Ho-Young Ki-Chul

Song, MD Choi, MD

Corrosive Effectiveness

Young-Mm

#{149}

Han,

MD

Hak-Nam

Esophageal ofBalloon

The safety and long-term effectiveness of fluoroscopically guided balloon dilation for corrosive esophageal stricture was evaluated in 22 patients with a follow-up period of more than 1 year (range, 13-52 months). The average interval between corrosive agent ingestion and initial balloon dilation was 18 years (range, 2 months to 51 years). Balloons with a diameter of 5-8 mm were used in the initial attempt. The caliber of the balloon catheter was increased gradually over subsequent dilations, up to a diameter that allowed patients to swallow solid foods. Dilation of more than 17 mm in diameter was performed in five patients. Patients underwent one to five sessions. Esophageal rupture occurred in seven patients and was treated nonoperatively in five and surgically in two. With exclusion of these latter two, 11 of 20 could tolerate swallowing all kinds of food and nine could tolerate

S

Kim,

#{149}

MD

Chong-Soo

Stricture: Dilation’

Safety

London et al (1) reported cessful treatment of esophageal

suc-

INCE

strictures

with

a Gruentzig-type

to be a safe,

treatment

easy,

the esophagus rates have been

and rupture 0%-8.6% in studies cluded more than 48 patients

effective

of strictures

in

rates have been that have in19 and fewer than

(3,4,6,9,10).

Some

authors

believed that esophageal rupture during fluoroscopically guided balloon dilation was virtually eliminated, not only because readily controlled transverse

apy, wire

forces

but

acted

also

because

was used (9). Few

tures

in the

balloon

ther-

a flexible

guide

to traverse the studies, however,

strichave

explored the rupture rate, the recurrence rate, and the long-term effec-

tion

tiveness of balloon dilation in corrosive strictures. With this study, we assess the safety and long-term effectiveness of fluoroscopically guided

hires

balloon

swallowing

most

foods.

Balloon

dila-

in corrosive esophageal stricis effective, but the high rupture rate indicates the need for extra caution.

sive

dilation esophageal

of corro-

1992;

interventional procestenosis or obstrucprocedures, com-

AND

184:373-378

I From the Department of Radiology, Chonbuk National University Medical School, San 2-20, Keumam Dong, Chonju City 560-182, Republic of Korea. From the 1991 RSNA scientific assembly. Received November 12, 1991; revision requested December 26; revision received March 2, 1992; accepted March 5. Address reprint requests to H.Y.S. C RSNA, 1992

Over formed dilation

loon dilation

stricture

and

METHODS

in 75 patients

with noncorrosive esophageal stricture (six patients with achalasia, 15 with postoperative anastomotic stricture, 52 with gastroesophageal neoplasia, and two with reflux esophagitis). One of the 28 patients with corrosive esophageal stricture was excluded from data analysis because of being lost to follow-up evaluation. Twelve months was considered the appropriate follow-up period for assessment of longterm effectiveness and recurrence rate, which resulted in five more patients being excluded from data analysis. A total of 51 sessions

of balloon

dilation

were

formed

in the remaining

a range

of one to five sessions

(mean,

2.4

male

patients

sessions).

and

per-

22 patients, There

14 female

with

per patient

were

eight

patients,

years was

(mean,

41

established

was 18 years

and

(range,

2

All except five patients (patients 2, 3, 4, 10, and 13) (Table had a history of endoscopic removal of impacted food, from one time in 2 years four times in a year. months

to 51 years).

To

assess

intake

clinical

improvement,

was categorized

ways:

aphagia,

liquids,

soft

foods,

most

foods

(all foods

except

for certain

foods

such

as steak),

and

patients

presented

aphagia

due

to acute

the remaining solid

foods

to food

with

acute

cally

guided

formed

Eleven

due

of

impaction, stricture

it-

In 11 patients

impaction,

fluoroscopi-

balloon

moved with catheters.

to the

and

with

impaction.

food

after

of 22

complaints

food

dilations

were

per-

the impacted

food

a stone

or balloon

basket

were

Esophagograms termine the length

and

was re-

reviewed exact

to de-

location

segment, the lesions three types to assess recurrence

rates

of dilatation:

that were less than 2 cm were short strictures (Fig 1), those

tween

2 cm

be moderate more than

and

5 cm

strictures 5 cm were

were

considered

(Fig

Topical an aerosol

anesthesia of the spray (Lidocaine;

Korea) balloon say

“no

conbeto

(Fig 2), and those considered long

strictures

3).

and intramuscular

diazepam

of

were the

Those sidered

Korea)

of

On the basis of the length

and

to

in five

11 had dysphagia

or soft

self, not

all foods.

with

1)

food

capacity

the narrowed classified into

a 5-year period, we have perfluoroscopically guided balloon in 28 patients with corrosive

esophageal

5-64

review of history and esophagofindings. The corrosive agent was acetic acid in eight patients and sodium hydroxide in 14 patients. The average interval between corrosive agent ingestion and the initial fluoroscopically guided bat-

rupture

Esophagus, . Esophagus, tion, 71.744 #{149} Interventional plications, 71.458

was diagnosis

the lesions.

strictures.

MATERIALS Index terms: dure, 71.1299

Radiology

in treatment

range The

graphic

(2-14). Overall success reported to be 67%-

97.5%,

the age through

bal-

and

for a variety

MD

and

years).

loon catheter in 1981, fluoroscopically guided balloon dilation has been shown

Kim,

#{149}

pharynx with Jeil, Taegu,

sedation

(Valuzepam;

Whan

with

In, Ansung,

were performed routinely. Before dilation, we asked the patient to more”

or

to lift

his

or her

left

hand

when the pain made them unable to tolerate the procedure. Initially, a technique similar to that described by McLean et al (3) was

used

to insert

the

balloon

catheter

through the stricture area, but we stopped using a nasogastric tube and a Lunderquist torque-controlled guide wire. Instead, we used a 0.035-inch angled exchange guide wire (Radiofocus wire;

373

Table

1 on 22 Patients

Data

with

Corrosive

Esophageal

Stricture

Length Patient

Esophageal

No./

Corrosive

Age (y)/Sex

Agent

1/45/F

SH

S

2/31/F

AA AA AA

M L S

SH

S

40y

6

AA

S

2lmo

SH SH SH

S S S

Sly 32y 30y

AA

2mo 35y 35y

3 7 7 7 3 7 7

28mo 38y

3/42/M 4/45/M

5/61/F 6/31/F 7/84/F 8/56/F 9/64/F 10/21/F

tntervat*

SH

15/56/F

AA SH SH

S S L

16/21/F

AA

S

17/10/M

AA

S

7y

18/411M

SH

S

19/40/M

SH SH SH SH

S L S S

36y 17y

22/58/M

Note.-SH Intervat

t Patient

=

sodium

hydroxide,

between corrosive agent esophageal rupture.

AA

18 11 10 17

Aphagia Liquid

All Most

Liquid Liquid

Op All

Aphagia

Most

2t

39

17 11 9

Liquid Aphagia Aphagia

All Most Most

4

9

Aphagia

Most

1 1

16 17 12 6 11 14 17 7 14 14 13 14 13.5

Liquid Aphagia Aphagia Soft

All

4

42 27 26 24 24

All

1

17

Most All

3t

22

Soft

Most

2 3t

Liquid Liquid Soft Aphagia Aphagia Aphagia Soft Aphagia

Most All Most

3 5 1

14 13 15 13

All

1

All Op All All

1 2t

26 17 52 48

1

32 33

9.5

3 4 3 3

2.5 8 7 6 5 9

acetic acid, S = short, M = moderate, and the initial balloon dilation.

L

ingestion

b.

of 5-mm

=

tong,

Op

=

operation

after

16.

(a) Esophagogram

before

dilation

shows

Tokyo)

with

tapered

angiographic

or without

a catheter

was

not previously

deter-

mined; the esophagus was dilated until the patients could manage solid foods with little difficulty. 374

Radiology

#{149}

1 3 2t

5

2t

rupture,

NA

=

Recurrence

43

Yes

42 31 24

NA Yes

Yes No No No

No Yes

Yes No No No No Yes Yes Yes No No

NA Yes No

not applicable.

d.

short

stricture of the

diameter

(Cook, Bloomington, Ind), which seemed to be enough for insertion of the balloon catheter. The luminal diameter of the esophagus

Sessions

C.

obtained

in the cervical esophagus. balloon at the level of the

and 3-cm length. Notice the “hourglass” deformity the hourglass deformity is evident after five separate sessions of dilation. (d) Esophagogram a widely patent esophageal lumen.

Terumo, straight,

Period (mo)

6 4 4 2.5

21y 39y 12y =

Follow-up

with

1. Patient

catheter

No. of Dilation

After

36y l7y

a. Figure

Intake

Before

9mo

13/5/M

21/45/F

Food

After

2mo 2mo

12/41/F

20/44/M

(mm)

Before

30y

S S M

14/40/F

*

Stricture

SH

11/56/F

Diameter

of

A 5-8-mm-diameter long)

was

inflated

slowly

balloon

(4-8

by

injecting

obtained

cm

with di-

luted water-soluble contrast medium (Conray 43; Matlinckrodt, St Louis) into until the hourglass deformity created by the stricture

disappeared

from

after

cedure it,

the balloon

contour and as tong as the procedure was well tolerated. The inflations were usually repeated two or three times. If dilation

final balloon

5-8 mm

plished catheter

same 12 mm

(b) Dilation with a balloon stricture. (c) Disappearance

and

dilation

balloons the

was

patient

well, the caliber was

increased

easily

tolerated

accomthe

pro-

of the balloon gradually

on

day up to 20 mm in adults in children.

of

demonstrates

Balloons

the

and up to

used

were

made by Medi-Tech/Boston Scientific (Watertown, Mass), Balt (Montmorency, France),

and

Cook

(Queensland,

Australia).

August

1992

a.

b.

Figure 2. Patient 12. (a) Esophagogram third session of dilation, with a balloon (c) Esophagogram with a small amount

there

is little

shows

difference

cessation

d.

C.

obtained catheter of barium

in the esophagus

before

before dilation shows of 15-mm diameter and demonstrates leakage

and after

dilation.

moderate stricture 8-cm length. Notice (arrow) of barium

(d) Follow-up

b.

tion

dilation was

or if the

lifted

Volume

obtained

14 days

after

esophageal

rupture

was

discontinued

unusually patient

resistant said

his or her

hand.

184

Number

#{149}

“no

After

2

if the to dila-

more”

completion

or

of

d.

C.

Figure 3. Patient 15. (a) Esophagogram obtained before dilation shows long with a balloon of 10-mm diameter and 8-cm length. Notice the short segment shorter balloon catheter (12-mm diameter and 4-cm length). (d) Esophagogram

Further

esophagogram

of leakage.

a.

stricture

in lower thoracic portion of the esophagus. (b) The the persistent hourglass deformity of the balloon. 3 cm below the most narrowed point. Notice that

the procedure, a (about 3 mL) was tient, to check for media. We prefer

stricture (arrow) after

small amount swallowed by extravasation to use barium

in lower thoracic that was resistant dilation demonstrates

of barium the paof contrast rather

portion of the esophagus. (b) Dilation to dilation. (c) Further dilation with reduction of stricture.

than iodinated allows better rations,

costs

is better

less

contrast visualization tolerated

(15). In case

a

media, because it of small perfoby

patients,

extravasation

Radiology

and

was

375

#{149}

Table

2 on Seven

Data

Patients

with

Esophageal

Rupture

Leukocytosis Patient

Rupture

No.

Site

Diameter

(d)

Treatment

1 cm

12/4

13,200-22,300

4

37.3-39.2

2

35

10/8 15/4 15/8

11,300-18,900 13,600-24,600 11,700-19,900

1

None

NA

6

2

None

NA

11

Conservative

37.2-37.8

1

14

Conservative

14

Inferior

2 cm

15/4

13,200-15,600

2 1

20

Inferior

1 cm

15/4

12,300-23,500

21

Inferior

2 cm

20/8

12,600-19,709

37.3-38.2 37.5-39.5 None

1 3 NA

10 16 7

Conservative Surgical Conservative

=

and

not applicable, WBC length of the balloon

a barium

white blood cells. used for dilation before

=

esophagogram

lowed a soft diet 2 hours dure and were encouraged

graphically

food,

however,

the

dilation

cedure was repeated at sessions apart. The amount of distention increased

until

pro-

diameter

for patients to tolerate solid foods was reached. The procedure was routinely performed on an outpatient basis, with use of prophylactic antibiotics hours. Outpatients

(ampicillin) for 24 who had no esopha-

geal rupture were discharged vation for I hour. Prophylactic discontinued

the other

hand,

patients

patients.

with

On

esophageal

rupture were admitted to the hospital. tients who showed gradual deterioration

Pa-

of clinical underwent

status after esophageal rupture surgery, while patients who

remained

stable

treated

fasting,

after

esophageal

nonoperatively

administration

parenterat cephalosporins

Korea)

of

of antibiotics,

alimentation.

and

A combination

(Ceforin;

and amikacin

Sam

Sung,

(Amikin;

of Seoul,

Bo Ryung,

Ansan, Korea) was used. Patients were discharged when follow-up esophagogra-

phy (performed every healing of the leakage,

5-7

days)

and when

showed

clinical

symptoms improved as well. After discharge, patients were reviewed regularly with 6-month follow-up esophagography

and were months,

contacted to obtain

to recurrence

by telephone information

of dysphagia,

every related

food intake

capacity, and chewing habits. We defined recurrence as reappearance of the patient’s symptoms of aphagia or dysphagia

with most foods (2). In each case, the diameter ture before and after balloon measured

on plain

radiographs

of the stricdilation was obtained

when the hourglass deformity appeared on the balloon contour during inflation and at the point of final inflation. The magwas

factor determined

376

#{149}

nffication

Radiology

of the plain radiograph by comparing the radio-

of the

diameter.

A total of 51 sessions of balloon dilation were performed in the 22 patients, with a range of one to five sessions per patient (mean, 2.4 sessions). In eight of these patients, the dilation procedure was performed in one session. In the remaining 14 patients, two to five different sessions, 3-15 days apart, were necessary to create a suitable diameter for the passage of solid food. Only five patients had the dilated to 17 mm or more 1). All patients, including the

sis to some

stricture hydroxide

extent

the esophagus or more with had residual (Fig

was secondary ingestion

was use of steno-

1).

to sodium in six and was

secondary to acetic acid ingestion in one. Rupture occurred in four of 17 patients (24%) with short stricture, in one of two (50%) with moderate stricture, and in two of three (67%) with long stricture. Four esophageal niplures occurred in the second session, and three occurred in the third session. From esophagograms or surgical findings, rupture did not occur at the most narrow point but at the relalively

less

most

narrow

proximately

Conservative

narrow

point. 1 cm

an 8-cm balloon, as we did in patient 15 (Fig 3). Esophageal ruptures in five patients by means

Rupture of the esophagus occurred in seven of 22 patients (32%). The

rupture

by means

with

(Table patients in whom dilated to 17 mm a 20-mm balloon,

after obserantibiotics

in those

diameter

its actual

determined

esophagus

Surgical

occurred.

RESULTS

3-15 days was grad-

a suitable

4 2

catheter

after the proceto resume in-

of solid foods on the next day. If a patient had no difficulty with solid foods, further dilation was not performed. For patients who could not tolerate swallowsolid

rupture

balloon

of at-

take

2-3

Hospitalization

(d)

4 cm 1 cm 3 cm

obtained with a regular amount barium (150-200 mL). Patients were

were

Duration

(#{176}C)

Inferior Inferior Inferior

was

were

Range

(d)

Inferior

Diameter

ualty

Duration

5 7 12

not identified,

ing

Range

(cm)*

3

Note-NA *

Balloon

(mm)/Length

Fever

area

around

the

It occurred below

the

apmost

row point in three patients, at 2 cm below in two patients, at 3 cm below in one patient (Fig 2), and at 4 cm below in one patient. In the seven in whom rupture occurred, the length of balloon catheter used for dilation was 4 cm in four and 8 cm in three. The rupture in two of the latter patients might have been prevented by use of a short balloon (3 or 4 cm) instead of

nonoperatively antibiotic admin-

istration, and parenteral alimentation for 7-15 days, and treatment was surgical in two patients (Table 2). No treatment-related deaths occurred in this

series.

Of 20 patients (excluding the two who were treated surgically after esophageal rupture), 11 could tolerate all foods, and the remaining nine could tolerate most foods after balloon dilation. Nine of the 20 patients (45%)

underwent

barium

esophagog-

raphy and repeat balloon dilation after symptoms recurred during the follow-up period of 13-52 months (mean, 28 months) after the final dilation. In six of these nine patients, recurrent symptoms of aphagia due to acute food impaction developed at 3-20 months (mean, 10.5 months) after the final dilation. Repeat balloon dilation

was

of the

impacted

symptoms

performed

foods.

of dysphagia

after

removal

Recurrent to solid

foods

due to recurrent stricture without food impaction developed in the remaining three patients (patients 4, 10, and 16) five to eight times within 8 months

after

the

though

their

strictures

final

dilation.

Al-

were

dilated

successfully over 17 mm by using 20-mm balloons at each recurrence,

we found that the esophageal lures in these patients narrowed less

nar-

were treated of fasting,

than

5 mm

at every

stricto

incident.

In-

terestingly, after the repeated recurrences, these patients have been completely free of symptoms for 17 months (patient 4), 16 months (patient 10), and 7 months (patient 16). Dilation of the strictures was easier at recurrence than during the initial procedure. Surprisingly,

when

fully

inflated,

the balloons have outer diameters that are different from the labeled August

di1992

tolerating ing (17).

The ageal Some prompt

discomfort

method

when

of treatment

treatment bidity and

ported

good

vative

For

example,

the actual

in our

diameter

lion

measure-

of the Medi-

tech/Boston Scientific balloons of 20-mm outer diameter and 4, 6, and 8 cm in length is about 17 mm. The Microvasive (Medi-tech/Boston Scientific) balloon (20-mm diameter, 8-cm length) is about 18 mm in diameter, the Bait balloon (18-mm diameter, 4-cm length) is about 13 mm in

diameter,

and

eter,

length)

4-cm

Even

though

is dilated

the

the

Cook

(20-mm

is about

an esophageal

fully

actual

with

dilated

esophagus

mm.

stricture

a 20-mm

diameter

cannot

diam-

18.3

balloon,

of the

reach

20 mm.

It is

therefore useful to know that use of the maximal diameter of the balloon for calculating the magnification factor is not accurate.

Accidental ingestion chemicals is encountered est frequency in children

of caustic with greatand alco-

holic

acetic

persons.

Because

acid

commonly is used domestically as a food seasoning in the Far East, the occurrence of accidental ingestion of

acetic the

acid other

who

is more parts

are not

ingest

cide.

to the

of the

alcoholic

corrosive

20%

esophageal

strictures

in

Adults

most

commonly

to commit

and

experience corrosive

than

world.

agents

Between

tients who penetrating

frequent

40% substantial chemical

wall

will

sui-

of painjury

develop

(16).

In our experience with patients with noncorrosive (n = 75) and corrosive (n = 28) esophageal stricture, pain during balloon dilation was more severe in those patients with corrosive

stricture

noncorrosive to 17 mm

was

(95%) patients stricture. Four

than

in those

stricture. achieved

with

Dilation of up in 71 of 75

with noncorrosive patients with postirra-

diative stricture of esophageal cancer were resistant to esophageal dilation up to 17 mm. On the other hand, dilaVolume

184

Number

#{149}

2

was

possible

in

(21%) with corimplies that

dilation of corrosive esophageal ture is much more difficult than tion of noncorrosive esophageal ture. McLean et al (3) reported that esophageal lumen diameter virtually Most of the authors

stricdilastrican

less than 12 mm assures dysphagia. who have re-

in

esophageal

luminal believe

stricture

by

targeting

a

diameter of 30-40 mm. We that dilation of the esophagus than 20 mm, for corrosive are as follows:

however, is too stricture. The reaFirst, to dilate cor-

rosive esophageal stricture up to 20 mm is difficult and might cause niplure in over half of all the patients. In our opinion, the rupture rate in corrosive stricture is high because of the dense

scarring

due

to long

duration

of symptoms, esophageal

tendency of severe damage, and diffuse

esophageal seen in our tients whose

involvement. results (Table final diameter

lated

esophagus

was

less

than

15 mm

could foods. solid

tolerate swallowing most or all The degree of dysphagia to food appears to vary by patient

with

medical

(4,22-25). rupture

Treatment should

there

is minimal

when

series,

servative

the

of be conser-

(a) self-

but the

four

criteria for confulfilled for esophageal rupture,

treatment

all patients

were

with

we could not rupture would

contamination,

determine whether lead to pleural

systemic

sepsis,

respi-

ratory failure, and shock. Two of seven patients with esophageal rupture underwent surgery within 24 hours after esophageal rupture, because their clinical status (fever, leukocytosis) gradually deteriorated. The

other

five

patients,

who

remained

stable

for

24 hours

after

esophageal

rupture,

were

by means antibiotics,

treated

nonoperatively

of fasting, administration and parenteral alimenta-

of

tion. No procedure-related deaths occurred. We believe that deterioration of clinical status would be an absolute

Second, as 3), 14 paof the di-

results

high morhave re-

contained extravasation and adequate natural internal drainage into the esophagus, (b) no evidence of pleural contamination, (c) minimal symptoms, and (d) minimal evidence of clinical sepsis (24-26). Michel et al (25) proposed that the criteria for immediate operative treatment should indude presence of (a) pneumothorax, (b) mediastinal emphysema with pleural effusion, (c) systemic sepsis, (d) respiratory failure, and (e) shock.

In our

ported on esophageal balloon dilation usually have targeted a luminal diameter of 20 mm for adult patients of esophageal strictures (2-5,10). Moreover, Starck et al (9) successfully treated 31 patients with benign

more much sons

DISCUSSION

of up to 17 mm

only six of 28 patients rosive stricture, which

because they or nonoperative

was attended by mortality. Others

treatment esophageal

ment,

for esoph-

rupture remains controversial. authors have emphasized surgical treatment of esopha-

geal rupture (18-21), thought conservative

ameters.

swallow-

indication

for surgical

In six of nine dilated esophagus

treatment.

patients with final diameter of more

than 15 mm, the recurrence rate was 67%, which was higher than that (36%; five of 14) in patients whose final esophagus diameter was less

than

15 mm

(Table

3). In our

opinion,

and dietary regimen. For instance, when patients with the same degree of stricture were given the same foods, the patients who had a habit of chewing the food steadily did not complain of dysphagia, but the patient without this habit did. We agree with the opinion that the optimal diameter for esophageal stricture de-

patients with a larger esophagus became less careful with regard to food than did the latter group. That is, patients of the former group usually chose and ate all foods without spe-

pends

balloon dilation in corrosive esophageal stricture is effective, but requires extra caution because of the high as-

on

the

actual

nature

of the

ob-

struction and its degree of elasticity and length; the power of the muscle pushing through the bolus of food; and the threshold of the patient for

cial consideration, while those of the latter group chewed foods steadily and made conclusion,

more careful fluoroscopically

sociated

ture.

rate

of esophageal

choices.

In guided

nip-

U

Radiology

#{149} 377

9.

References 1.

London

at.

Dilatation

hires 2.

RL, Trotman

BW, Di Marino

of severe

by an inflatable

esophageal

balloon

catheter.

troenterology 1981; 80:173-175. McLean GK, Cooper GS, Hartz

DR, Meranze

SG.

balloon dilation

WH,

Radiologically

of

Gas-

stric-

Part II. Results of long-term followup. Radiology 1987; 165:41-43. McLean GK, Cooper GS, Hartz WH, Burke DR. Meranze SC. Radiologically guided tures.

3.

balloon

tures.

dilation

of gastrointestinal stricand factors influsuccess. Radiology 1987;

procedural

165:35-40.

5.

6.

de Lange EE, Shaffer HA. Anastomotic strictures of the upper gastrointestinal tract: results ofballoon dilation. Radiology 1988; 167:45-50. de Lange EE, Shaffer HA, Daniel TM, Kron IL. Esophageal anastomotic teaks: prelimmary results of treatment with balloon ditation. Radiology 1987; 165:45-47.

Maynar

M, Guerra

Esophageal 7.

strictures:

in children:

loon catheter 153:655-658.

Radiology

#{149}

11.

12.

cathe-

strictures:

a

Gastrointest

treatment

dilatation.

13.

by serial

Radiology

stricbat1984;

dilatation.

Radiology

Hegedus V, Poutsen PE. Balloon dilatation of alimentary tract strictures. Acta Radiot Diagn 1986; 27:681-686. Hegedus

V. Raaschou

Johnson

HO.

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