Esophageal dilation

Diagnosis and initial management of gastroesophageal complications

Chronic esophageal exposure to reflux of gastroduodenal contents can result in complications of GERD including esophageal stricture, Barrett's oesophagus or extraesophageal symptoms such as laryngitis, chronic cough or asthma. Endoscopy is the main diagnostic tool for patients with chronic reflux presenting with dysphagia to visualise esophageal mucosa and identify the underlying pathology. Barrett's oesophagus should be suspected in those with chronic reflux disease. Patients with Barrett's oesophagus should undergo surveillance endoscopy in order to risk stratify to dysplasia or adenocarcinoma. New endoscopic ablative therapies in patients with Barrett's oesophagus and high grade dysplasia are promising new treatment modality for those who may not be candidates for definitive intervention. Given poor sensitivity of diagnostic tests in extraesophageal reflux, empiric therapy with proton pump patients is the initial recommended approach. Diagnostic testing with esophagogastroduodenoscopy and ambulatory pH and impedance monitoring is usually reserved for those unresponsive to acid suppressive therapy. Many uncertainties remain in this group of patients including which patient subgroups might benefit from acid suppressive therapy. Future outcome studies are needed to assess the role of impedance/pH monitoring in this group of patients and to determine who might symptomatically benefit from medical or surgical intervention.

Nonoperative management of esophageal strictures following esophagomyotomy for achalasia

The optimal management of reflux-induced esophageal strictures that occur after esophagomytomy for achalasia is uncertain. This paper presents our experience with the nonsurgical treatment of postesophagomyotomy strictures in achalasia patients using endoscopic dilation and gastric acid suppression. Six patients with achalasia who had undergone prior esophagomyotomy subsequently developed recurrent dysphagia and were found to have an esophageal stricture. Esophagrams typically showed a markedly dilated esophagus with a narrowed, sharply angulated gastroesophageal junction. Esophageal manometry confirmed esophageal aperistalsis and, when measured, the LES pressure was < 5 mm Hg. Endoscopy showed esophageal inflammation and a fixed stricture at the gastroesophageal junction. Strictures were dilated under direct visualization using through-the-scope balloon dilators. Patients began gastric acid suppressive treatment at the same time. Five patients who remained symptomatic underwent repeat endoscopy, which demonstrated improvement in esophagitis. Dilation was then repeated with a larger balloon dilator. Over a mean follow-up period of 3.8 years, the average number of repeat dilations per patient was 3.6 (range: 0-12). All patients had symptomatic improvement and weight gain. No patient required surgery. We conclude that esophageal strictures after esophagomyotomy for achalasia can be safely treated using endoscopic dilation and gastric acid suppression, thus avoiding the need for reoperation.