JWST654c100JWST654TalleyPrinterYettoComeJuly42016146279mm - PDF document

JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverviewTable100.2Relativeandabsolutecontraindicationstoesophagealdilation. RelativeAbsolute BleedingdiathesisAcuteabdomenUseofanticoagulants(ASGEguidelinesforstoppinganticoagulationpriortotheprocedureshouldbefollowed)AcuteorincompletehealingofesophagealorGIperforationSeverepulmonarydiseaseRecentmyocardialinfarctionPharyngealorcervicaldeformityRecentlaparotomyLargethoracicaneurysm ASGE,AmericanSocietyforGastrointestinalEndoscopy;GI,gastrointestinal.lowerinflationtime(aslittleas10seconds)maybeasefficaciousasalongerone(inthiscase,2minutes)whenusedinthetreatmentofbenignstrictures[12].Through-the-scopeballoondilatorsdonotexertlongitudinalsheerforces,providedtheyareheldinastaticpositionwithinthestrictureduringthedilation.Itisimportanttoknowthecompleteanatomy(length,angulation,etc.)beforeballoondilationisperformed.Theballoonshouldcompletelytraversethestricture,soastoavoidasymmetricpressuresacrossthestricturedareas,whichmaybemoreofariskforperforation.ComplicationsandContraindicationsEsophagealdilationisasafeandeffectiveprocedureforthemanage-mentofbenignandmalignantstrictures,thoughesophagealperfo-rationisarecognizablerisk[13].Perforationtypicallyoccursatorimmediatelyabovetheproximalmarginofthestricture,whichiswhysomeexpertsrecommendendoscopicreevaluationuponcom-pletionofthedilationprocedure.Theliteraturesuggeststhatper-forationratesrangefrom0.1to2.6%,withamortalityrateofupto1%[4,8,9,14,15].Thereisapropensitytowardhighcomplicationratesincomplexandmalignantstrictures.Complexstricturesareaclearrisk,particularlyinpatientswithstricturesrelatedtosurgeryorradiation,orwithstrictureswithmorethanjustmucosalfibro-sis.Table100.2summarizesboththeabsoluteandtherelativecon-traindications.Dilationwithbougiedilatorsisverysafeandeffective,withasuccessrateofupto90%[16].Recentdatasuggestthatpatientsmaybeabletoperformhomeself-dilationonrecurrentstrictureswiththesedilators[17].Wire-guideddilationsofferasaferapproachthanbougiedilatorsbyinsuringthatthedilatorremainsintheaxisofthelumenanddoesnotbuckleorbendlaterallyintothewallofthestrictureandcreateanincreasedriskofperforation[8].Thistechniqueisconductedunderfluoroscopy,toallowvisualiza-tionofthedilatorpassingthroughthestricture.Wire-guideddila-tionsarepreferredforcomplexandlongerstricturesinparticular,especiallyifthereisanyangulationorifthereareanydiverticularchangesthatmightcreateamisdirectedpathwayforabougiepassedblindly.Therearecertaincircumstances,however,inwhichalon-gitudinalshearingforceshouldbeavoided,suchaswhenstricturesarecausedbyepidermolysisbullosaorwhenatracheoesophagealpuncturevoiceprosthesisispresent.Insuchcases,balloondila-tionshouldbethepreferredmethod[2,18].Additionally,thelitera-turesuggestsanincreaseinmucosalfragilityandtissueremodelinginpatientswitheosinophilicesophagitis,whichpredisposesthemtoesophagealmucosaltears.Thoughthiswasinitiallythoughttoincreasetheriskofperforation[19…22],subsequentreportshavenotshownsuchanincreasedrisk[23…27].Recognizably,thesepatientshaveattimesprofounddisruptionswithdilation,sotheselectionofdilatorsize,dilationtarget,andscheduleshouldbewellconsidered.Weroutinelyreassesstheextentofmucosaldisruptionaftereachballoonsizeinsufflation.Whenmucosaldisruptionisevident,therisk/benefitoffurtherdilationinthecurrentsessionshouldbecare-fullyweighed.Mucosaldisruptiontothelevelofmuscularisexpo-sureisanabsolutecontraindicationtofurtherdilation.Chestpainisverycommonafteresophagealdilationinthisgroupofpatients,beingreportedin75%ofpatientsinoneprospectivestudy[25].Unfortunately,therearenoprospectivetrialscomparingdilationtechniquesinthesepatients,butesophagealballoondilationratherthanrigiddilatorsseemstobepreferable[25,28,29].TechniquesofDilationTheRuleofThreeŽTheruleofthree,Žasitappliestobougiedilators,hasbecomethestandardguidetothenumberofdilatorspassedpersession[3,30].Thisrulesuggeststhatinasinglesession,nomorethanthreedila-torsofsequentialsizeshouldbepassedoncemoderateorgreaterresistanceisevident.Dilatorspassedwithnoormildresistancedonotcounttowardthistotal.Accordingly,therateofdilationshouldbecarefullyplannedtomeettheneedsanddefinedgoalsforeachindividualpatient.Acaveathereisthatthisruleisbestappliedtotheblindbougiepassage.Savarydilatorsmay(thoughthisismoretypicallydoneusingawire-guidedtechnique)ormaynotofferthesametactileresistance.Inthesecases,thestartingsizeofthelumenatthestrictureshouldbeestimated,andtheoptimaltar-getforluminalpatencyshouldbedeterminedbytheunderlyingetiology,pathologicfeatures,duration,initialstricturelumendiam-eter,andthepatientsdietaryneedsandpreferences.Ingeneral,diettolerancemaybepredictedbasedonluminaldiameter,asshowninTable100.3[3,31,32].Endoscopy/FluoroscopyAfteranyimagingstudieshavebeenreviewed,esophagoscopyshouldbeperformedtofurtherdelineatetheanatomyofthestric-ture…includingthelumendiameter…inordertoassistinselectingtheappropriateinitialdilatorsize.Tothisend,theendoscopistcanestimatethemeasurementusinganopenbiopsyforcepsinthenar-rowestlumenofthestricture(standardopenbiopsyjaws7mm).Theinitialdilatoristypically1…2mmlarger

thantheestimatedluminaldiameter(correlationofluminalsizewithdilatorsizeis13French).Theuseoffluoroscopyishelpful;itisrecom-mendedformostcomplexstricturedilationsandisarequisiteforpositioningoftheballoonforachalasiadilation.Table100.3Tolerabledietconsistencyasitrelatesdirectlytolumendiameter. EsophageallumenTypeofdiet 7mmLiquid/pureed10mmPureed/soft13mmSoft15mmModiedwithexclusions18mmRegular,withcare Inallcases,emphasisshouldbeplacedontheappropriatecuttingoffood,pacedchewingandswallowing,foodstoavoid,andtheimportanceofliquidushes.Withemphasisoncuttingfoodintosmallpieces.Exclusionoftoughmeat,hardrawvegetables(e.g.,carrots),hardfreshfruits(e.g.,apples),largebitesofdoughybreadorpasta,andfruitandvegetableskins(e.g., CHAPTER100 JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm CHAPTER100EsophagealDilation:AnOverview ParthJ.ParekhandDavidA.JohnsonDepartmentofInternalMedicine,EasternVirginiaMedicalSchool,Norfolk,VA,USAEsophagealstricturesmaydevelopfrombothbenignandmalig-nantcauses.Patientswithesophagealstricturestypicallypresentwithprogressivedysphagiaforsolids,whichifleftuntreatedmayprogresstoincludeliquids.Esophagealdilationisfrequentlyrequiredforthesymptomaticmanagementofdysphagia.Thereareanumberofavailableoptionsforsuccessfuldilationofmoststric-tures,aswellasadjunctivetechniquesreservedformorerefractoryŽcases.Inordertooptimizetherapyandminimizerisk,itisessentialtofullyunderstandtheunderlyingcauseandanatomyofthestric-ture.Carefulselectionofdilationtechniqueandestablishmentofthegoalsforluminalrestorationareimportantas,ineachcase,thesefactorsmayneedtobealteredtosuittheetiologyandpathologyofthestricture. A58-year-oldfemalepresentswitha3-monthhistoryofintermittentbutnotprogressivesolidfooddysphagia.Foodseemstobecatchinginthemid-sternalarea.Shehasnotnotedthiswithliquidsorsoftfoods,buthassymptomsinparticularwithmeats,freshvegetables,doughybreadproducts,andpasta.Shehasnoassociatedheartburn.Hermedicationsincludealendronate,amultivitamin,andrare-useaspirin,butnoothernon-steroidalanti-inammatorydrugsPhysicalexamisnormal.Thephysicianalertlynotesthatthepatientistakingbisphosphonateandisconcernedaboutapill-inducedstricture.BariumX-rayisconsidered,butasthisseemstobeanon-complexstricture,thepatientisinsteadreferredforendoscopy.Thegoalsoftherapyarediscussed:thetargetistore-establishnormaldietaryhabits.Endoscopyshowsaluminalnarrowingestimated(usingtheopenbiopsyforceps)tobe14mm.Thestrictureisimmediatelyabovetheesophagogastricjunctionandthereisnoevidenceofesophagitis.Ahydrostaticballoonischosenanddilationisperformedusingthegraduated15…18mmdilator.Careistakentodeatethestomachbeforethedilationandtodeatetheballoonbetweensizeincrementsinordertoassessformucosaldisruption.Withthe18mmballoon,thereisaslightmucosaltearintheareaofluminalnarrowing.Thepatientiscounseledtoavoidherbisphosphonateforamonthandtodiscussalternativetherapywithherprimaryphysician.Sheisgivenaprotonpumpinhibitor(PPI)for8weeksandadvisedtofollowasoftdiet(cuttingfoodintosmallpieces)forseveralweeks,before slowlyadvancingtoamorenormaldietastolerated.Sheisinstructedtonotifythegastroenterologistifpersistentorrecurrentdysphagiaisevidentorifshedevelopsheartburn. IntroductionEsophagealstricturesarisefromanintrinsicdisease(suchasinflam-mation,fibrosis,orneoplasia)thatnarrowstheesophageallumen,anextrinsicdiseasecompromisingtheesophageallumenbydirectorindirectinvasion,ordiseasesdisruptingesophagealperistalsisand/orloweresophagealsphincter(LES)function.Esophagealstric-turesarefurthersubdividedintothosewithabenignandthosewithmalignantorigin.Theetiologiesofbenignstricturesincludegastroesophagealrefluxesophagitis,Schatzkisring,radiation,caus-ticingestion,nasogastricintubationwithacidreflux,primaryorsecondarypill-inducedinjury,anastomoticstricturewithrelatedischemiaorhistoryofananastomoticleak,ringedŽstricturesasso-ciatedwitheosinophilicesophagitis,andseveralraredisorders.Malignantstricturesmaydevelopasaresultoflocaltumorgrowthormetastaticdisease[1].Forcenturies,thecornerstoneoftherapyhasbeenesophagealdilation.Thisdatesbacktothe17thcentury,whencarvedwhale-bonewasusedtotreatachalasia.Bougienagewasfirstreportedintheearly1800s,andsincethentheequipmentusedtotreatesophagealstrictureshasevolvedconsiderablytoincludeflexi-blebougies,wire-guideddilators,andthrough-thescopeballooncatheters[2].Thegoaloftherapyisultimatelytoprovideadequatesymp-tomaticreliefandpreventtherecurrenceofstrictureformation.Thepatientsdietaryhabitsandnutritionalneedsmustbeconsideredwhenconstructinganappropriatetreatmentplan.Additionally,itisimportanttodifferentiatethestructuralcharacteristicsbetweensimpleandcomplexesophagealstrictures.Thischapterwillpro-videanupdateonthecategoriesofesophagealstricture,categoriesofesophagealdilator,andtechniquesusedforesophagealdilation.CategoriesofEsophagealStrictureEsophagealstricturesarecategorizedbystructuralanatomyasbeingsimpleorcomplexdependingonsize,symmetry,andthepassageofadiagnosticupperendoscope[3].Simplestricturesareconcen-tric(withaluminaldiameterof12mm)orsymmetric(easily CHAPTER100 PracticalGastroenterologyandHepatologyBoardReviewToolkit,S

econdEdition.EditedbyNicholasJ.Talley,KennethR.DeVault,MichaelB.Wallace,BasharA.AqelandKeithD.Lindor.2016JohnWiley&Sons,Ltd.Published2016byJohnWiley&Sons,Ltd.Companionwebsite:www.practicalgastrohep.com JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverview Figure100.2Fluroscopicimageofthecorrectpositioningofthewireduringpneumaticachalasiadilation.Notethegentlebendofthewirealongthegastricwall,withthewirepointedtowardthegastricantrum…andnotinadirectioninwhichitcouldpenetratethegastricwall.RigidDilatorsIdeally,themouthpieceshouldberemovedfordilationandlubrica-tionshouldbeappliedtothelipsinordertominimizeresistanceofpassage.Whenamouthpieceisinplace,thedilatorisforcedtoenterperpendiculartotheposteriorpharyngealwall,andmustthereforefollowa90turnagainsttheposteriorpharyngealwallinordertoenterthehypopharynx.Thissharpturnasthedilatortraversesbetweenoropharynxandhypopharynxmaycauseconsid-erablepressureonthetissuesanteriortothecervicalspine,whichaccordinglyincreasestheriskofpain,contusion,orpossiblecrushinjurywithperforation.Thismaybeaparticularproblemwhenlarge-diameterdilatorsareused,asthesehaveagreaterresistancetobending.Thepotentialforpressure-relatedinjurycanbeminimizedbyremovingthemouthpiece,movingthedilatorshaftintoonecor-nerofthemouth,andkeepingtheextraoralsegmentofthedilatorshaftelevated(inthedirectionoftheupperposteriormolars)andmoreparalleltotheaxisofthehypopharyngeallumen.Antegradedilationforceshouldbedirectedmorecloselyintothedirectlumenaxisbetweenthehypopharynxandthestricturebeyond.Thisin-axisŽorientationallowstheoperatortomoreaccuratelyappreciatethetruestrictureresistance,ratherthansensetheangulatedbendingresistanceofthedilatorimpingingagainsttheposteriorpharyngealwall[31].Thepatientsheadpositionshouldbechin-neutralor…down,andneverextendedwiththeheadback.Thisflexedpositionreducesthenaturalcervicalspinelordosisandhelpstoopenthehypopharynx.WithpassageofeitherMaloneyorSavarydilators,theoropharyn-gealcurvecanalsobereducedbypositioningtheindexandmiddlefingersintheoropharynxtoguidethedilatorwithanteriordisplace-ment.Theshaftofthedilatorshouldbegrippedfirmlyforpushingwiththethumbandfirstthreefingertipsoftherighthandandnotbyafull,closed,tighthandgrasp.Thistechniqueallowsforbettertactilesensationwithwhichtojudgestrictureorotherstructuralresistanceduringdilatorpassage.Additionally,thenurseassistantshouldsupportthedistalendofthedilatorsothatthereisnoback-wardweightingandtheendoscopistcanhaveabettertactilesenseofanyresistanceasthedilatorispassedperos.Assessingthedistancemeasurementnumbersontherigiddilatorshaftshouldbestandardproceduretoinsurethatthedilatorispassedthroughtheextentofthestrictureasmeasuredduringtheendoscopicexam.Fluoroscopymayalsobeneededinselectedcasesandisalwaysrequireddur-ingwire-guideddilation.Duringpassageofover-the-wiredilators,eithertheoperatororanassistantshouldprovideslightwireretrac-tionandavoidantegradeorretrogradewiredisplacement.ThisismosteasilyachievedbyfluoroscopicobservationorusingdistancemarksetchedontheSavaryguidewire.Dilatorsshouldberemovedslowlyandcarefullyfollowingeachpassage,takingparticularcareintheareaoftheoropharyngealcurve.Additionally,itiscriticaltovisualizethetipofthewireinthestomachasthedilatorispassed.Thereshouldbeagentlecurvatureofthewireagainstthegreatercurvatureofthestomachtoinsurethatthetipdoesnotcreateaforceforperforationthroughthegastricwall(Figure100.2).Similarly,itiskeytoavoidasharpangulationinthewirealongtheaxisfromtheesophagustotheanteriorgastricwall.Itisthereforeimportanttoimagethisareaandthelocationofthedistaltipofthewire,inordertoavoidwire-inducedperforationrisks.BalloonDilatorsBalloondilationshouldonlybeusedinstrictureswhentheballoondilatorcanbepositionedtotraversetheentirestrictureandtheexactanatomyofthestricturehasbeendefinedbyendoscopyorX-ray.Dilationwiththeballoonstillwithinthestricturemayintroduceashouldereffect,Žwithanasymmetricdeliveryoftheradialdilation,andtheoreticallyincreasetheriskofperforation.Complexstricturestypicallydonotrespondwelltohydrostatic,through-the-scopedila-tors.Thesedilatorsworkwellforover90%ofsimple,benign,usuallyreflux-relateddistalesophagealstricturesandrings[31].Pneumaticballoondilationremainsoneofthemosteffectivefirst-linetherapiesforachalasia.Currently,theRigiflexpneumaticdilator(BostonScientific,Boston,MA)isthemostwidelyusedsystemforachalasia,butsimilardevicesareavailablefromothermanufacturers(CookMedical,Bloomington,IN;HobbsMedical,StaffordSprings,CT).Thepolyethyleneballooncomesinthreesizesthatinflatetofixeddiametersof30,35,and40mm.Thissystemoffersasafetyadvantageoverearliercompliantlatexballoons,whichdelivereddifferentdiametersatdifferentinflationpressures.Typ-ically,astepwiseapproachusingtheRigiflexsystemstartswitha30mmballoonforthefirstsession.Ifthereisnoimprovementnotedatfollow-up(bysymptomassessmentandX-rayevaluationforapersistentstandingcolumnonatimedbariumstudy),the CHAPTER100 JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverviewpatientcanbebroughtbackforarepeatdilationsessionwitha35mmandthen,ifneeded,a40mmballoon.Wedonot

recom-mendtheuseofa40mmballoon,however,andwillreferthepatientforper-oralendoscopicmyotomy(POEM)orsurgicalmyotomy.Inour30yearsexperience,thisgraduated-dilationapproachhasbeenextremelysafe,withnoperforationstodate.Additionally,ithasyieldedanoverall93%responseratetodilationoverameanfollow-upperiodof4yearsandhasbecomeanacceptedmethodologyoftreatment[33].Aguidewireisusedwiththepneumaticballoon,whichispassedwiththeendoscopeinthestomach.Thedistaltipispositionedintheantrum.Astheendoscopeisremovedoverthewire,caremustbetakentowatchthedistalendofthewireinordertoinsurethatitdoesnotpushintothewallordevelopanangulationkinkalongthegreatercurvature.Thewireshouldformagentlebend(Fig-ure100.2),whichthenneedstobecarefullywatchedastheballoondilatorispassedoverit.Asthedilatorispositioned,thekeyistoavoidapuncture-typeperforationinjury,whichmightresultfromthewiretiporanysharpangulation.Beforepositioningtheballoon,theendoscopistshouldbecare-fultofullydecompressthestomach.Whentheballoonisinflated,ifthereisoverdistensionofthestomachandwretchingagainstthetightlyoccludedesophagogastricjunction,theremaybesignificantriskofrelatedesophagealbarotrauma.Theballoonispositionedinthestricture,ideallywithitscentralportioncorrespondingtothecentralpointofthestenosis.Thisisconfirmedbyendoscopy,fluoroscopy,orboth.Priortoinsufflation,theproximalmarginoftheballoonshouldbepositionedatthetipoftheendoscopeandtheshaftoftheballoondilatorgraspedfirmly(atthebiopsyportoftheendoscopy)bytheendoscopistsfingers,inordertobraceagainstthedownwardpullingmovementthattypicallyoccursastheballoonisinflated.Ifitisnotbracedappropriately,theballoonmayslipbelowthestrictureandsonotachievethetargeteddila-tion.Thisisespeciallycommoninachalasiadilation,whichistyp-icallycarriedoutwithoutreinsertionoftheendoscope,sothattheoperatorneedstofirmlygraspandholdtheshaftoftheballoonattheentrancethroughthebiteblock.Insuchpneumaticdilationsinparticular,astheballoonisinflated,thereisatendencyforittomove,usuallypullingdownantegrade,andthedilatormaymovethroughthehypertensiveLESwithoutapplicationoftheintendedradialforce.Nostandardhasyetbeenestablishedfortheoptimaldurationofballoondilation.Historically,adurationof30…60sec-ondswasadequate,with60secondsmorethestandardforachalasiadilation.Recentstudiesindicatethatalowerinflationtime(aslit-tleas10seconds)maybeasefficaciousinthetreatmentofbenignstrictures[12].Wewillroutinelycarryouttwoinsufflations,pay-ingparticularattentiontotheobliterationofthewaistŽeffectonthedilatorastheballoonisinsufflated.ThiswaistŽisthenarrow-ingatthelevelofcompressionbytheLES.Thepressureappliedinordertonotetheinitialeffectofthefirstdilationshouldbecom-paredtowhenthewaistŽisevidentontheseconddilation.Follow-ingallachalasiapneumaticdilations,oncepatientsareawakeintherecoveryroom,wehavetheradiologistperformacontrast-swallowexam,firstwithgastrograffinandthen,ifthereisnoevidenceofperforation,withdilutebarium.Forthrough-the-scopeballoons,deflationoftheballoonbetweensequentialdilationsisadvised,soastoassessthelevelofmucosaltraumaandbetterdirecttherateofprogressionofsequentialdila-tion.Careshouldbetakentolimitfurtherdilationoncemorethanaminormucosaldisruptionisevident,oroncethereisanyevidenceofdisruptiontothelevelofthemuscularis.AdjunctiveandNovelTherapiesIntramuralSteroidInjectionsThereisonlylimitedevidencetosuggestthattheuseofintramuralsteroidinjectionsmaybeofbenefitinrefractorystrictures,thoughthedataarevariable[34,35].Thepathophysiologyremainsunclear,butithasbeensuggestedthatithastodowtihsteroid-relatedinhi-bitionofavarietyofmatrixproteingenes,namelyprocollagenandfibrnoectin,inadditiontoothercytokines,whichinhibitcolla-genformation,ultimatelyincreasingstricturecompliance[36].Asbenignesophagealstricturesarethoughttoresultfromfibroustis-sueinvolvedinkeloidandscarformation,thistechniquemaybehelpfulinstricturesdeemedrefractorytostandarddilation.Typi-cally,followingdilation,triamcinolone40mgisdilutedwith5ccofsalineandinjectedinquadrantinjections(0.5…1.0ccaliquots),aiminginparticularforthefibrouspartofthestructure…assug-gestedbythetearpointsnotedfollowingdilation.Thisfibrousareaisalsoparticularlyevidentfromanincreasedresistancetoinjectionviathesclerotherapyneedle…thisindicatestheinjectionisinthecorrectplace!Thegoalofthisinjectionistodecreasetheinflam-matoryresponseinducedbythemucosaldisruptionofthestrictureandreducethereformationoffibroushealing.Thereisalackofprospectivedataonthebestsequenceofdilation/injection,andthismaybeanareaforfutureinvestigation.Weperformtheinjectionsubsequenttoballoondilation,asthishelpfulinidentifyingthetearpointsforthefibrousstrictureand,hopefully,avoidingthetheoreticconcernofcreatingleadpointsformucosaltearingifthestrictureisdilatedfollowingtherepeatedintramuralinjections.RetrogradeDilationInsomecases,theanatomyofthestricturemayprecludethegas-troenterologistfromstandardendoscopicmanagement,particu-larlywhenaguidewirecannotbepositionedviaanantegradeapproachthroughthestricture.Thismaybeespeciallyevidentintheproximalesophagusofpatientswhohavereceivedradi-ationforheadandneckcancers.Insuchcases,anendoscopicrendezvousŽapproachcanbeemployed,

typicallyinconcertwiththeotolaryngologist[37…40].Asmall-diameterendoscopeisintro-ducedthroughamaturepercutaneousendoscopicgastrostomy(PEG)tractandadvancedinaretrogradefashionintotheesophagusuntilthestrictureisidentified.Aflexibleguidewirecanbepassedthroughthestrictureand,usingdirectvisualization(endoscopyorrigidlaryngoscope),grabbedontheproximalsideofthestricturebytheassistingphysician.EndoscopicStricturoplastyInsomecases,athinmembraneprecludespassageoftheguidewire.Insuchcases,astifferguidewirewith/withoutassistusinganeedle-knifecanbeusedtopuncturethemembraneinfourquadrants,withsubsequentSavarydilation.Dataontheuseofthistechniquearelimited,butthoseavailablesuggestthatitmaybeaviablealternativeinpatientswithrefractorystrictures,ifperformedbyanextremelyskilledendoscopistwithacompleteunderstandingoftheanatomy(inordertoavoidcreatingafalsechannel)[41,42].PharyngoesophagealPuntureŽRecently,Tangetal.[43]coinedthetermpharyngoesophagealpunctureŽ(PEP).Theyappliedtheirexpertendoscopicretro-gradecholangiopancreatography(ERCP)techniqueandtheirskillinpancreaticobiliaryobstructiontothemanagementandtreat-mentofrefractorypharyngoesophagealstenosis(PES)andupper CHAPTER100 JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverviewesophagealstricture[43].TheyreportedthreesuccessfulcasesofpatientswithsevereorcompletePESmanagedwithPEP.Inallcases,PEPutilizedacombinedantegradeandretrogradeapproach,per-formedunderfluoroscopy.Underbidirectionalendoscopy,thedis-talendsofbothscopeswerealignedalongthesameaxisinordertoobtainoptimaltrans-stenosisilluminationandPEP.ThestiffendoftheERCPguidewirewasusedtopuncturetheobstruction,withmoderatepressure.Oncethelesionwaspunctured,thehydrophilictipoftheguidewirewasusedtoconfirmthesuccessfulPEP.Useoftheflexibletipminimizestheriskofcreatingafalsetract.Thegoalofesophagealdilationistoprovidesymptomaticrelief.Thereareanumberofoptionsforthesuccessfuldilationofmoststrictures,butcarefulselectionofaspecificandindividualizedapproachisnecessaryinordertominimizecomplicationsandmax-imizetherapeuticbenefit.Itisimportantthattheendoscopisthaveathoroughunderstandingoftheunderlyingetiologyandtheanatomyofthestricturepriortodevelopingastrategicapproach.Thenovelandadjunctivetherapiespresentedrequireextremeendoscopicskillandknowledgeoftheanatomy,andshouldonlybeperformedbythoseattertiaryandquaternarycenterswithhigh-volumeexperience. TakeHomePointsThebestinitialprocedureafterathoroughhistoryandphysicalexaminationisaproperbariumesophagram.Endoscopyaloneisnotalwaysreliableasasubstituteforagoodbariumcontraststudyinpatientswithstrictures.Afterthehistory,physical,strictureetiology,andesophagealanatomyaredetermined,athoughtfulplan(includingendoscopyanddilation)canbedeveloped.Esophagoscopyshouldincludeanestimateofthelumendiameter,toassistinselectinganappropriateinitialdilatorsize.Thismeasurementisestimatedusinganopenbiopsyforcepsinthenarrowestlumenofthestricture.Complexstricturesdonotrespondwelltohydrostatic,through-the-scopedilators.Thesedilatorsworkwellforover90%ofsimple,benign,usuallyreux-relateddistalesophagealstricturesandrings.NocleardifferenceineffectivenesshasbeenreportedbetweentheSavary-Gilliardandthrough-the-scopeballoondilatorsinthetreatmentofbenignesophagealstricturesForallwire-guideddilations,itiscriticaltouseuoroscopytovisualizethetipofthewireinthestomachasthedilatorispassed.Thewireshouldhaveagentlecurvatureagainstthegreatercurvatureofthestomach,toinsurethatthetipdoesnotcreateaperforativeforcethroughthegastricwall.Itisalsokeytoavoidasharpangulationinthewire,whichmightposeasimilarperforationThetactilesensationofstrictureresistanceduringantegradedilationisimportantinselectingsuccessivedilatorsizesanddeterminingthepaceofdilationRarelyarecomplexstricturessafelyresponsivetoasingledilationsession,sothepatientmustunderstandthatgradualprogressivedilationduringsequentialfollow-upwilllikelybenecessary.Theintervalsbetweentheinitialdilationsessionsarebestkepttobetween2and4weeks.Afterthegoalforpresumedoptimumdiameterisreached,theintervalscanbeincreasedbasedonthepatientsopinionofdysphagiarelief.Theetiologyandcomplexityofthestrictureshouldbeestablishedasaguidetotherapy.Thetechnique,equipment,andluminal restorationtarget(inmm)mayneedtobealteredtosuitthepathologyofthestrictureandthegoalsforthepatient.Theultimategoalfordilationofesophagealstricturesneednotnecessarilybeaspeciclumensize,butshouldbetailoredtowhatissafeandacceptabletothepatient.Long-termmodicationofdietaryintakemaybenecessaryevenafterdilation,dependingonthenatureofthestricture.Thisshouldbemadecleartothepatientaspartoftheinitialassessmentand References1SiersemaPD.Treatmentoptionsforesophagealstrictures.NatClinPractGastroen-terolHepatol(3):142…52.2LewRJ,KochmanML.Areviewofendoscopicmethodsofesophagealdilation.ClinGastroenterol(2):117…26.3EganJV,BaronTH,AdlerDG,etal.Esophagealdilation.GastrointestEndosc(6):755…60.4Pereira-LimaJC,RamiresRP,ZaminI,etal.Endoscopicdilationofbenignesophagealstrictures:reporton1043procedures.AmJGastroenterol5KochharR,PoornachandraKS.Intralesionalsteroidinjectiontherapyintheman-agementofr

esistantgastrointestinalstrictures.WorldJGastrointestEndosc(2):61…8.6SiddiquiUD,BanerjeeS,BarthB,etal.Toolsforendoscopicstricturedilation.trointestEndosc(3):391…404.7HoSB,CassO,KatsmanRJ,etal.FluoroscopyisnotnecessaryforMaloneydilationofchronicesophagealstrictures.GastrointestEndosc(1):11…14.8HernandezLV,JacobsonJW,HarrisMS,HernandezLJ.ComparisonamongtheperforationratesofMaloney,balloon,andSavarydilationofesophagealstrictures.GastrointestEndosc(4Pt.1):460…2.9RileySA,AttwoodSE.Guidelinesontheuseofoesophagealdilatationinclinicalpractice.(Suppl.1):i1…6.10KabbajN,SalihounM,ChaouiZ,etal.Safetyandoutcomeusingendoscopicdilata-tionforbenignesophagealstricturewithoutfluoroscopy.WorldJGastrointestPhar-macolTher(6):46…9.11RaymondiR,Pereira-limaJC,ValvesA,etal.Endoscopicdilationofbenignesophagealstrictureswithoutfluoroscopy:experienceof2750procedures.Hepato-gastroenterology(85):1342…8.12WallnerO,WallnerB.Balloondilationofbenignesophagealringsorstrictures:arandomizedclinicaltrialcomparingtwodifferentinflationtimes.DisEsophagus(2):109…11.13MonkemullerK,KalauzM,FryLC.Endoscopicdilationofbenignandmalignantesophagealstrictures.IntTherGastrointestEndosc(1):91…105.14PiotetE,EscherA,MonnierP.Esophagealandpharyngealstrictures:reporton1862endoscopicdilatationsusingtheSavary-Gilliardtechnique.EurArchOtorhi-nolaryngol(3):357…64.15JethwaP,LalaA,PowellJ,etal.Aregionalauditofiatrogenicperforationoftumoursoftheoesophagusandcardia.AlimentPharmacolTher(4):479…84.16HarrisonME,SanowskiRA.Mercurybougiedilationofbenignesophagealstric-tures.Hepatogastroenterology(6):497…501.17ZehetnerJ,DemeesterSR,AyaziS,DemeesterTR.Homeself-dilatationforesophagealstrictures.DisEsophagus(1):1…4.18AndersonSH,MeenanJ,WilliamsKN,etal.Efficacyandsafetyofendoscopicdila-tionofesophagealstricturesinepidermolysisbullosa.GastrointestEndosc(1):28…32.19LucendoAJ,DeRezendeL.Endoscopicdilationineosinophilicesophagitis:atreat-mentstrategyassociatedwithahighriskofperforation.Endoscopy20CohenMS,KaufmanAB,PalazzoJP,etal.Anauditofendoscopiccomplicationsinadulteosinophilicesophagitis.ClinGastroenterolHepatol(10):1149…21EisenbachC,MerleU,SchirmacherP,etal.Perforationoftheesophagusafterdila-tiontreatmentfordysphagiainapatientwitheosinophilicesophagitis.Endoscopy(Suppl.2):E43…4.22KaplanM,MutluEA,JakateS,etal.Endoscopyineosinophilicesophagitis:felineŽesophagusandperforationrisk.ClinGastroenterolHepatol(6):433…7.23JungKW,GundersenN,KopacovaJ,etal.Occurrenceofandriskfactorsforcom-plicationsafterendoscopicdilationineosinophilicesophagitis.GastrointestEndosc(1):15…21. CHAPTER100 JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverviewTable100.1Characteristicsofsimpleversuscomplexstrictures. SimpleComplex AllowforpassageofYesNo(typically)Short(2cm)Long(2cm)YesNoAngulation/irregularityNoYes(typically)ShatzkisringCausticingestionPhotodynamictherapyPreferreddilationmethodBalloonorrigiddilatorRigiddilatorFluoroscopyRarelyneededRecommended1…3(typically)RiskofrecurrenceLowHigh allowpassageofadiagnosticupperendoscope).Conversely,com-plexstricturesaredefinedashavingaluminaldiameterof12mm,asbeingasymmetricwithangulation,orasnothavingtheabilitytopassadiagnosticupperendoscope.Table100.1summarizesthedif-ferencesincharacteristicsbetweenasimpleandacomplexstricture.Simpleesophagealstricturestendtobeshort,focal,andstraight,ortohaveadiameterthatissufficienttoallowthepassageofanormal-diameterendoscope.Commonetiologiesofsim-pleesophagealstricturesincludegastroesophagealrefluxdisease(GERD)(upto70%ofcases),Schatzkisring,andmembranouswebs.Typically,thesestricturesareamenabletothestandardtech-niqueofbougieorthrough-the-scopeballoondilation.Inmostcases,onetothreedilationsarerequiredforsymptomaticrelief,butinupto35%ofpatientsarepeatdilationisrequired[2,4].Fordila-tionofaShatzkisring,whichdoesnotcontainanymuscularispro-priaandiscomposedentirelyofmucosaandsubmucosa,theresultsofasingledilation(15…18mmdilator)aretypicallysufficient[2].Complexesophagealstricturestendtobelong(2cm),tortuous,orassociatedwithaseverelynarroweddiameterthatprecludesthepassageofanendoscope.Commonetiologiesofcom-plexesophagealstricturesincludecausticingestion,radiation,surgi-calanastomosis(withrelatedlocalvascularcompromise),photody-namicorsclerotherapy,andseverepepticinjury(particularlyrelatedtorefluxinpatientswithprolongeduseofanasogastrictube).Com-plexstricturesrequiretheuseoffluoroscopicguidanceinordertoplanandexecutesafeandeffectivedilation.Theytypicallyrequirerepeatdilationsforsymptomaticreliefand,dependingontheunderlyingpathogenesis,areassociatedwithhighrecurrencerates.Refractorycomplexstricturesarethosethatcannotbedilatedtoasufficientdiametertoallowpassageofsolidfood,thatrecurwithinatimeintervalof2…4weeks,orthatrequireongoing(morethan10)dilationsessions[2].Thereareseveralnoveltreatmentmodalitiesavailableforrefractorystrictures,includingincisionaltherapy(par-ticularlytorefractoryShatzkisring)andtemporaryplacementofacoveredstent(particularlyforlongercomplexstrictures)[5].Malig-nantstricturesaretypicallymoredefinitivelytreatedbydilationfol-lowedbyathermaldestructivetherapy(

e.g.,laser,photodynamic,brachytherapy,cryotherapy)withorwithoutesophagealstenting.CategoriesofEsophagealDilatorTherearethreecategoriesofesophagealdilatorcurrentlyinuse:bougiesfilledwithmercuryortungsten,wire-guidedpolyvinyldila-tors,andthrough-the-scopeballoondilators[6](Figure100.1).Theexpansiveforcegeneratedbythesedilatorsdiffersbasedonthe Figure100.1(a)Bougiedilator.(b)Wire-guidedpolyvinyldilator.(c)Through-the-scopeballoondilator.deliveryofthedeviceandthemechanismsofaction.Radialdila-tioniskeytoattainingeffectivedilationofastricture.Mostbougieandwire-guidedpolyvinyldilatorsaredesignedsothattheycanbereused.Usersshouldthereforerefertothemanufacturersinstruc-tionsforguidanceonreprocessing.BougieDilators(Maloneydilators,MedovationsInc.)Bougiedilatorsareaseriesofflexibledilatorsofincreasingthick-nessfilledwithmercuryortungsten,withataperedtipthatcanbepassedeitherblindlyorfluoroscopically[7].Theyofferbothradialandlongitudinaldilationastheyarepassed,accordingtothenatureofthepassage[6,8].Wire-GuidedPolyvinylDilators(Savary-Gilliard,CookMedical)Wire-guideddilationsoffergreaterassurancetotheoperatorthatthedilatorisfollowingthelumenoftheesophagus,thusreducingtheriskofperforation[9].Fluoroscopyisrecommended,tomon-itorthepositionoftheguidewire,whichshouldbetargetedatleast30cmbelowthelowestpointofthestricture.Typically,thedistaltipispositionedinthegastricantrumalongthegreatercurvatureofthestomach[9].Recentreportssuggestthattheuseofwire-guideddilatorswithoutfluoroscopyissafeandeffectiveinthetreatmentofesophagealstrictures[10,11],thoughthisisnotourcurrentpractice.Wire-guideddilatorsofferthepotentialeffectsofbothradialandlongitudinaldilation,dependingonwhetheradditionalto-and-fromovementisperformedaftertheinitialstaticradialdilation.Through-the-ScopeBalloonDilators(ControlledRadialExpansion(CRE),BostonScientic)Through-the-scopeballoondilationisperformedunderdirectendoscopicvisualization,utilizingaballoondilatorpasseddowntheworkingchanneloftheendoscope[9].Themid-portionoftheballoonshouldtypicallybecenteredatthetightestpointinthestricture,withdilatingpressuresrangingbetween30and45psi,varyinginrelationtoballoonsize.Recentstudiesindicatethata CHAPTER100 JWST654-c100JWST654-TalleyPrinter:YettoComeJuly4,201614:6279mm EsophagealDilation:AnOverview24DellonES,GibbsWB,RubinasTC,etal.Esophagealdilationineosinophilicesophagitis:safetyandpredictorsofclinicalresponseandcomplications.Gastroin-testEndosc(4):706…12.25SchoepferAM,GonsalvesN,BussmannC,etal.Esophagealdilationineosinophilicesophagitis:effectiveness,safety,andimpactontheunderlyinginflammation.JGastroenterol (5):1062…70.26BohmME,RichterJE.Reviewarticle:oesophagealdilationinadultswitheosinophilicoesophagitis.AlimentPharmacolTher(7):748…57.27JacobsJW,SpechlerSJ.Asystematicreviewoftheriskofperforationduringesophagealdilationforpatientswitheosinophilicesophagitis.DigDisSci(6):1512…15.28SchoepferAM,GschossmannJ,ScheurerU,etal.Esophagealstricturesinadulteosinophilicesophagitis:dilationisaneffectiveandsafealternativeafterfailureoftopicalcorticosteroids.Endoscopy(2):161…4.29MoawadFJ,CheathamJG,DezeeKJ.Meta-analysis:thesafetyandefficacyofdila-tionineosinophilicoesophagitis.AlimentPharmacolTher(7):713…20.30BoyceHWJr.Preceptsofsafeesophagealdilation.GastrointestEndosc31BoyceHW.Dilationofdifficultbenignesophagealstrictures.AmJGastroenterol(4):744…5.32KochmanML.Minimizationofrisksofesophagealdilation.GastrointestEndoscClinNAm(1):47…58.33WalzerN,HiranoI.Achalasia.GastroenterolClinNorthAm(4):807…25.34HirdesMM,vanHooftJE,KoornstraJJ,etal.Endoscopiccorticosteroidinjectionsdonotreducedysphagiaafterendoscopicdilationtherapyinpatientswithbenignesophagogastricanastomoticstrictures.ClinGastroenterolHep:795…801.35RamageJI,RumallaA,BaronTH,etal.Aprospective,randomized,double-blind,placebo-controlledtrialofendoscopicsteroidinjectiontherapyforrecalcitrantesophagealpepticstrictures.AmJGastroenterol(11):2419…25.36PregunI,HritzI,TulassayZ,HerszenyiL.Pepticesophagealstricture:medicaltreat-ment.DigDis(1):31…7.37McgrathK,BrazerS.Combinedantegradeandretrogradedilation:anewendo-scopictechniqueinthemanagementofcomplexesophagealobstruction.Gastroin-testEndosc(1):163…4.38LewRJ,ShahJN,ChalianA,etal.Techniqueofendoscopicretrogradepunctureanddilatationoftotalesophagealstenosisinpatientswithradiation-inducedstrictures.HeadNeck(2):179…83.39KosMP,DavidEF,MahieuHF.Anterograde-retrograderendezvousapproachforradiation-inducedcompleteupperoesophagealsphincterstenosis:casereportandliteraturereview.JLaryngolOtol(7):761…4.40AmateauSK,KhashabMA.Successfulbluntrecanalizationofanobliteratedlongesophagealstricturebyendoscopicrendezvous.Endoscopy(Suppl.2UCTN):E49…50.41RaijmanI,SiddiqueI,RachalLT.Endoscopicstricturoplastyinthemanage-mentofrecurrentbenignesophagealstrictures.GastrointestEndosc42HagiwaraA,TogawaT,YamasakiJ.Endoscopicincisionandballoondilata-tionforcicatricialanastomoticstrictures.Hepatogastroenterology43TangSJ,SinghS,TruelsonJM.Endotherapyforsevereandcompletepharyngo-esophagealpost-radiationstenosisusingwires,balloonsandpharyngo-esophagealpuncture(PEP)(withvideos).SurgEndosc(1):210…14. CHAPTER