Fluoroscopically guided balloon dilation of benign esophageal strictures: incidence of esophageal rupture and its management in 589 patients

Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center

INTRODUCTION

Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators.

METHODS

Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14 mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications.

RESULTS

Of the 189 patients (mean age 32.17 ± 12.12 years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success.

CONCLUSION

Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.

Balloon dilatation complications during esophagogastric anastomotic stricture treatment under fluoroscopy: Risk factors, prevention, and management

BACKGROUND

Balloon dilatation (BD) is a common treatment for esophagogastric anastomotic stricture (EAS), but with complications. This study investigates the risk factors, prevention, and management of BD complications to provide clinical guidance.

METHODS

We retrospectively analyzed the clinical data of 378 patients with EAS treated by BD from March 2011 to June 2021. The association between esophagogastric anastomotic rupture outcome and patient and stricture characteristics and treatment were analyzed by logistic regression.

RESULTS

BD was performed 552 times and technical success, 98.0%; overall clinical success, 97.8%; major adverse events, 1.3%; minor adverse events, 9.4%; mortality, 0.3%. Logistic regression showed that age (p = 0.080), sex (p = 0.256), interval from surgery to stricture development (p = 0.817), number of dilatations (p = 0.054), cause of stricture (p ≥ 0.168), and preoperative chemotherapy (p = 0.679) were not associated with anastomotic rupture. Balloon diameter (p < 0.001), preoperative radiotherapy (p = 0.003), and chemoradiotherapy (p = 0.021) were correlated with anastomotic rupture. All patients with type I and II ruptures resumed oral feeding without developing into type III rupture. Type III rupture occurred in six cases, who resumed oral feeding after 7-21 days of nasal feeding and liquid feeding. One patient died of massive bleeding after BD.

CONCLUSIONS

Symptomatic treatment for type I and II ruptures and transnasal decompression and jejunal nutrition tubes for type III rupture, are suggested pending rupture healing. Tumor recurrence, preoperative radiotherapy, and balloon diameter affected the anastomotic rupture outcome.

Self-dilatation of benign oesophageal strictures: a literature review

BACKGROUND

Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures.

METHODS

This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures.

RESULTS

This study identified 13 articles with 274 participants.

CONCLUSION

Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.

Indocyanine green fluorescence imaging for subtotal esophagectomy due to esophageal stenosis after acute esophageal necrosis: a report of two cases

Although esophageal stricture after acute esophageal necrosis (AEN) is often refractory to dilation therapy, there have been few reports of surgical intervention. We report two rare cases of successful subtotal esophagectomy and esophagogastrostomy for esophageal strictures after AEN using indocyanine green (ICG) fluorescence imaging. In case 1, emergent esophagogastroduodenoscopy (EGD) in a 56-year-old man with coffee-ground emesis revealed black esophageal mucosa in the middle to lower esophagus, indicating AEN. Despite conservative therapy, an esophageal stricture developed after 2 weeks. Repeated endoscopic balloon dilation (EBD) did not resolve the stenosis; esophagectomy was thus performed approximately 6 months after AEN onset. We evaluated the blood flow to the esophagus using ICG fluorescence imaging to determine the proximal surgical resection line. The postoperative course was uneventful. In case 2, an 81-year-old woman with upper gastrointestinal bleeding with hematemesis and chest pain was diagnosed with AEN by EGD and was treated with conservative therapy. An esophageal stricture developed after 3 weeks, and repeated EBD was ineffective. Approximately 2 months after AEN onset, she underwent esophagectomy using ICG fluorescence imaging. The postoperative course was uneventful. Considering that AEN is a blood flow disorder, ICG fluorescence imaging is a useful technology to prevent surgical morbidity.

National Database Outcomes of Esophageal Dilations

OBJECTIVES/HYPOTHESIS

To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes.

STUDY DESIGN

Observational, retrospective cohort study.

METHODS

We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged.

RESULTS

We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%.

CONCLUSIONS

Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations.

LEVEL OF EVIDENCE

IV Laryngoscope, 2020.

Endoscopic balloon dilation and submucosal injection of triamcinolone acetonide in the treatment of esophageal stricture: A single-center retrospective study

Effect and prognosis of endoscopic balloon dilatation combined with submucosal triamcinolone acetonide on treating benign esophageal lesions were explored. This retrospective study included patients with esophageal stricture treated in the Department of Gastroenterology, the Third Affiliated Hospital of Soochow University from March 2012 to March 2015. Enrolled patients were divided into the treatment and control group depending on the therapy differences. Endoscopic balloon dilation combined with submucosal injection of triamcinolone acetonide was performed in the treatment group and the endoscopic balloon dilatation was performed in the control group. In addition, the treatment group was further divided into the <16- and >16-mm subgroup according to the degree of balloon dilatation. During 1-year follow-up, changes of esophageal stenosis, esophageal stenosis recurrence rate, postoperative complications and adverse reactions were observed and analyzed. The improvement of esophageal stenosis of the treatment group was significantly superior to that of the control group at 2 and 4 months after operation, respectively (P=0.002, 0.013). The esophageal stenosis recurrence rate was 62.2 and 77.2% in the treatment and control group, respectively (P=0.027); the recurrence time of stenosis was 101.4±8.6 days in the treatment group and 75.4±5.2 days in the control group (P=0.006). Additionally, the recurrence time of esophageal stenosis was significantly shorter in the >16-mm subgroup compared with that of the <16-mm subgroup (P<0.001). Endoscopic balloon dilatation combined with local injection of triamcinolone acetonide in the treatment of esophageal stricture had a better therapeutic effect than that of the simple balloon dilatation, which was more effective when the balloon dilatation was >16 mm. It could significantly prolong the recurrence time of esophageal stricture.

Radiation-induced esophageal strictures treated with fluoroscopic balloon dilation: clinical outcomes and factors influencing recurrence in 62 patients

Background Balloon dilation is safe and effective for the treatment of radiation-induced esophageal stricture (RIES), with favorable short-term and mid-term outcomes; however, few reports of long-term outcomes exist. Few studies have evaluated factors associated with recurrence after balloon dilation. Purpose To evaluate the long-term outcome of balloon dilation in patients with RIES and to identify factors associated with stricture recurrence. Material and Methods The medical records of 62 consecutive patients who had undergone fluoroscopic balloon dilation for RIES at our institution between December 1998 and June 2016 were reviewed. Results One hundred and twenty balloon dilation sessions were performed in 62 patients (mean = 1.9 sessions per patient). Clinical success was achieved in 53 (86%) patients after single (n = 37) or multiple (n = 16) dilation sessions. Complications occurred in 27% of the dilation sessions. The primary patency rates at one, two, three, and five years were 60%, 56%, 52%, and 52%, respectively. Secondary patency rates at one, two, three, and five years were 87%, 85%, 85%, and 80%, respectively. Multivariate logistic regression analysis identified an interval from radiation therapy (RT) to stricture of ≥6 months (hazard ratio [HR] = 0.205; P < 0.001), strictures located at the cervical esophagus (HR = 5.846; P < 0.001), and stricture length of ≥2 cm (HR = 2.923; P = 0.006) as significant predictors of recurrence. Conclusion Despite the high incidence of ruptures and recurrences, fluoroscopic balloon dilation is valuable as an initial therapeutic option for patients with RIES.

Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach

BACKGROUND

Patients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient's autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution.

METHODS

This study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events.

RESULTS

Seventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11-27] procedures during a median period of 9 (IQR 6-36) months to 1.5 (IQR 0-3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5-33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13-15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage.

CONCLUSIONS

In this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.

Endoscopic dilation of benign esophageal anastomotic strictures over 16 mm has a longer lasting effect

Background

The optimal target of endoscopic dilation of postsurgical esophageal strictures is unknown. Our aim was to compare the dilation-free period of patients who underwent dilation up to 16 mm with patients who were dilated up to 17 or 18 mm.

Methods

We retrospectively analyzed adult patients who received bougie/balloon dilation for a benign anastomotic stricture after esophagectomy. An anastomotic stricture was defined as dysphagia in combination with a luminal diameter of ≤13 mm at endoscopy. We analyzed the dilation-free period using Kaplan–Meier and multivariable Cox regression analysis.

Results

Eighty-eight patients were dilated up to a maximum diameter of 16 mm and 91 patients to a diameter >16 mm. The stricture recurrence rate was 79.5 % in the 16 mm group and 68.1 % in the >16 mm group (p = 0.083). The overall dilation-free period had a median of 41.5 (range 8–3233) days and 92 (range 17–1745) days, respectively (p < 0.001). For patients who developed a stricture recurrence, the median dilation-free period was 28 (range 8–487) days and 63 (range 17–1013) days, respectively (p = 0.001). Cox regression analysis showed a reduced risk of stricture recurrence for patients who were dilated up to >16 mm: crude hazard ratio (HR) 0.57 (95 % confidence interval (CI) 0.41–0.81) and adjusted HR 0.48 (95 % CI 0.33–0.70).

Conclusions

Endoscopic dilation over 16 mm resulted in a significant prolongation of the dilation-free period in comparison with dilation up to 16 mm in patients with benign anastomotic strictures after esophagectomy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5187-0) contains supplementary material, which is available to authorized users.

Incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation in children with benign strictures

OBJECTIVES

The purpose of this study is to investigate the incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation (FBD) in children with benign oesophageal strictures.

METHODS

Sixty-two children with benign oesophageal strictures underwent FBDs. Oesophageal rupture was categorized as intramural (type 1), transmural (type 2), or transmural with free leakage (type 3). The possible risk factors for oesophageal ruptures were analyzed.

RESULTS

One hundred and twenty-nine FBDs were performed in these patients. The oesophageal rupture rate was 17.1 % (22/129). The majority (21/22) of ruptures were type 1 and type 2, both were treated conservatively. Only one patient had a type 3 rupture and underwent oesophagoesophagostomy. The patient gender, age, and the length and cause of the stricture showed no significant effect on the rupture (P > 0.05). However, for the patients ≤2 years old, the initial balloon with a diameter ≥10 mm showed a higher oesophageal rupture rate than those <10 mm during the first session (P = 0.03).

CONCLUSIONS

Although the oesophageal rupture rate in children was 17.1 %, the type 3 rupture rate was 0.8 %, which usually requires aggressive treatment. For children ≤2 years old, the initial balloon diameter should be <10 mm in the first session for decreasing the risk of oesophageal rupture.

KEY POINTS

• The oesophageal rupture rate following balloon dilatation in children was 17.1 %. • The incidence of transmural rupture with free leakage is very low. • Only transmural rupture with free leakage needs aggressive treatment. • For children ≤2 years, the initial balloon diameter should be <10 mm.

Full-thickness esophageal perforation after fluoroscopic balloon dilation: incidence and management in 820 adult patients

OBJECTIVE

The purpose of this study is to investigate the incidence, management, and outcomes of esophageal perforation after fluoroscopic balloon dilation in 820 adult patients with esophageal diseases.

MATERIALS AND METHODS

Between December 1990 and April 2014, a total of 820 adult patients (age range, 21-93 years) underwent 1869 fluoroscopic balloon dilation sessions (mean, 2.3 sessions/patient; range, 1-29 sessions/patient) for esophageal diseases. We retrospectively reviewed the prospectively collected medical records and images of these patients and collected the data of patients who developed esophageal perforations after fluoroscopic balloon dilation.

RESULTS

During this period, 12 patients (six men and six women; mean age, 51 years; age range, 28-69 years) developed perforations. The perforation rate was 1.5% per patient and 0.6% per dilation. Among the first eight patients, four who were treated with surgery had perforations 2 cm or larger, and the other four who underwent fasting, parenteral alimentation, and treatment with antibiotics had perforations smaller than 2 cm. The last four patients underwent stent placement immediately after the diagnosis, regardless of the perforation's size. The median hospital stay was 11.5 days.

CONCLUSION

Fluoroscopic balloon dilation of esophageal diseases is a safe procedure with a low perforation rate. A perforation size greater than 2 cm is considered large and requires aggressive treatment. Although the number of patients with esophageal perforation we treated is relatively small and further clinical trials are needed, temporary stent placement seems to be an initial choice in the management of esophageal perforations after fluoroscopic balloon dilation.

Comparison of endoscopic balloon dilation with metal stent placement in the treatment of achalasia

OBJECTIVE

To compare the outcomes of endoscopic balloon dilation and metal stent placement in patients with achalasia.

METHODS

The patients with newly diagnosed achalasia between July 2001 and December 2011 were retrospectively studied. A total of 88 patients underwent either balloon dilation (n = 41) or metal stent placement (n = 47), their global symptom score and esophageal kinetics index were determined before, one week after and one month after the treatment. All the patients were followed up in the Outpatient Clinics or with a telephone interview every 6 months.

RESULTS

There were significant improvements in the global symptom scores and esophageal kinetics indices in all patients. No major complications were encountered in either group. There were no significant differences with regard to overall treatment failure or long-term outcome.

CONCLUSION

Balloon dilation and removable stents can effectively relieve clinical manifestations in patients with achalasia.

Esophageal strictures and diverticula

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Outcomes of balloon dilation for the treatment of strictures after endoscopic submucosal dissection compared with peptic strictures

BACKGROUND

The outcomes of balloon dilation for the treatment of strictures caused by endoscopic submucosal dissection (ESD) have not been evaluated previously. This study was designed to evaluate and compare the effectiveness and complications of balloon dilation for post-ESD strictures and peptic strictures.

METHODS

The medical records of 14 patients with post-ESD strictures and 48 patients with peptic strictures who underwent fluoroscopically or endoscopically guided balloon dilation between January 1997 and April 2011 at the Asan Medical Center in Korea were reviewed retrospectively.

RESULTS

The technical success rates (defined as successful dilation without major complications) of the post-ESD and peptic stricture groups were 92.9% (13/14) and 93.8% (45/48), respectively (p = 1.000). For the post-ESD and peptic stricture groups, the clinical success rates (defined as symptom improvement, as determined by the patient) at 1 month were 92.9% (13/14) and 83.3% (40/48), respectively (p = 0.67). Their clinical success rates at 6 months were 71.4% (10/14) and 70 % (28/40), respectively (p = 1.000). The mean weight gains of the post-ESD stricture group 1 and 6 months after balloon dilation were 1.1 and 4.8 kg, respectively, whereas the peptic group gained 1.4 and 3.4 kg, respectively (p = 0.814). All complications were perforations. The complication rates of the post-ESD and peptic stricture groups were 7.1 % (1/14) and 10.5 % (5/48), respectively (p = 1.000).

CONCLUSIONS

Balloon dilation is an effective and safe treatment for post-ESD strictures.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.