The present study was performed due to all of the above and the lack of data with regard to complications associated with endoscopic esophageal dilation in our region. The overall objective was to assess the safety of esophageal dilation and to determine the factors associated with complications. The specific goals include the following: a to determine the most common etiologies of esophageal stricture in a tertiary referral hospital; b to estimate the rate of complications associated with esophageal dilation; c to identify associations between nonadherence to the "rule of 3" and the development of complications; and d to identify predictors of complications.
This was a single-center retrospective cohort study performed in a tertiary institution in Lima, Peru, from January to June Patients with an esophageal stricture who underwent endoscopic esophageal dilation were included. The inclusion criteria were age above 18 years and esophageal stricture with associated dysphagia regardless of the etiology. The study was conducted in accordance with the principles of the Declaration of Helsinki.
The protocol was assessed and approved by the Gastroenterology Department and the hospitals' Ethics Committee. Epidemiological and clinical data were recorded for all cases, as well as their prior endoscopic dilation history.
The following characteristics were assessed in all patients with ES: sex, age, stricture etiology, structural type simple or complex according to the American Society for Gastrointestinal Endoscopy [ASGE] criteria [1] , dilator type balloon or bougie , dilation extent in mm according to dilator diameter and the number of increments in one session according to the "rule of 3".
Furthermore, the application of the "rule of 3" was assessed not only for bougie dilations but also for balloon dilations, as many endoscopists use this during the latter procedure 9. Drug selection was based on patient assessment and no cases required general anesthesia. Most procedures were carried out on an outpatient basis. Procedures were performed by two practitioners trained in advanced therapeutic endoscopy.
One had a vast experience in esophageal dilation and the other endoscopist was properly trained but had performed fewer procedures. Hence, he was always accompanied by his more experienced colleague. A contrast-enhanced esophageal scan was performed prior to the first dilation, only for suspected complex strictures. The decision to use a specific dilator and a given number of increments in one session was left to the discretion of each endoscopist. The duration of dilation was approximately 60 seconds for each diameter.
Usually, one to four progressively larger in diameter dilators were used per session, depending on patient tolerance and stricture type. No fluoroscopy was used for dilation procedures as the required equipment was not available in therapeutic endoscopy rooms. When more than one session was required, the procedures were scheduled every weeks, until a diameter of at least mm was reached. Subsequent sessions were planned for recurrent dysphagia. With regard to patients with peptic ES, the use of proton-pump inhibitors PPIs was advised with routine anti-reflux measures.
Patients were observed for potential complications following each session. Complications were managed by a multidisciplinary team using endoscopic techniques when feasible or surgery.
All continuous-variable results were summarized using average, standard deviation and range values, according to their distribution. Categorical variables were reported as a number and percentage. Relationships between categorical variables were analyzed using the Chi-squared test and Fisher's exact test when necessary.
A bivariate and multivariate logistic regression analysis was used to estimate odds ratios for each predictor and the occurrence of a complication. The analysis was performed using the Stata 10 statistical system. The average age at the first dilation was The most prevalent etiology was stricture at the surgical anastomosis in 43 patients A total of dilations were performed and each patient underwent an average of 2.
A stricture at the surgical anastomosis required a larger number of dilations per patient. Two patients had a pharyngocolonic anastomosis and were intervened following caustic esophagitis that required 28 and eleven sessions, respectively. Table 1 shows the characteristics of patients included in the study and their endoscopic esophageal dilations. The dilation extent varied according to etiology, and increments from 1 mm to 7 mm were applied, the latter for a patient with a stricture at the surgical anastomosis.
Table 1 Characteristics of the patients and the endoscopic dilation procedure. Complications associated with endoscopic dilation occurred in six cases 1. There were three perforations 0. All complications were intra-procedural and no significant association was found between stricture etiology and the occurrence of a complication. Four of the six complications occurred during the first dilation session. The remaining two complications developed during the sixth and twelfth session, respectively, both in the setting of a stricture at the surgical anastomosis.
One perforation occurred during the sixth dilation session. Two of the three perforations developed during dilation for a complex stricture. All perforations were treated satisfactorily with self-expandable metal stents. One perforation unusually occurred in a patient with a stricture of an unknown origin that was later found to be malignant.
Bleeding episodes were resolved with endoscopic therapy. The painful event required no specific therapy and none of the complications required surgery. Table 2 Complications according to their origin. Table 3 shows the association between complications related to esophageal dilation and five potential risk factors. No complications occurred after dilations of over 3 mm or dilations for achalasia.
In the multivariate analysis, only balloon dilation was found to be significantly associated with the development of complications. Predictive factors for a perforation after esophageal dilation are also listed in Table 3. All perforations occurred after esophageal dilation using a balloon dilator. None of the factors assessed were related to perforation development following dilation.
Table 3 Variables associated with complications and perforations. Perforations occurred in 4 patients. Three of these four patients had undergone endoscopy with conscious sedation immediately before the dilation.
The immediate outcome of surgery was good in all 4 patients with no deaths. Alternatively, your healthcare provider may use a spray anesthetic to numb your throat to perform your procedure. If this method is used, you will be fully awake for the procedure and would be able to drive. Many people, however, prefer to use sedation, because the thought of a long tube being inserted into your throat down to your stomach can be scary, particularly if you are prone to claustrophobia.
After the procedure, you will be given instructions on when you can eat and drink. Drinking will be withheld until any anesthetic effects have worn off.
This is so that you do not have liquid go into your lungs instead of your stomach, since the anesthetic inhibits the normal swallowing functions. You will likely also have a mild sore throat for several days after the procedure. It is common for symptoms to eventually return after an esophageal dilation.
How long it takes for symptoms to recur is variable and dependent on many factors including the severity and cause of the stricture. In many cases, dietary management, use of proton pump inhibitors PPIs , and other medical therapies can help delay if not prevent the need for future esophageal dilations. Working closely with your healthcare provider and following your individualized treatment plan can help keep symptoms under control for longer periods of time.
Esophageal dilation is a treatment and not a cure. However, symptom relief makes this procedure very useful to improve your quality of life. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Tools for endoscopic stricture dilation. Gastrointest Endosc. American Society for Gastrointestinal Endoscopy. Understanding esophageal dilation. American College of Gastroenterology.
Dysphagia: Causes. Updated November Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis.
Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures. Surg Endosc. Control of inflammation decreases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis. Dis Esophagus. Your Privacy Rights. To change or withdraw your consent choices for VerywellHealth. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page.
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