surgery and the first endoscopic evaluation or symptoms development was 7.3 months (1.3-60.7). Electrocautery dilation was successful in all the patients. There were no procedure-related complications. Median follow-up was 35.5 months (2.0-144.0). Anastomotic stricture recurrence was observed in three patients who were successfully treated with electrocautery dilation and Savary dilation. Endoscopic electrocautery dilation is a safe and effective treatment for annular benign anastomotic postsurgical colonic strictures.

Successful Combined Intralesional Corticosteroid Therapy and Wire-Guided Dilation of Severe Esophageal Graft-Versus-Host Disease

Introduction: This 63-year-old woman first presented in 2009 with a 4 year history of severe dysphagia following allogenic hematopoetic transplantation for aplastic anemia/leukemia in 2004, which was complicated by severe acute and chronic GVH. This was managed with tracrolimus. Barium studies showed severe proximal 2 cm and 9cm mid-distal esophageal strictures which progressed over time despite oral GVH therapy. She had been on a liquid only diet for 2 years, following an unsuccessful attempt at dilation in 2007 at NIH. Since then symptoms progressed and esophagectomy or gastrostomy were recommended. Initial EGD showed typical esophageal GVH changes, with areas of mucosal slough, friability and severe structuring precluding passage past the proximal esophagus. Biopsies confirmed GVH. Fluoroscopic wire guided Savary dilation to 7mm resulted in severe proximal slough and deep ulceration, with post procedural odynophagia, but no perforation. This was treated with oral liquid sucralfate. Patient remained severely symptomatic with difficulty maintaining hydration and taking her oral medications for GVH which had to be given in elixir form. 9 weeks later at repeat EGD, the stricture had recurred. This time we injected triamcinolone 40mg/2cc in 0.25-0.5cc/injection via sclerotherapy needle in the reachable strictured areas, followed by fluoroscopic wire-guided dilation to 8mm. Over the subsequent 3 years a total of 15 endoscopic sessions, with 4 to 8 0.25-0.5ml endoscopic injections of 40 mg of triamcinolone/session, followed by progressive fluoroscopic wire-guided Savary dilation. There was gradual improvement in the endoscopic appearance. After the 5th session we could dilate the entire esophagus the the point where the endoscope could be advanced into the stomach. By 2012 the esophagus was dilated to a 14 mm diameter, the mucosal GVH changes were much improved/resolved. This allowed the patient to eat normally, and take all her po medications. Only complication was recurrent candida esophagitis, which was treated with fluconazole. Since then patient has been dilated every 6-9 months and the stricture has remained stable. Chronic GI tract GVH is less frequent with advances in hematopoetic transplantation but remains disabling. Submucosal corticosteroid injections combined with oral immunotherapy have been used to treat oral GVH, but we could not find a case of similar case of combined endoscopic therapy for esophageal GVH. This approach had minimal morbidity and resulted in a marked symptomatic and endoscopic response.

The role of endoscopy in the evaluation and management of dysphagia

The role of endoscopy in the evaluation and management of dysphagia

Savary Dilation is a Safe and Effective Long-term Means of Treatment of Symptomatic Cricopharyngeal Bar

Dilation of a cricopharyngeal (CP) bar can be a safe and effective means of nonsurgical treatment as elderly patient population has high morbidity and is at a higher risk of surgical complications. CP bar is a relatively uncommon radiologic finding, which is an infrequent cause of oropharyngeal dysphagia in the elderly population. Patients were included in study from January 2007 to January 2012, if their dysphagia was solely attributed to CP bar on predilation radiologic imaging by either modified barium swallow or barium esophagogram. A functional outcome swallowing score (FOSS) was calculated at 1, 4, and 6 months from initial and last dilation performed. A total of 31 patients with a mean age of 71.65 (54 to 88) years and mean body mass index 27.81 (15 to 41) were included in the study. Over the time period of 5 years, a total of 53 dilations were performed. The median predilation FOSS was 3. The median postdilation FOSS was 1 at the end of 6 months from last dilation performed. There were no immediate or remote complications. On follow-up from first dilation, 65% patients had statistically significant improvement in FOSS lasting for at least 6 months. Savary dilation seems to be a safe and effective treatment for symptomatic CP bar patients.

Novel Use of Metal Stenting for an Esophageal Stricture after Radiofrequency Ablation Treatment of Barretts Esophagus

Figure: No Caption available.Purpose: Radiofrequency ablation (RFA) is an effective, safe, and well-tolerated treatment of dysplastic and non-dysplastic Barrett's esophagus; however there is risk of post-ablative stricture formation. Stricture rates may be increased in those with long-segment Barrett's esophagus. These strictures are usually treated with endoscopic balloon or Savary dilators, however multiple dilations may be required to achieve stricture resolution. We report a case of a post RFA-stricture that was completely relieved by a self-expandable metal stent. Case Description: A 71-year old male with long segment Barrett's esophagus C7M7 had low grade dysplasia and underwent circumferential radiofrequency ablation. A month later, he experienced symptoms of dysphagia. Repeat endoscopy showed a tight stricture with circumferential ulceration at the proximal end of the RFA treated Barrett's epithelium. A 5.9-mm diameter gastroscope was advanced to the proximal end of the stricture. However, the distal end of the stricture could not be traversed. An 8.8-mm diameter gastroscope was reinserted and a 9-12 mm extraction balloon was introduced through the channel of the scope. Contrast revealed a 4 cm long stricture in the mid esophagus. A stent introducer was passed over a 0.035-inch guide wire which crossed the stricture under fluoroscopic and endoscopic guidance. A fully covered metal esophageal stent 23 x 105 mm was deployed. Repeat attempt at traversing the stricture was unsuccessful. The extraction balloon was reintroduced and injection of contrast showed a waist in the mid portion of the stent with free flow of contrast into the stomach. The patient underwent repeat upper endoscopy 2 months later for removal of the stent. Six months later he had no symptoms of dysphagia post stent removal. Discussion: The incidence of strictures after RFA treatment of Barrett's esophagus ranges from 1-8% and happens more often after treatment of long segment Barrett's esophagus. Dilation of these strictures with active inflammation carries a risk of perforation. Placement of covered metal stents for management of this condition has not been reported to date. To our knowledge, this is the first case of an esophageal stricture post-RFA treatment of Barrett's esophagus that resolved with placement of a fully covered removable metal stent. Placement of a stent may also save multiple repeat dilations that might be required and may be cost-saving. It should be noted that this is not an FDA approved indication for placement of a fully covered metal stent.

Obliteration of Schatzki Rings in Patients with Refractory Dysphagia Utilizing Multiple Standard Endoscopic Biopsies

Purpose: The Schatzki ring, a benign lower esophageal structural anomaly, is one of the most common causes of dysphagia and intermittent food impaction. Therapy for Schatzki rings has traditionally utilized esophageal dilation with either bougienage or balloon dilators. No clear advantage has been demonstrated between these dilator types and both are associated with recurrent dysphagia. Alternatively, endoscopic electrosurgical incision of the fibrous, elastic core of Schatzki rings has been shown to be an efficacious treatment modality ever since it was first described almost 30 years ago in two patients who did not respond to conventional bougienage. However, the needle knife is not commonly employed during upper endoscopy, and its use in the treatment of benign esophageal strictures is likely to be technically difficult among most gastroenterologists with a risk of serious complications. In a fashion similar to that of electrosurgical incision, direct disruption of Schatzki rings may be more feasibly achieved with standard endoscopic biopsy forceps. To our knowledge, no study or case series has described ring obliteration by endoscopic biopsy forceps in patients who have refractory dysphagia after Savary dilation or through-the-scope balloon dilation. In our case series, we describe three individuals who underwent Schatzki ring obliteration utilizing multiple biopsies with standard forceps after undergoing conventional esophageal dilation that did not relieve their dysphagia. In the presence of acid suppression, obliteration was performed by obtaining four to five circumferential biopsies from various points of the Schatzki ring; no complications were encountered and dilation was immediately confirmed by the passage of a 13.5 or 15 millimeter through-the-scope balloon without resistance. Two of the patients reported no symptoms of dysphagia at follow-up 6-8 months later. The third patient had recurrent dysphagia that was later discovered to have an oropharyngeal etiology. Based on these outcomes, we suggest that multiple standard biopsies performed at equidistant sites around the Schatzki ring “break” the ring and relieve refractory dysphagia in a manner that is comparatively safer, more cost-effective, and more widely accepted in routine practice than electrosurgical incision.

A New Technique for Safe and Efficient Treatment of Acute Esophageal Obstruction in Achalasia

Introduction: Achalasia is a motility disorder of esophagus that can cause impaction of large amount of food in patients causing megaesophagus. These patients typically present with acute onset of dysphagia. While endoscopic retrieval of the material is usually safe, but it can be very time-consuming and challenging. It can take hours to clean the esophagus with traditional Roth net and suction technique. We describe a new technique for safe and efficient removal of impacted food from megaesophagus using overtube and large bore gastric lavage tube. Case Description: Our case is a 73-year-old female who presented with acute dysphagia for both solids and liquids, including saliva for one day. She had similar episodes in the past and her esophagus was dilated with a 51 French Savary dilator one year ago. She did not have any recurrence until present episode. During work up chest X-ray showed air-fluid level overlying the upper mediastinum within a dilated esophagus. Patient was intubated for airway protection and upper endoscopy was performed, which showed large amount of food in a severely dilated esophagus. After placing an overtube, a large bore tube was placed and advanced close to gastro esophageal (GE) junction. Water lavage with 2-3 liters of normal saline was performed. This maneuver was able to clear the esophagus in less than 20 minutes. After clearing the esophagus, scope was advanced through the tight GE junction and retroflexion in the cardia did not reveal any mass. Patient eventually underwent esophageal manometry and esophagogram, which confirmed the diagnosis of achalasia. Subsequently patient underwent forceful balloon dilation of esophagus. Conclusion: In achalasia, acute obstruction may result in large amount of food retention in esophagus. Calcium channel blocker, nitrates, phosphodiesterase inhibitors, and glucagon reduce the lower esophageal sphincter (LES) pressure and may be used as a supportive therapy for patients with achalasia. The use of hot water may improve symptoms but should be avoided in acute esophageal obstruction, and endoscopic clearance of impacted food remains the method of choice. While endoscopic retrieval of impacted food by traditional Roth net and suction technique is usually safe, it is challenging and can take hours to clean the esophagus. Pushing the material through the LES can be hazardous and best be avoided to prevent perforation. Our new technique is safe, effective, and efficient and takes about 20 minutes to clean the entire esophagus. It can be tried after the airway is secured with endotracheal intubation. Further studies on technical methods and long-term follow-up is required before recommending it as method of choice.

Endoscopic Corticosteroid Injections Do Not Reduce Dysphagia After Endoscopic Dilation Therapy in Patients With Benign Esophagogastric Anastomotic Strictures

Benign anastomotic strictures are often difficult to treat. We assessed the efficacy of adding corticosteroid injections to endoscopic dilation therapy with Savary bougienage. In a multicenter, double-blind trial, 60 patients (mean age, 63 ± 9 years; 78% male) with an untreated cervical anastomotic stricture after esophagectomy with gastric tube reconstruction and dysphagia for at least solid food were randomly assigned to groups given 4 quadrant injections of 0.5 mL triamcinolone (40 mg/mL, n = 29) or saline (controls, n = 31) into the stricture, followed by Savary dilation to 16 mm. Dysphagia, complications, and quality of life were assessed after 1 and 2 weeks and 1, 3, and 6 months. The primary end point was a dysphagia-free period of 6 months. In the corticosteroid group, 45% of the patients remained dysphagia-free for 6 months, compared with 36% of controls (relative risk, 1.26; 95% confidence interval, 0.68-2.36; P = .46). Median time to repeat dilation was 108 days (range, 15-180 days) in the corticosteroid group vs 42 days (range, 17-180 days) for controls (P = .11). A median number of 2 dilations (range, 1-7) was performed in the corticosteroid group vs 3 dilations (range, 1-9) in controls (relative risk, 0.76; 95% confidence interval, 0.42-1.38; P = .36). Two major intervention-related complications occurred, 1 submucosal laceration in the corticosteroid group and 1 hemorrhage in the control group. Four patients in the corticosteroid group, but none of the controls, developed Candida esophagitis (P = .03). Corticosteroid injections do not provide a statistically significant decrease in frequency of repeat dilations or prolongation of the dysphagia-free period in patients with benign anastomotic esophagogastric strictures. Dutch Trial Registration Number 2236.

Savary Dilation Is a Safe and Effective Means for Treatment of Symptomatic Cricopharyngeal Bar: A Single Center VA Experience

Purpose: To evaluate the efficacy and safety of Savary dilation as a treatment option for symptomatic Cricopharyngeal (CP) Bar. Methods: Retrospective chart review was performed for 327 patients who underwent esophageal dilation with Savary dilators for dysphagia at VA Loma Linda between 2007 and 2011. Out of 327 patients, 27 patients had dysphagia attributed solely to a diagnosis of CP bar confirmed by modified barium swallow and/or barium esophagogram. Details including demographics, symptomatology, other causes of dysphagia, size and number of Savary dilators, complications and pre/post dilation Functional Outcome Swallowing Score (FOSS) were obtained. Results: Over the time period, 48 dilations were performed on 27 patients. Most of the first dilations were performed with 54 Fr Savary dilators. Repeat dilations were performed with 60 Fr dilators. The end point of the follow up was improvement lasting 6 months after dilation as assessed by the pre- and post treatment FOSS. 16 patients reached endpoint after first dilation. 7 patients underwent repeat dilation for recurrence of symptoms within 6 months of first dilation. Median pre dilation FOSS was 3. Median post dilation FOSS was 1. All except 3 patients had significant improvement that lasted for variable time from initial dilation. On follow up from last dilation, 63% patients had statistically significant improvement in FOSS lasting for at least 6 months. No complications were noted. Conclusion: Savary dilation appears to be a safe and effective treatment for symptomatic CP bar patients in our VA population. A significant majority of patients had consistent improvement in symptoms for more than six months.Figure: No Caption available.Figure: [8]

Empiric Esophageal Dilatation for Nonobstructive Dysphagia

Purpose: Dysphagia is one of the most common complaints encountered in gastroenterology. Endoscopy frequently does not reveal any obstruction. Empiric esophageal dilatation is performed in many of these cases for symptomatic relief. The purpose of this prospective study is to determine if there is a significant, sustained response to esophageal dilatation in cases with nonobstructive dysphagia. Methods: Patients presenting with dysphagia who had no obstruction demonstrated upon endoscopy and had empiric dilatation of esophagus were included in the study. Dilatation was achieved utilizing 48 F wire guided Savary dilators in most cases. 102 patients with dysphagia were enrolled. Dysphagia scores [1] were recorded before the procedure and at 2 months, 6 months and 18 months after the procedure. An increase in dysphagia score of one or more was considered an improvement. Number of patients using a proton pump inhibitor (PPI) also was recorded. Paired sample t-test was used to determine the significance of response to the dilatation at the 2-month, 6-month and 18 month intervals. Results: Of the 102 patients enrolled, 88 reported improvement at the 2 month follow up. At the 6 month follow up, 78 patients reported an improvement. At 18 month interval, 68 reported an improvement 18 patients reported no improvement and 16 patients were lost to follow up. Results for 3 follow up intervals achieved statistical significance [Table 1]. Analysis of biopsy results was done. 17 patients had inflammatory changes and 12 had reactive changes. No cases with eosinophilic esophagitis were found. When the study commenced 85 of 102 were on PPI and at closing of study 74 of 86 patients were on proton pump inhibitors (PPI). Of the 12 who were not on PPI, all improved with dilatation alone. No complications were reported from the procedure.Table 1: Results of paired sample t testConclusion: The number of patients reporting improvement in dysphagia scores at all three follow up intervals after dilatation reached statistical significance. Based on the sustained response to the procedure and the lack of complications it can be concluded that esophageal dilatation offers significant relief for non obstructive dysphagia.

Adverse events of upper GI endoscopy

Adverse events of upper GI endoscopy