214
EDITORIAL
nature publishing group
ESOPHAGUS
see related article on page 206
Eosinophilic Esophagitis Dilation in the Community— Try It—You will Like It—But Start Low and Go Slow Joel E. Richter, MD, FACP, MACG1, 2
Abstract: The saga of esophageal dilation for patients with eosinophilic esophagitis and strictures reads like a historical novel. Currently, data from over 500 eosinophilic esophagitis (EoE) patients now convincingly prove that esophageal dilation is effective for prolonged relief and safe. It can easily be performed in the gastroenterologists community but follow the basic tenets of starting low with small diameter bougies/balloons and progressing slowly as you gradually dilate these strictures to 16–18 mm. Table 1 outlines my approach. Am J Gastroenterol 2016; 111:214–216; doi:10.1038/ajg.2015.433
The saga of esophageal dilation for patients with eosinophilic esophagitis (EoE) and strictures reads like a historical novel (1). In the beginning, before even the EoE syndrome was known, physicians were dilating patients with the “ringed or stiff esophagus” noting variable length of symptom improvement (1–24 months). Unusual side effects were observed including deep esophageal tears associated with pain, but patients tolerated these well and perforations were not seen (1). These optimistic case series were soon followed by other reports highlighting the high rates of mucosal tears, need for hospitalization, and rare reports of esophageal perforations. In total, 84 adult EoE patients reported before 2008 underwent esophageal dilation with 5% experiencing esophageal perforations and 7% hospitalization for chest pain, rates substantially higher than for other esophageal diseases (2). During these “dark ages”, the first international EoE guidelines published in 2007 recommended “whenever possible medical or dietary therapy for EoE should be attempted prior to performing esophageal dilation” (2). However, several experienced esophagologists including Worth Boyce, Walt Hogan, and myself continued to safely dilate our EoE patients as primary therapy
while developing thriving referral practices from patients seeking dysphagia relief after failing steroids or dietary treatments. The “renaissance period” for esophageal dilation began in 2010, with the publication of three papers from four groups detailing their success in treating EoE patients with strictures (3–5). These reports included a total of 109 adult EoE patients dilated with either Savary/Maloney bougies or through-the-scope (TTS) balloons. Dilations required a mean of 1.2–2.5 sessions to obtain an esophageal diameter of 16–17 mm. Most impressive was the consistent observation that 91% of patients experienced dysphagia relief for an average of 22–23 months. Mucosal eosinophilia did not change and complications were infrequent—3 mucosal tears, 2 requiring short hospitalization for pain, and no perforations. Since the initial 2010 reports, three more US centers have reported their successes in another 102 EoE patients with similar efficacy and safety (1). As a result, the second international EoE guidelines published in 2011 (6) have begun to liberalize their recommendations—“Esophageal dilation with or without concomitant medical or dietary therapy can provide relief of dysphagia in selected patients. In the absence of high grade esophageal stenosis, a trial of medical or dietary therapy before esophageal dilation is reasonable. For high grade strictures, dilation before initiation of medical therapy has been well tolerated and effective”. Runge et al. (7) from the University of North Carolina further bring esophageal dilation into the “modern age” with their report of effective and safe dilation in an additional 164 patients treated from 2002 to 2014 by several endoscopists. Overall, 87% had symptomatic relief of their dysphagia, but 58% required more than one session of dilations (mean of 4.4±4.3 sessions per patient) to get to an average diameter of 15–16 mm. Not surprisingly, the only predictor of requiring multiple dilations was a smaller baseline esophageal diameter (12.5±2.8 mm for single dilation vs. 11.3±2.9 mm for multiple dilations, P=0.01). Dilation was well tolerated, with no major bleeds, perforations, or deaths. The overall complication rate was 5% primarily for post-procedure pain requiring narcotics or ER visit. In contrast to other reports, 75% of patients requiring multiple dilations needed the proce-
1
Division of Digestive Diseases and Nutrition; 2Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA. Correspondence: Joel E. Richter, MD, FACP, MACG, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, Florida 33612, USA. E-mail: [email protected] Received 17 December 2015; accepted 24 December 2015
The American Journal of GASTROENTEROLOGY
|
VOLUME 111 FEBRUARY 2016 www.amjgastro.com
Editorial
215
Forewarn the patient that some degree of post-dilation pain is to be expected. Careful endoscopy prior to dilation to assess the location of strictures and estimate esophageal diameter. Start low with small diameter bougie/balloons and gradually dilate to 16–18 mm, if possible. Gradual slow dilation is key with sessions separated by 3–4 weeks. Limit the progression of dilation per sessions to ≤3 mm after resistance is noted. Stop with moderate resistance or blood on the dilator. Look for tears if you must—but they only represent an adequate dilation. For post-procedure chest pain, mild analgesia is recommended and rarely narcotics. Expected chest pain is monitored during recovery period and by telephone, if necessary. After induction dilation sessions to 16–18 mm, repeat dilations are triggered by recurrence of dysphagia symptoms. Many patients will only need maintenance dilations every 2–3 years.
dures repeated within 1 year with a median of 4 months after first dilation. However, the retrospective nature of their report did not allow them to explain this discrepancy compared with other series (3–5). Hence, the data are out, and they are robust; esophageal dilation is effective and safe in EoE patients with esophageal strictures. In fact, the efficacy of this approach has better long-term symptom relief than traditional medical therapies and may be more “palatable” than dietary regimens and more reliable and less expensive than steroid therapy in adults. However, why then are community gastroenterologists still reluctant to dilate their EoE patients? Some may not realize that the complaint of dysphagia in EoE patients is a complex pathophysiological process with both mechanical and psychological factors. Although the inciting event is the mucosal eosinophilic inflammation, the degree of eosinophilia does not correlate with the severity of dysphagia (6). Dysphagia is related to mechanical factors including the degree of esophageal dysmotility present, extent of mucosal inflammation, and fibrostenosis from esophageal remodeling. The contribution of each varies in the individual patient and often is incompletely evaluated if only endoscopy with biopsies is performed. Recently, the Mayo Clinic found that endoscopy had poor sensitivity (14.7%) and only modest specificity (79.2%) for identifying esophageal strictures in EoE patients previously noted on careful barium esophagrams. Even at a cutoff diameter of
EDITORIAL
nature publishing group
ESOPHAGUS
see related article on page 206
Eosinophilic Esophagitis Dilation in the Community— Try It—You will Like It—But Start Low and Go Slow Joel E. Richter, MD, FACP, MACG1, 2
Abstract: The saga of esophageal dilation for patients with eosinophilic esophagitis and strictures reads like a historical novel. Currently, data from over 500 eosinophilic esophagitis (EoE) patients now convincingly prove that esophageal dilation is effective for prolonged relief and safe. It can easily be performed in the gastroenterologists community but follow the basic tenets of starting low with small diameter bougies/balloons and progressing slowly as you gradually dilate these strictures to 16–18 mm. Table 1 outlines my approach. Am J Gastroenterol 2016; 111:214–216; doi:10.1038/ajg.2015.433
The saga of esophageal dilation for patients with eosinophilic esophagitis (EoE) and strictures reads like a historical novel (1). In the beginning, before even the EoE syndrome was known, physicians were dilating patients with the “ringed or stiff esophagus” noting variable length of symptom improvement (1–24 months). Unusual side effects were observed including deep esophageal tears associated with pain, but patients tolerated these well and perforations were not seen (1). These optimistic case series were soon followed by other reports highlighting the high rates of mucosal tears, need for hospitalization, and rare reports of esophageal perforations. In total, 84 adult EoE patients reported before 2008 underwent esophageal dilation with 5% experiencing esophageal perforations and 7% hospitalization for chest pain, rates substantially higher than for other esophageal diseases (2). During these “dark ages”, the first international EoE guidelines published in 2007 recommended “whenever possible medical or dietary therapy for EoE should be attempted prior to performing esophageal dilation” (2). However, several experienced esophagologists including Worth Boyce, Walt Hogan, and myself continued to safely dilate our EoE patients as primary therapy
while developing thriving referral practices from patients seeking dysphagia relief after failing steroids or dietary treatments. The “renaissance period” for esophageal dilation began in 2010, with the publication of three papers from four groups detailing their success in treating EoE patients with strictures (3–5). These reports included a total of 109 adult EoE patients dilated with either Savary/Maloney bougies or through-the-scope (TTS) balloons. Dilations required a mean of 1.2–2.5 sessions to obtain an esophageal diameter of 16–17 mm. Most impressive was the consistent observation that 91% of patients experienced dysphagia relief for an average of 22–23 months. Mucosal eosinophilia did not change and complications were infrequent—3 mucosal tears, 2 requiring short hospitalization for pain, and no perforations. Since the initial 2010 reports, three more US centers have reported their successes in another 102 EoE patients with similar efficacy and safety (1). As a result, the second international EoE guidelines published in 2011 (6) have begun to liberalize their recommendations—“Esophageal dilation with or without concomitant medical or dietary therapy can provide relief of dysphagia in selected patients. In the absence of high grade esophageal stenosis, a trial of medical or dietary therapy before esophageal dilation is reasonable. For high grade strictures, dilation before initiation of medical therapy has been well tolerated and effective”. Runge et al. (7) from the University of North Carolina further bring esophageal dilation into the “modern age” with their report of effective and safe dilation in an additional 164 patients treated from 2002 to 2014 by several endoscopists. Overall, 87% had symptomatic relief of their dysphagia, but 58% required more than one session of dilations (mean of 4.4±4.3 sessions per patient) to get to an average diameter of 15–16 mm. Not surprisingly, the only predictor of requiring multiple dilations was a smaller baseline esophageal diameter (12.5±2.8 mm for single dilation vs. 11.3±2.9 mm for multiple dilations, P=0.01). Dilation was well tolerated, with no major bleeds, perforations, or deaths. The overall complication rate was 5% primarily for post-procedure pain requiring narcotics or ER visit. In contrast to other reports, 75% of patients requiring multiple dilations needed the proce-
1
Division of Digestive Diseases and Nutrition; 2Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA. Correspondence: Joel E. Richter, MD, FACP, MACG, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, Florida 33612, USA. E-mail: [email protected] Received 17 December 2015; accepted 24 December 2015
The American Journal of GASTROENTEROLOGY
|
VOLUME 111 FEBRUARY 2016 www.amjgastro.com
Editorial
215
Forewarn the patient that some degree of post-dilation pain is to be expected. Careful endoscopy prior to dilation to assess the location of strictures and estimate esophageal diameter. Start low with small diameter bougie/balloons and gradually dilate to 16–18 mm, if possible. Gradual slow dilation is key with sessions separated by 3–4 weeks. Limit the progression of dilation per sessions to ≤3 mm after resistance is noted. Stop with moderate resistance or blood on the dilator. Look for tears if you must—but they only represent an adequate dilation. For post-procedure chest pain, mild analgesia is recommended and rarely narcotics. Expected chest pain is monitored during recovery period and by telephone, if necessary. After induction dilation sessions to 16–18 mm, repeat dilations are triggered by recurrence of dysphagia symptoms. Many patients will only need maintenance dilations every 2–3 years.
dures repeated within 1 year with a median of 4 months after first dilation. However, the retrospective nature of their report did not allow them to explain this discrepancy compared with other series (3–5). Hence, the data are out, and they are robust; esophageal dilation is effective and safe in EoE patients with esophageal strictures. In fact, the efficacy of this approach has better long-term symptom relief than traditional medical therapies and may be more “palatable” than dietary regimens and more reliable and less expensive than steroid therapy in adults. However, why then are community gastroenterologists still reluctant to dilate their EoE patients? Some may not realize that the complaint of dysphagia in EoE patients is a complex pathophysiological process with both mechanical and psychological factors. Although the inciting event is the mucosal eosinophilic inflammation, the degree of eosinophilia does not correlate with the severity of dysphagia (6). Dysphagia is related to mechanical factors including the degree of esophageal dysmotility present, extent of mucosal inflammation, and fibrostenosis from esophageal remodeling. The contribution of each varies in the individual patient and often is incompletely evaluated if only endoscopy with biopsies is performed. Recently, the Mayo Clinic found that endoscopy had poor sensitivity (14.7%) and only modest specificity (79.2%) for identifying esophageal strictures in EoE patients previously noted on careful barium esophagrams. Even at a cutoff diameter of
