0016-5107/92/3805-0586$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy
Endoscopic balloon dilation of esophageal strictures following surgical anastomoses, endoscopic variceal sclerotherapy, and corrosive ingestion Pang-Chi Chen, MD Taipei, Taiwan, Republic of China
Between 1987 and 1991, endoscopic balloon dilation was performed for esophageal strictures which developed after operation in 28 cases, after sclerotherapy in 9 cases, and after corrosive injury in 8 cases, for a total of 45 cases. The locations of stricture were upper third in 20 cases, mid-third in 2 cases, and lower third in 23 cases. The stricture appeared clinically 1 to 3 months after esophageal injury. Endoscopic follow-up interval was 1 week. A total of 136 dilations were done in these 45 patients with an average of 2.6 times/case (range, 1 to 8). The result of dilation was good in 9 cases, improved in 18 cases, slightly improved in 15 cases, with only 3 cases having no response. The follow-up period was 2 years on average (range, 0.5 to 4 years). The data suggest that endoscopic balloon dilation is a safe, effective, and easy method for the management of esophageal stricture caused by surgical anastomosis, sclerotherapy, and corrosive injury. (Gastrointest Endosc 1992;38:586-589)
The therapeutic modalities for esophageal strictures include dilation with bougienage or balloons, endoprosthesis intubation, laser therapy, microwave, electrocoagulation therapy, and surgery.I-3 During the 1970s, polyvinyl tapered dilators and hydrostatic balloons were introduced after the usage of mercuryweighted bougies and metal dilators. 1 The balloon dilator may be used through-the-scope (TTS) or endoscope guided and may be inflated with water or air for dilation. The balloon-type dilator exerts only radial force against the stricture site, in contrast to the conventional push-type dilator which exerts both axial (mainly) and radial force as the stricture is dilated. Theoretically, balloon dilation is less likely to be complicated by traumatic rupture or perforation due to longitudinal stretching. I-15 In most reported series, esophageal strictures secondary to chronic reflux esophagitis accounted for 75% or more of the benign stenoses requiring dilation therapy. 1,6, 7, 12, 16 In contrast, benign peptic stricture
is rare in Taiwan where pyloric obstruction due to chronic duodenal ulcer is the main cause of reflux esophagitis. 17 Pyloric obstruction rarely causes esophageal stricture before therapeutic action is taken for the gastric outlet obstruction. Because of the recent popularity of endoscopic variceal sclerotherapy and end-to-end anastomotic (EEA) stapling in esophageal surgery, post-sclerotherapy and post-anastomotic strictures have become the main types of esophageal stenoses requiring dilation therapy. Laser therapy with Nd:YAG photocoagulation was previously used for treating esophageal strictures due to EEA stapling in our hospital, but this treatment resulted in a good response only in limited cases. 18,19 TTS balloon dilation was therefore tried in our patients with benign esophageal strictures due to surgical anastomosis and sclerotherapy as well as those due to corrosive injury. The efficacy of TTS balloon dilation, follow-up results, and side effects were evaluated and described in this communication.
Received July 16, 1991, For revision October 21, 1991. Accepted April 13,1992. From the Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taipei, Taiwan, Republic of China. Reprint requests: Pang-Chi Chen, MD, Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, Taiwan, Republic of China.
The patients enrolled for this therapeutic regimen were those with an overt clinical dysphagia history and evidence of esophageal stricture or stenosis diagnosed by esophagoscopy (Fig. lA) and/or barium meal esophagography (Fig. 2). The patients were classified according to the past history of
586
MATERIALS AND METHODS
GASTROINTESTINAL ENDOSCOPY
Figure 2. Esophagogram; tiny lumen over stricture site (A), widened lumen after balloon dilation during follow-up (B).
and pre-medication were those for routine panendoscopy. Meperidine (1 mg/kg intramuscular injection) was given. Under direct vision, a deflated 15-mm TTS balloon (Rigiflex; Microvasive, Watertown, Mass.) was passed through the 2.8-mm biopsy channel of an Olympus GIF-XQ20 fiberscope and positioned within the stricture. The balloon was inflated with water and the pressure was monitored with a gauge to achieve maximum recommended pressure without rupturing the low compliance balloons (Fig. IB). The pressure of inflation was maintained for 30 to 60 sec, reinflation after deflation for another minute was performed until the desired dilation effect was obtained (Fig. Ie) or the patient lost tolerance. Bed rest for 4 hours and fasting for 6 hours were advised, then a milk diet for 1 day after dilation, and diet as tolerable was resumed on the next day if there were no contraindications. Follow-up endoscopy was performed 1 week later to evaluate the efficacy of dilation and repeat dilation was performed if needed. If dysphagia recurred, then endoscopic follow-up could be done at any time. The results were graded according to Cox et al. 7 , and were defined as "good" if patients had no recurrent dysphagia (score 0), "improved" if dysphagia occurred only with meat, bread, rice (score 1 to 2), "slightly improved" if dysphagia occurred with semi-solids or liquids (score 3 to 4), and "none" if total dysphagia persisted (score 5).
RESULTS
Figure 1. A, Esophageal stricture, lower third, anastomotic, post-EEA stapling. B, Balloon inflated with water. Full expansion in site of stricture. C, After balloon dilation, widened lumen with laceration and bleeding.
operative anastomosis with or without an EEA stapling procedure, endoscopic esophageal sclerotherapy, or corrosive ingestion with strong acid or alkali. The Olympus GIF-P20 endoscope (Tokyo, Japan; with a diameter of 9 mm) always failed to pass through the stricture site. After informed consent was obtained, patients were kept fasting for at least 4 hours before the procedure. Preparation VOLUME 38, NO.5, 1992
During a 4-year period, 45 consecutive patients were enrolled for treatment of esophageal stenosis with endoscopic balloon dilation. The patient population consisted of 29 men and 16 women, with an age range of 27 to 72 years old (mean age, 50 years old). Twentyeight patients had post-operative anastomotic stricture, nine had post-sclerotherapy stricture, and eight had corrosive ingestion stricture. The clinical features, including the location and length of strictures with different etiologies, are shown in Table 1. Of the patients with operative anastomotic stricture, the indication for operation was esophageal cancer in eight, esophageal varices in eight, gastric cancer in six, gastric leiomyosarcoma in two, esophageal perforation in 587
two, and peptic esophagitis complicating gastric cancer surgery in two. In the corrosive injury group, six patients suffered from strong acid (Hel)-induced strictures. The duration from esophageal injury (surgery, sclerotherapy, corrosion) to the appearance of clinical dysphagia was mostly within 2 months (36 of 45, 80%). A total of 136 dilations were performed in these 45 patients. An average of 2.6 dilations (range, 1 to 8) were required in post-operative anastomotic strictures, 2.5 dilations (range, 2 to 3) in post-sclerotherapy strictures, and 2 dilations in corrosive strictures to relieve symptoms of dysphagia. During a mean follow-up period of 2 years (range, 0.5 to 4 years), 93.3% of patients remained improved (42 of 45). Although only 60% (27 of 45) showed good results, only 3 cases failed in this series. The results of the three groups were quite similar (Table 2). No serious complications such as massive bleeding or perforation were noted. Two patients died during follow-up. One was a 51year-old man with gastric leiomyosarcoma who died 9 months after dilation due to liver metastasis and sepsis. The other was a 55-year-old man with esophTable 1. Clinical features of the patients with esophageal strictures
Total patients Age (mean (range) yr) No. of males Age No. of females Age Stricture Location Upper third Mid-third Lower third Length (em) Duration (months)
Surgical Sclerotherapy anastomosis induced
Corrosive ingestion
28
8
18 52 (28-72) 10 48 (32-63)
9 6 48 (42-52) 3 54 (45-57)
17 0 11 0.5 (0.3-1) 2 (1-3)
5 46 (27-54) 3 49 (30-66)
0 0 9 1.5 (0.5-2) 1.5 (1-2)
3 2 3 2 (1-2.5) 1.5 (1-3)
Table 2. Results of balloon dilation in patients with esophageal strictures Surgical Sclerotherapy Corrosive anastomosis induced ingestion Total patients Dilations (sessions) Follow-up (months) Results Good
28 2.6 (1-8) 10-42
9 2.5 (2-3) 12-40
4 (14%)
5 (55.6%)
Ia
la Improved Slightly improved None Complications, serious a
b
14 (50%) 9 (32%) 1 (4%) Ob
0 4 (44.4%) 0 0
X , p > 0.975. Two died of other causes during follow-up.
588
2
8 2 (2) 6-48 0 0
1 4 (50%) 2 (25%) 2 (25%) 0
ageal cancer who died 6 months after dilation due to a cerebral vascular accident, coma, and respiratory failure. No antibiotic prophylaxis was used because no patients had heart valve prosthesis, prior endocarditis, or rheumatic fever and valvular heart disease in this group. DISCUSSION
In 1981 London et a1. 9 described the first use of a modern balloon dilator. Balloons have since gained in popularity, possibly because of the theoretical appeal of applying a localized dilating pressure in a controlled fashion, exerting only radial force on the stricture. 7 In particular, the TTS balloon offers direct vision of manipulation,13 so it is simpler for the beginner to use, although some do not recommended balloon dilation for routine use in treating benign esophageal stricture. 7,8 It can be used with complex strictures that have severe stenoses, long segmental lesions, tight lumens, angular narrowing, irregular stricture,12, 13 and especially in upper inlet stenoses; it is also useful in firm fibrotic strictures such as post-operative strictures. 5 Because it has been associated with fewer complications and morbidity, it can be performed on an out-patient basisY The procedure can be easily repeated if needed. The main disadvantages are that it requires a large channel endoscope, and the balloons currently used are relatively fragile and expensive. The results of this study have confirmed that balloon dilation is a safe, easy, convenient, effective technique for treating esophageal strictures. 1. 14 We used Nd:YAG laser therapy for treating post-operative strictures at the anastomosis performed with EEA stapling with limited effects in some cases. 19 The present study suggests that balloon dilation appears to be better than laser therapy and is safer. Some authors have pointed out that post-operative strictures are easily dilated but rapidly re-stenose 1,4, 13 and that the risk of requiring a subsequent dilation was greatest in the first year of follow-up.6 However, only a few of our cases needed repeat dilations during a 2year period of follow-up. It has been shown that the result of balloon dilation is good if the stricture site is not too long, and if the procedure is performed early enough. 20 Our results in post-sclerotherapy strictures, as well as in corrosiveinduced stricture, have confirmed this observation (Tables 1 and 2). Endoscopic sclerotherapy for esophageal varices is being used frequently and about 1 to 7% of patients develop post-ulcer scarring. 1 Balloon dilation should provide a good therapeutic modality for these patients. In our experience endoscopic TTS balloon dilation is a safe, effective, and easy therapy for the management of esophageal, anastomotic, post-sclerotherapy, and corrosive-induced strictures. GASTROINTESTINAL ENDOSCOPY
ACKNOWLEDGMENT
The author is grateful for the assistance of YunFan Liaw, MD.
11.
REFERENCES
12.
1. Lieberman DA, Keeffe EB. Dilation of benign esophageal strictures. In: Barkin JS, O'Phelan CA, eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990. 2. Cotton PB, Williams CB (ed.). Practical gastrointestinal endoscopy. 3rd ed. London: Blackwell Scientific Publications, 1990. 3. Takemoto T, Nagasako K, ed. Applied gastroenterological endoscopy. Tokyo: Bunkodou, 1990. 4. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-9. 5. Lindor KD, Ott BJ, Hughes RW. Balloon dilation of upper digestive tract strictures. Gastroenterology 1985;89:545-8. 6. Patterson DJ, Graham DY, Smith JL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983;85:346-50. 7. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilatation of benign esophageal stricture? An interim report of a randomised controlled trial. Gut 1988;29:1741-7. 8. Kozarek RA. To stretch or to shear: a perspective on balloon dilators. Gastrointest Endosc 1987;33:459-61. 9. London RL, Trotman BW, Dimarino AJ, et al. Dilation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 10. Gallinger VI, Chernousov AF, Andrew AL, Vantsian EN. Endoscopic balloon hydrodilatation and endoprosthetic treatment
VOLUME 38, NO.5, 1992
13.
14. 15. 16. 17.
18. 19. 20.
of esophageal and esophageal anastomotic stricture. Endoscopy 1989;21:11-4. Lindor KD. Balloon dilation of upper digestive tract strictures. In: Bennett JR, Hunt RH, eds. Therapeutic endoscopy and radiology of the gut. 2nd ed. London: Chapman and Hall Medical, 1990. Taub S, Rodan BA, Bean WJ, Koerner RS, Mullin DM, Feng TS. Balloon dilatation of esophageal strictures. Am J Gastroenterol 1986;81:14-8. Graham DY, Tabibian N, Schwartz JT, Smith JL. Evaluation of the effectiveness of through-the-scope balloon as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 1987;33:432-5. Whitworth PW, Richardson RL, Larson GM. Balloon dilation of anastomotic stricture. Arch Surg 1988;123:759-62. DeLange EE, Shaffer HA Jr. Anastomotic strictures of the upper gastrointestinal tract. Radiology 1988;167:45-50. Sullivan SN, Coeke M, Watson WC. Self dilation of esophageal strictures. Can J Gastroenterol 1991;5:49-50. Wang CS, Tzen KY, Huang MJ, Chen PC, Chen MF. Change of gastric liquid emptying after highly selective vagotomy and pyloric dilation for patients with obstructing duodenal ulcer. World J Surg 1991;15:286-92. Chen PC, Wu CS, Liaw YF. YAG laser endoscopic treatment of an esophageal and sigmoid stricture after end-to-end anastomosis stapling. Gastrointest Endosc 1984;30:258-60. Fang JF, Hwang TL, Chen PC, et at. The treatment of esophagojejunal anastomotic stricture after total gastrectomy. Chang Gung Med J 1989;12:148-55. Haynes WC, Sanowski RA, Foutch DG, Bellapravalu S. Esophageal strictures following endoscopic variceal sclerotherapy: clinical course and response to dilatation therapy. Gastrointest Endosc 1986;32:202-5.
589
Endoscopic balloon dilation of esophageal strictures following surgical anastomoses, endoscopic variceal sclerotherapy, and corrosive ingestion Pang-Chi Chen, MD Taipei, Taiwan, Republic of China
Between 1987 and 1991, endoscopic balloon dilation was performed for esophageal strictures which developed after operation in 28 cases, after sclerotherapy in 9 cases, and after corrosive injury in 8 cases, for a total of 45 cases. The locations of stricture were upper third in 20 cases, mid-third in 2 cases, and lower third in 23 cases. The stricture appeared clinically 1 to 3 months after esophageal injury. Endoscopic follow-up interval was 1 week. A total of 136 dilations were done in these 45 patients with an average of 2.6 times/case (range, 1 to 8). The result of dilation was good in 9 cases, improved in 18 cases, slightly improved in 15 cases, with only 3 cases having no response. The follow-up period was 2 years on average (range, 0.5 to 4 years). The data suggest that endoscopic balloon dilation is a safe, effective, and easy method for the management of esophageal stricture caused by surgical anastomosis, sclerotherapy, and corrosive injury. (Gastrointest Endosc 1992;38:586-589)
The therapeutic modalities for esophageal strictures include dilation with bougienage or balloons, endoprosthesis intubation, laser therapy, microwave, electrocoagulation therapy, and surgery.I-3 During the 1970s, polyvinyl tapered dilators and hydrostatic balloons were introduced after the usage of mercuryweighted bougies and metal dilators. 1 The balloon dilator may be used through-the-scope (TTS) or endoscope guided and may be inflated with water or air for dilation. The balloon-type dilator exerts only radial force against the stricture site, in contrast to the conventional push-type dilator which exerts both axial (mainly) and radial force as the stricture is dilated. Theoretically, balloon dilation is less likely to be complicated by traumatic rupture or perforation due to longitudinal stretching. I-15 In most reported series, esophageal strictures secondary to chronic reflux esophagitis accounted for 75% or more of the benign stenoses requiring dilation therapy. 1,6, 7, 12, 16 In contrast, benign peptic stricture
is rare in Taiwan where pyloric obstruction due to chronic duodenal ulcer is the main cause of reflux esophagitis. 17 Pyloric obstruction rarely causes esophageal stricture before therapeutic action is taken for the gastric outlet obstruction. Because of the recent popularity of endoscopic variceal sclerotherapy and end-to-end anastomotic (EEA) stapling in esophageal surgery, post-sclerotherapy and post-anastomotic strictures have become the main types of esophageal stenoses requiring dilation therapy. Laser therapy with Nd:YAG photocoagulation was previously used for treating esophageal strictures due to EEA stapling in our hospital, but this treatment resulted in a good response only in limited cases. 18,19 TTS balloon dilation was therefore tried in our patients with benign esophageal strictures due to surgical anastomosis and sclerotherapy as well as those due to corrosive injury. The efficacy of TTS balloon dilation, follow-up results, and side effects were evaluated and described in this communication.
Received July 16, 1991, For revision October 21, 1991. Accepted April 13,1992. From the Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taipei, Taiwan, Republic of China. Reprint requests: Pang-Chi Chen, MD, Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, Taiwan, Republic of China.
The patients enrolled for this therapeutic regimen were those with an overt clinical dysphagia history and evidence of esophageal stricture or stenosis diagnosed by esophagoscopy (Fig. lA) and/or barium meal esophagography (Fig. 2). The patients were classified according to the past history of
586
MATERIALS AND METHODS
GASTROINTESTINAL ENDOSCOPY
Figure 2. Esophagogram; tiny lumen over stricture site (A), widened lumen after balloon dilation during follow-up (B).
and pre-medication were those for routine panendoscopy. Meperidine (1 mg/kg intramuscular injection) was given. Under direct vision, a deflated 15-mm TTS balloon (Rigiflex; Microvasive, Watertown, Mass.) was passed through the 2.8-mm biopsy channel of an Olympus GIF-XQ20 fiberscope and positioned within the stricture. The balloon was inflated with water and the pressure was monitored with a gauge to achieve maximum recommended pressure without rupturing the low compliance balloons (Fig. IB). The pressure of inflation was maintained for 30 to 60 sec, reinflation after deflation for another minute was performed until the desired dilation effect was obtained (Fig. Ie) or the patient lost tolerance. Bed rest for 4 hours and fasting for 6 hours were advised, then a milk diet for 1 day after dilation, and diet as tolerable was resumed on the next day if there were no contraindications. Follow-up endoscopy was performed 1 week later to evaluate the efficacy of dilation and repeat dilation was performed if needed. If dysphagia recurred, then endoscopic follow-up could be done at any time. The results were graded according to Cox et al. 7 , and were defined as "good" if patients had no recurrent dysphagia (score 0), "improved" if dysphagia occurred only with meat, bread, rice (score 1 to 2), "slightly improved" if dysphagia occurred with semi-solids or liquids (score 3 to 4), and "none" if total dysphagia persisted (score 5).
RESULTS
Figure 1. A, Esophageal stricture, lower third, anastomotic, post-EEA stapling. B, Balloon inflated with water. Full expansion in site of stricture. C, After balloon dilation, widened lumen with laceration and bleeding.
operative anastomosis with or without an EEA stapling procedure, endoscopic esophageal sclerotherapy, or corrosive ingestion with strong acid or alkali. The Olympus GIF-P20 endoscope (Tokyo, Japan; with a diameter of 9 mm) always failed to pass through the stricture site. After informed consent was obtained, patients were kept fasting for at least 4 hours before the procedure. Preparation VOLUME 38, NO.5, 1992
During a 4-year period, 45 consecutive patients were enrolled for treatment of esophageal stenosis with endoscopic balloon dilation. The patient population consisted of 29 men and 16 women, with an age range of 27 to 72 years old (mean age, 50 years old). Twentyeight patients had post-operative anastomotic stricture, nine had post-sclerotherapy stricture, and eight had corrosive ingestion stricture. The clinical features, including the location and length of strictures with different etiologies, are shown in Table 1. Of the patients with operative anastomotic stricture, the indication for operation was esophageal cancer in eight, esophageal varices in eight, gastric cancer in six, gastric leiomyosarcoma in two, esophageal perforation in 587
two, and peptic esophagitis complicating gastric cancer surgery in two. In the corrosive injury group, six patients suffered from strong acid (Hel)-induced strictures. The duration from esophageal injury (surgery, sclerotherapy, corrosion) to the appearance of clinical dysphagia was mostly within 2 months (36 of 45, 80%). A total of 136 dilations were performed in these 45 patients. An average of 2.6 dilations (range, 1 to 8) were required in post-operative anastomotic strictures, 2.5 dilations (range, 2 to 3) in post-sclerotherapy strictures, and 2 dilations in corrosive strictures to relieve symptoms of dysphagia. During a mean follow-up period of 2 years (range, 0.5 to 4 years), 93.3% of patients remained improved (42 of 45). Although only 60% (27 of 45) showed good results, only 3 cases failed in this series. The results of the three groups were quite similar (Table 2). No serious complications such as massive bleeding or perforation were noted. Two patients died during follow-up. One was a 51year-old man with gastric leiomyosarcoma who died 9 months after dilation due to liver metastasis and sepsis. The other was a 55-year-old man with esophTable 1. Clinical features of the patients with esophageal strictures
Total patients Age (mean (range) yr) No. of males Age No. of females Age Stricture Location Upper third Mid-third Lower third Length (em) Duration (months)
Surgical Sclerotherapy anastomosis induced
Corrosive ingestion
28
8
18 52 (28-72) 10 48 (32-63)
9 6 48 (42-52) 3 54 (45-57)
17 0 11 0.5 (0.3-1) 2 (1-3)
5 46 (27-54) 3 49 (30-66)
0 0 9 1.5 (0.5-2) 1.5 (1-2)
3 2 3 2 (1-2.5) 1.5 (1-3)
Table 2. Results of balloon dilation in patients with esophageal strictures Surgical Sclerotherapy Corrosive anastomosis induced ingestion Total patients Dilations (sessions) Follow-up (months) Results Good
28 2.6 (1-8) 10-42
9 2.5 (2-3) 12-40
4 (14%)
5 (55.6%)
Ia
la Improved Slightly improved None Complications, serious a
b
14 (50%) 9 (32%) 1 (4%) Ob
0 4 (44.4%) 0 0
X , p > 0.975. Two died of other causes during follow-up.
588
2
8 2 (2) 6-48 0 0
1 4 (50%) 2 (25%) 2 (25%) 0
ageal cancer who died 6 months after dilation due to a cerebral vascular accident, coma, and respiratory failure. No antibiotic prophylaxis was used because no patients had heart valve prosthesis, prior endocarditis, or rheumatic fever and valvular heart disease in this group. DISCUSSION
In 1981 London et a1. 9 described the first use of a modern balloon dilator. Balloons have since gained in popularity, possibly because of the theoretical appeal of applying a localized dilating pressure in a controlled fashion, exerting only radial force on the stricture. 7 In particular, the TTS balloon offers direct vision of manipulation,13 so it is simpler for the beginner to use, although some do not recommended balloon dilation for routine use in treating benign esophageal stricture. 7,8 It can be used with complex strictures that have severe stenoses, long segmental lesions, tight lumens, angular narrowing, irregular stricture,12, 13 and especially in upper inlet stenoses; it is also useful in firm fibrotic strictures such as post-operative strictures. 5 Because it has been associated with fewer complications and morbidity, it can be performed on an out-patient basisY The procedure can be easily repeated if needed. The main disadvantages are that it requires a large channel endoscope, and the balloons currently used are relatively fragile and expensive. The results of this study have confirmed that balloon dilation is a safe, easy, convenient, effective technique for treating esophageal strictures. 1. 14 We used Nd:YAG laser therapy for treating post-operative strictures at the anastomosis performed with EEA stapling with limited effects in some cases. 19 The present study suggests that balloon dilation appears to be better than laser therapy and is safer. Some authors have pointed out that post-operative strictures are easily dilated but rapidly re-stenose 1,4, 13 and that the risk of requiring a subsequent dilation was greatest in the first year of follow-up.6 However, only a few of our cases needed repeat dilations during a 2year period of follow-up. It has been shown that the result of balloon dilation is good if the stricture site is not too long, and if the procedure is performed early enough. 20 Our results in post-sclerotherapy strictures, as well as in corrosiveinduced stricture, have confirmed this observation (Tables 1 and 2). Endoscopic sclerotherapy for esophageal varices is being used frequently and about 1 to 7% of patients develop post-ulcer scarring. 1 Balloon dilation should provide a good therapeutic modality for these patients. In our experience endoscopic TTS balloon dilation is a safe, effective, and easy therapy for the management of esophageal, anastomotic, post-sclerotherapy, and corrosive-induced strictures. GASTROINTESTINAL ENDOSCOPY
ACKNOWLEDGMENT
The author is grateful for the assistance of YunFan Liaw, MD.
11.
REFERENCES
12.
1. Lieberman DA, Keeffe EB. Dilation of benign esophageal strictures. In: Barkin JS, O'Phelan CA, eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990. 2. Cotton PB, Williams CB (ed.). Practical gastrointestinal endoscopy. 3rd ed. London: Blackwell Scientific Publications, 1990. 3. Takemoto T, Nagasako K, ed. Applied gastroenterological endoscopy. Tokyo: Bunkodou, 1990. 4. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-9. 5. Lindor KD, Ott BJ, Hughes RW. Balloon dilation of upper digestive tract strictures. Gastroenterology 1985;89:545-8. 6. Patterson DJ, Graham DY, Smith JL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983;85:346-50. 7. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilatation of benign esophageal stricture? An interim report of a randomised controlled trial. Gut 1988;29:1741-7. 8. Kozarek RA. To stretch or to shear: a perspective on balloon dilators. Gastrointest Endosc 1987;33:459-61. 9. London RL, Trotman BW, Dimarino AJ, et al. Dilation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 10. Gallinger VI, Chernousov AF, Andrew AL, Vantsian EN. Endoscopic balloon hydrodilatation and endoprosthetic treatment
VOLUME 38, NO.5, 1992
13.
14. 15. 16. 17.
18. 19. 20.
of esophageal and esophageal anastomotic stricture. Endoscopy 1989;21:11-4. Lindor KD. Balloon dilation of upper digestive tract strictures. In: Bennett JR, Hunt RH, eds. Therapeutic endoscopy and radiology of the gut. 2nd ed. London: Chapman and Hall Medical, 1990. Taub S, Rodan BA, Bean WJ, Koerner RS, Mullin DM, Feng TS. Balloon dilatation of esophageal strictures. Am J Gastroenterol 1986;81:14-8. Graham DY, Tabibian N, Schwartz JT, Smith JL. Evaluation of the effectiveness of through-the-scope balloon as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 1987;33:432-5. Whitworth PW, Richardson RL, Larson GM. Balloon dilation of anastomotic stricture. Arch Surg 1988;123:759-62. DeLange EE, Shaffer HA Jr. Anastomotic strictures of the upper gastrointestinal tract. Radiology 1988;167:45-50. Sullivan SN, Coeke M, Watson WC. Self dilation of esophageal strictures. Can J Gastroenterol 1991;5:49-50. Wang CS, Tzen KY, Huang MJ, Chen PC, Chen MF. Change of gastric liquid emptying after highly selective vagotomy and pyloric dilation for patients with obstructing duodenal ulcer. World J Surg 1991;15:286-92. Chen PC, Wu CS, Liaw YF. YAG laser endoscopic treatment of an esophageal and sigmoid stricture after end-to-end anastomosis stapling. Gastrointest Endosc 1984;30:258-60. Fang JF, Hwang TL, Chen PC, et at. The treatment of esophagojejunal anastomotic stricture after total gastrectomy. Chang Gung Med J 1989;12:148-55. Haynes WC, Sanowski RA, Foutch DG, Bellapravalu S. Esophageal strictures following endoscopic variceal sclerotherapy: clinical course and response to dilatation therapy. Gastrointest Endosc 1986;32:202-5.
589
