UK GUIDELINES ON OESOPHAGEAL DILATATION IN CLINICAL PRACTICE
(Continuation. Start at No. 1 (1) July 2018)
SARMED S SAMI,1 HASAN N HABOUBI,2 YENG ANG,3,4 PHILIP BOGER,5 PRADEEP BHANDARI,6 JOHN DE CAESTECKER,7 HELEN GRIFFITHS,8 REHAN HAIDRY,9 HANS-ULRICH LAASCH,10 PRAFUL PATEL,5 STUART PATERSON,11 KRISH RAGUNATH,12 PETER WATSON,13 PETER D SIERSEMA,14 STEPHEN E ATTWOOD15
Gut: first published as 10.1136/gutjnl-2017-315414 on 24 February 2018. Downloaded from http://gut.bmj.com/ on 26 June
2018 by guest. Protected by copyright.
The dilatation technique
This section describes the general technique of benign stricture dilatation. Achalasia dilatation and disease-specific considerations will be discussed in subsequent sections.
Strictures can be simple or complex.33 34 Simple strictures are short (<2 cm), concentric, straight, and allow the passage of a normal diameter endoscope.33 34 Examples include Schatzki’s rings, oesophageal webs and peptic strictures.33 34 Overall, one to three dilatation sessions are sufficient to relieve dysphagia in simple strictures. Only 25-35% of patients require additional sessions, with a maximum of five dilatations in >95% of patients.35 Complex strictures are usually longer (>2 cm), angulated, irregular or have a severely narrowed diameter.33 34 These are more difficult to treat and have a tendency to be refractory or to recur despite dilatation.
(a) What size dilator should be initially chosen?
The initial dilator choice should be based on the known or estimated stricture diameter, length and the underlying pathology.
► Consider limiting the initial dilatation to 10-12 mm in diameter (corresponding to 30-36F) in cases of very narrow strictures not passable by the adult gastroscope. The target for filiform strictures should be even lower (<9 mm) (GRADE of evidence: very low; strength of recommendation: weak).
(b) What is the recommended number of dilatations or size increments per session?
► Consider using no more than three successively larger diameter increments in a single session for both bougie and balloon dilators. The precise restriction of 3×1 mm diameter increments is not evidence based34 36 (GRADE of evidence: low; strength of recommendation: low).
Although a ‘rule of three’ is recommended by many practice guidelines and authorities,34 no studies have demonstrated improvement in safety or efficacy with this approach. On the other hand, a recent retrospective study showed that non-adherence to the rule of three did not appear to increase the risk of adverse events, particularly perforation, after oesophageal dilatation using bougie dilators, except for malignant strictures.36 For very tight or long strictures, it may be safer to limit the initial dilatation to one or two size increments (2×1 mm) only. Conversely, larger increments may be safely used (4×1 mm or 3×2 mm) in less tight strictures or in those which have completely recurred after the first dilatation session.37 Patients usually need several sessions to achieve resolution of dysphagia and they should be informed of this possibility before the first procedure.
(c) The need for wire guidance or endoscopic control?
► Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients to enhance safety18 38-40 (GRADE of evidence: moderate; strength of recommendation: strong).
► Do not use weighted (Maloney) bougies with blind insertion, because safer dilators are available41 (GRADE of evidence: high; strength of recommendation: strong).
(d) What is the role of fluoroscopy in stricture dilatation?
► Perform dilatation without fluoroscopy for simple strictures as efficacy and safety have been shown in several studies18 38-40 (GRADE of evidence: moderate; strength of recommendation: strong).
► Use fluoroscopic guidance to enhance safety during dilatation of strictures that are either high risk (such as post-radiation and caustic); cannot be passed endoscopically and
are long; angulated; or multiple18 38-40 (GRADE of evidence: moderate; strength of recommendation: strong).
The use of radiographic screening in non-simple strictures gives additional assurance and control of the dilatation process. During wire-guided dilatation, it demonstrates that the wire has passed the stricture, and kinking of the wire has not occurred within or distal to the stricture. Fluoroscopy also shows that the dilator is following the line of the oesophageal lumen. During balloon dilatation, it indicates whether the balloon has slipped during inflation and whether obliteration of the stricture waist has occurred.34
Radiographic screening is particularly helpful when the stricture is tortuous or complex or associated with a large hiatus hernia or a diverticulum. It may also be of value when the guidewire meets resistance during passage through the stricture or when an adequate length of wire cannot be passed distal to the stricture. Although comparative trials are not available, the selective use of radiological screening appears safe and effective and is supported by extensive clinical experience.43 The use of small calibre gastroscopes should also be considered in narrow strictures.
► Perform repeat endoscopy or injection of contrast after dilatation in cases where perforation is suspected, to consider immediate treatment with a fully covered self-expandable metal stent6 (GRADE of evidence: low; strength of recommendation: strong).
► Use carbon dioxide insufflation instead of air during endoscopy whenever possible, in complex strictures to minimise luminal distension and postprocedural pain44 (GRADE of evidence: high; strength of recommendation: strong).
Upper oesophageal sphincter disturbances, including motor disorders and mechanical disorders, can result in symptoms of dysphagia.45 Pathologies associated with disordered neurally mediated opening of the upper oesophageal sphincter, including oculopharyngeal muscular dystrophies, may be amenable to dilatation to relieve symptoms.4 Furthermore, while a cricopharyngeal bar is often an incidental radiological finding in cricopharyngeal fibrosis, treatment of associated dysphagia by both balloon and bougie dilatation methods can be successful.47
► Consider upper oesophageal sphincter dilatation in the treatment of dysphagia with disordered upper oesophageal sphincter opening, post-cricoid web, cricopharyngeal bar with or without the presence of a Zenker’s diverticulum, or to permit passage of radiofrequency ablation (RFA) catheters45-53 (GRADE of evidence: moderate; strength of recommendation: strong).
Aftercare and follow-up
(a) Postprocedure and discharge instructions
► Monitor patients for at least 2 hours in the recovery room and provide clear written instructions with advice on fluids, diet and medications after the procedure10 25 (GRADE of evidence: moderate; strength of recommendation: strong).
► Do not perform imaging and contrast studies routinely after the procedure, unless patients— during recovery—develop persistent chest pain, fever, breathlessness or tachycardia (GRADE of evidence: very low; strength of recommendation: weak).
► Ensure that patients are well and tolerating water on leaving the hospital4 (GRADE of evidence: low; strength of recom¬mendation: strong).
► Suspect perforation when patients develop pain, breathlessness, fever or tachycardia.15 Transient chest pain is not uncommon following dilatation but persistent pain should prompt a CT scan with oral contrast to look for perfora- tion54 (GRADE of evidence: low; strength of recommendation: strong).
A chest X-ray examination may show pneumothorax, pneumomediastinum, air under the diaphragm or a pleural effusion but normal appearances do not exclude perforation. If clinical suspicion is high or if endoscopy examination raises the possibility of a deeper laceration than just mucosal, then ideally a CT scan with oral contrast should be performed. Conventional contrast studies are less sensitive and may miss small perforations.54-56 Moreover, CT can detect other complications, such as pleural effusions, pneumopericardium and pneumoperitoneum.57
► Perform endoscopic re-inspection if the patient becomes symptomatic while in the procedure room, in order to assess for the presence of perforation and to undertake treatment which may include immediate endoscopic stent placement6 (GRADE of evidence: low; strength of recommendation: strong).
Iatrogenic perforation is a medical emergency. The patient should be assessed by an experienced physician and experienced surgeon in order to formulate an appropriate plan, which may include surgical, endoscopic or conservative management.4
► Provide patients with contact information for the on-call team should they experience chest pain, breathlessness or become unwell4 (GRADE of evidence: low; strength of recommendation: strong).
(b)Timing of next follow-up and procedure end points
The timing of subsequent dilatation sessions may depend on the degree of success of initial dilatation and the patient’s response to the procedure. Patients often require multiple sessions, especially if the stricture has a narrow diameter or any complex features.58 In the majority of studies, a repeat procedure was performed after 1 week and a subsequent follow-up at 2-4 weeks.31 59 In some patients, however, symptoms tend to recur rapidly following dilatation, hence they may require more frequent weekly or biweekly dilatations based on symptoms and stricture resolution.34
As a general rule, the last dilator size used in the previous session must be passed first. However, the degree of fibrosis and stricture healing is unpredictable and not all patients are expected to tolerate passage of the largest diameter dilator used during the previous session. Reassessment of stricture diameter is required and a smaller size dilator may be used if deemed appropriate.
Most patients respond well to oesophageal dilatation but outcomes are influenced significantly by the underlying pathology, with better clinical response rates achieved in peptic and post-surgical strictures than in caustic and post-radiation pathology.43
There is no consensus on the definition of end point for dilatation. In one case series of 321 patients, 98% of those in whom a 15 mm (45F) dilator was inserted, achieved clinical response over a mean follow-up period of 18.8 months.43 In one prospective study, all patients underwent dilatation to 15 mm then were randomised to either a subjective (end point is alleviation of dysphagia, n=19) or objective (end point is passage of 12 mm barium pill, n = 15) group. Patients in the objective group had less recurrent dysphagia (P=0.02) and required fewer redilatation sessions (P<0.05) than the subjective group.59 The size of the oesophageal lumen will vary depending on the height
and weight of the patient, and a 15 mm lumen end point is for someone of average size.
► Perform weekly or two-weekly dilatation sessions until easy passage of a >15 mm dilator is achieved along with symptomatic improvement31 43 59 (GRADE of evidence: moderate; strength of recommendation: strong).
A brief checklist is shown in figure 1. This may be used as a guide.
This section discusses features of specific diseases, which may affect the dilatation procedure and patient outcomes.
Pneumatic balloon dilatation (PD) is one of a number of effective treatments for achalasia, which include surgical or endoscopic myotomy. However, the latter are outside the remit of this guideline.60 Bougie dilators are not used for achalasia dilatation.
► Perform dilatation with pneumatic balloons 30-40 mm in diameter starting at 30 mm in the first session to reduce the risk of complications5 19 61 (GRADE of evidence: high; strength of recommendation: strong).
The dilatation technique varies across different studies and there is no consensus in the literature on the optimal method of performing pneumatic dilatation for achalasia. The balloon is usually positioned at the oesophagogastric junction and inflated according to the manufacturers’ instructions for 1-3 min.
► Perform a second dilatation session 2-28 days later with a larger size balloon of 35 mm5 (GRADE of evidence: high; strength of recommendation: strong).
Most authors advocate a third session either routinely or in cases where symptoms remain (Eckardt score >3) with the cautious use of 40 mm balloon if possible. If the Eckardt score remains >3 after the third session, the treatment is usually considered to have failed.5 Patients with a recurrence of symptoms during follow-up may require further dilatation.5
► Consider repeat dilatation (after the initial series) during follow-up to maintain symptom response5 (GRADE of evidence: high; strength of recommendation: strong).
The procedure is effective in 90% of patients in the first year and this reduces to 86% in the second year.5 Up to one-third of patients may have recurrence of symptoms during 4-6 years of follow up.62 63 The vast majority can be successfully treated by repeat dilatation, achieving remission rates of up to 97% and 93% at 5 and 10 years, respectively.62
► Perform dilatation under endoscopic or fluoroscopic control based on clinician’s preference and local expertise64-66 (GRADE of evidence: moderate; strength of recommendation: strong).
Fluoroscopic control is used in the majority of studies reporting safety and efficacy of balloon dilatation in achalasia; however, the safety of endoscopic control alone has been shown in a few studies.64-66 Comparative studies between the latter two approaches are lacking. Routine oesophagograms obtained after PD for achalasia did not reveal any clinically unsuspected perforations and no perforations were missed in cases that were not followed by oesophagograms.67 Impedance planimetry may be a tool that improves decision-making in dilating achalasia.68
► Consider proton pump inhibitor (PPI) therapy after dilatation as the technique has 10-40% rate of symptomatic gastro-oesophageal reflux disease (GORD) or ulcerative oesophagitis after treatment69-72 (GRADE of evidence: high; strength of recommendation: strong).
PD does not preclude a subsequent myotomy. Similarly, PD may be performed for recurrence of dysphagia following 73—79myotomy.
► Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, but it is not essential67 80 (GRADE of evidence: moderate; strength of recommendation: weak).
PD is contraindicated in patients with poor cardiopulmonary function, frailty or other comorbid illnesses preventing surgery, should an oesophageal perforation occur.81 Patients with hiatal hernia or oesophageal diverticulum have undergone PD safely by experienced operators.82
► Peptic strictures requiring dilatation have been reported to occur in about 1-2% of patients with reflux oesophagitis, the proportion remaining relatively constant over the past three decades despite a rising incidence of reflux oesophagitis.83 This has been attributed to the widespread adoption of PPI therapy.84 Between 40% and 60% of peptic strictures require only one dilatation,30 83 85 86 with the need for redilatation being highest in the subsequent 1-2 years.86 A recent snapshot of practice in the USA suggests that more than 80% of patients with peptic strictures require only one dilatation.87 This may be because peptic strictures tend to be short and straight, and with the widespread use of PPIs for GORD this more recent survey of practice may reflect the fact that peptic strictures are becoming less severe. Patients with smaller stricture diameter and longer strictures are less likely to respond to dilatation and vice versa.32 58 85
It is clear that dysphagia in patients with reflux oesophagitis may result from oesophagitis rather than stricture, and symptoms may improve with healing of oesophagitis using PPI therapy without the need for dilatation.88 In addition, oesophagitis as well as stricture diameter contribute to the severity of dysphagia,89-91 and healing of oesophagitis in patients with strictures is associated with a reduced need for redilatation.92 Finally, PPI therapy, but not H2 receptor antagonist treatment, reduces the need for, and frequency of, dilatation of peptic strictures after the initial dilatation.92-95
(e) Offer PPI therapy to patients with GORD and dysphagia, as this treatment has been shown to reduce the need for oesophageal dilatation83 84 89 92 (GRADE of evidence: high; strength of recommendation: strong).
(f) Offer PPI therapy after endoscopic dilatation for peptic strictures in order to reduce recurrence rate89 92-94 (GRADE of evidence: high; strength of recommendation: strong).
(g) Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dila-tation (stricture recurrence), less effective in healing of oesophagitis and in providing symptom relief from GORD and dysphagia89 92-95 (GRADE of evidence: high; strength of recommendation: strong).
► The management of refractory peptic strictures will be discussed in the relevant section.
to be continued…