Esophageal Dilation Safe and effective esophageal dilation necessitates an anatomically amenable stenosis and proper localization of such a stenosis with fluoroscopy, endoscopy, or both. 1 Sequential dilation is essential because effective bougienage is more likely the result of fracture or laceration of the stricture than of simple stretch.' and, as such, rapid enlargement of the stenosis has been associated with an increased risk of esophageal bleeding or perforation.' Whether all dilating systems are equally safe and effective when the variables of cause and localization of the stricture, rapidity of dilation, and ultimate size of the dilator are controlled is currently conjectural. In this issue of the Mayo Clinic Proceedings (pages 228 to 236), Yamamoto and associates attempt to answer such safety and efficacy issues by comparing Eder-Puestow metal olives and guidewire-directed dilating balloons (Fig. 1) in patients with newly diagnosed peptic strictures of the esophagus. Historically, most benign esophageal strictures have been dilated with mercury-filled Hurst or Maloney dilators.':' Long, acutely angulated, eccentric, or extremely tight (less than 7 mm) stenoses have traditionally necessitated guidewire-facilitated dilation. These guidewires ensured endoluminal passage of the dilator and were used to place sequentially sized Eder-Puestow metal olives until the gastrointestinal adaptation of pneumatic and hydrostatic balloons became available in the mid-1980s. 5,6 Yamamoto and colleagues randomized 31 patients in a comparison of these two methods and also prospectively reviewed an additional 92 patients treated with either olives or balloons who did not undergo such randomization. These authors noted that all but 1 of the 123 patients treated with either of these modalities had immediate relief of dysphagia and that the probability of continued relief at 1 year approximated 20%. Major and minor complications occurred, respectively, in 1 and 5% of patients and in 0.4 and 3% of the total number of dilations. Although not statistically significant, the single perforation and five of six minor complications occurred in patients who underwent dilation with the Eder-Puestow system. The authors concluded that although balloon dilators may be safe, they seem to have efficacy that is equivalent to that of metal olives and ultimately are considerably more expensive. Therefore, the endoscopist's preference

should be the major factor in determining which dilating system is used. Unfortunately for this study, advances in technology have rendered both of the aforementioned dilating systems obsolete. Eder-Puestow dilators, for instance, have not been used at my institution since 1985. Current guidewire-facilitated dilators are polyvinyl and have a gradually tapered tip.' This taper facilitates passage through tight or acutely angulated strictures; thus, successful bougienage is more likely, and the risk of perforation is decreased. Two systems are currently marketed: Savary" (Wilson-Cook, Inc., Winston-Salem, North Carolina) and American (C. R. Bard, Inc., Billerica, Massachusetts) (Fig. 2). The latter are shorter, less tapered, and impregnated with barium for easier fluoroscopic visualization (Fig. 2 B). Both systems are readily used, should yield comparable results, and have supplanted Eder-Puestow olives. Dilating balloons, in turn, are now used almost exclusively in a "through-the-scope" approach (Fig. 3).9,10 This technology allows more precise localization of the stricture. Moreover, successful dilation can be immediately assessed, and diagnostic endoscopy, including biopsy, can be effected with a single intubation. Therefore, the current issues in esophageal bougienage are not metal olives versus guidewire-directed balloons but rather use of hollow-core polyvinyl dilators in lieu of, or in addition to, "through-the-scope" balloons. Considerations include safety, short- and long-term efficacy in relieving dysphagia, and costs to purchase and maintain the various

Fig. 1. Various devices used for esophageal dilation. At top, EderPuestow dilating system with variably sized metal olives. At bottom, guidewire-facilitated balloon dilating system. Although pneumatic system (pictured) was initially used, a fluid medium provides more effective dilation of a stenosis.

Address reprint requests to Dr. R. A. Kozarek, Section of Gastroenterology, Virginia Mason Clinic, P.O. Box 900, Seattle, WA 98111. Mayo Clin Proc 67:299-300, 1992

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Fig. 2. A, Savary-Gilliard (top) and American (bottom) esophageal dilating systems. B, Former are longer, more tapered, and less radiopaque than barium-impregnated American system.

systems. These issues have, in part at least, already been addressed, and advocates for both systems have claimed superior efficacy or relative safety. 10.1I The reality is that, in 1992, a menu of progressively improved dilating instruments has become available. When used with a modicum of common sense and in conjunction with antireflux therapy, H 2blockade, or proton-pump inhibition, bougienage with such instruments safely prevents impaction of food and allows adequate maintenance of nutrition in most patients with reflux-induced esophageal stenoses.":" Richard A. Kozarek, M.D. Chief of Gastroenterology Virginia Mason Clinic Seattle, Washington REFERENCES 1. Kozarek RA: Gastrointestinal dilation. In Textbook of Gastroenterology. Edited by T Yamada, DH Alpers, C Owyang, DW Powell, FE Silverstein. Philadelphia, JB Lippincott Company, 1991, pp 2587-2595 2. Kozarek RA: To stretch or to shear: a perspective on balloon dilators (editorial). Gastrointest Endosc 33:459-461, 1987 3. Tulman AB, Boyce HW Jr: Complications of esophageal dilation and guidelines for their prevention. Gastrointest Endosc 27:229-234, 1981 4. Webb WA: Esophageal dilation: personal experience with current instruments and techniques. Am J Gastroenterol 83:471-475,1988 5. Lindor KD, Ott BJ, Hughes RW Jr: Balloon dilatation of upper digestive tract strictures. Gastroenterology 89:545548, 1985 6. Kozarek RA: Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 32:15-19, 1986 7. Kadakia SC, Cohan CF, Starnes EC: Esophageal dilation with polyvinyl bougies using a guidewire with markings without the aid of fluoroscopy. Gastrointest Endosc 37: 183187, 1991 8. Dumon J-F, Meric B, Sivak MV Jr, Fleischer D: A new method of esophageal dilation using Savary-Gilliard bougies. Gastrointest Endosc 31:379-382, 1985

Fig. 3. Variable diameter "through-the-scope" dilating balloons.

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Graham DY, Tabibian N, Schwartz JT, Smith JL: Evaluation of the effectiveness of through-the-scope balloons as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 33:432-435,1987 10. Graham DY: Treatment of benign and malignant strictures of the esophagus. In Therapeutic Gastrointestinal Endoscopy. Second edition. Edited by SE Silvis. New York, IgakuShoin, 1990, pp 1-41 11. Kozarek RA, Gelfand MD, Patterson DJ, Ball TJ: A prospective trial of American Savary (A-S) dilators versus hydrostatic balloons (HB) in complex esophageal strictures (abstract). Gastrointest Endosc 32:172-173, 1986 12. Hetzel DJ, Dent J, Reed WD, Narielvala FM, Mackinnon M, McCarthy JH, Mitchell B, Beveridge BR, Laurence BH, Gibson GG, Grant AK, Shearman DJC, Whitehead R, Buckle PJ: Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology 95:903-912, 1988 13. Bianchi-Porro G, Pace F, Sangaletti 0, Peracchia A, Bonavina L, Vigneri S, Termini R: High-dose famotidine in the maintenance treatment of refractory esophagitis: results of a "medium-term" open study. Am J Gastroenterol 86:15851587, 1991