Dilation
Julius Špičák, Jan Martínek
Institute for Clinical and Experimental Medicine,
Prague
Complications - terminology
Immediate complications
Technical failure
Ineffectiveness
Costs
Extended hospitalization
Patient dissatisfaction
Complications
Adverse effects
Unplanned effects
Dilation - indications
9 All kinds of GI and BP strictures which can be visualised
endoscopically
9 Benign strictures
9 Malignancies - temporary relief only, stenting
and debulking techniques should be preferred
Stenoses of GIT
Schatzki ring
M.Crohn
peptic stenosis
Dilation - techniques
9 Balloons: Through-the-scope (TTS)
Over-the-wire (OTW)
Controlled-radial-expansion (CRE)
9 Bougies, olives
9 Temporary stenting
9 Electrocautery
9 Combined techniques
Dilation of esophageal strictures without fluoroscopy
Savary-Gilliard dilators, rule of three, 2-3 sessions within 10 days
Malignant 30, benign 25 strictures
N patients
N sessions
Immediate success
Stent
Complications
55
177
100%
5
0
Conclusions: Safe and effective in various conditions.
Wang YG et al., World J Gastroenterol 2002;8:766-768.
Esophageal dilation – comparison of balloon
and bougienage
TTS vs. Savary bougies, end point dilation: 45F / 15mm
N
Sessions/patient
Balloon
Bougie
17
1.1±0.1
17
1.7±0.2
Saed ZA et al. Gastrointest Endosc 1995;41:189-195
Esophageal balloon dilation - review
Study
Year
Allmendiger
Babu
Goldthorn
Hoffer
Jayakhrisnan
Johnsen
Kukkady
Lang
Lisy
Said
Sandgren
Sato
Shah
Yeming
Lan
1996
2001
1984
1984
2001
1986
2002
2001
1998
2003
1998
1988
1993
2002
2003
Injury
Noncaustic
5
5
8
9
35
10
0
34
21
25
33
17
16
13
74
Caustic
3
0
0
0
2
0
10
0
3
0
3
3
1
7
3
Perforation %
0
0
0
3.8
1.6
0
0.47
3.8
0
1.7
0
0
0.75
5
1.5
Failure %
0
20
25
33
0
0
0
0
0
0
21
0
5.8
10
97
Predictors of early recurrence
of esophageal strictures
9 Heartburn
9 Hiatal hernia
9 Nonpeptic strictures
9 Narrow stricture diameter
Said A et al. Am J Gastroenterol 2003;98:1252-1256
Esophageal dilatation in children
Balloon dilatation, postesophagial atresia repair 63, reflux7,
caustic 3
N, patients
N, sessions
Perforations
Surgery
Success
77
260 (3.4)
4 (1.5%)
1
75 (97%)
Conclusions: safe and effective .
Lan BLCL et al. J Pediatric Surg 2003;38: 1713-1715
Esophageal dilatation in children
4 Complications
2 Learning curve
2 Larger size balloon catheter than recomended
Therapy: chest drainage, fasting, antibiotics
collection on CT – surgery – 1
Lan BLCL et al. J Pediatric Surg 2003;38: 1713-1715
Endoscopic dilation in epidermolysis bullosa
TTS dilation, 75% single (1-6) strictures, median 20 cm from incisors,
Dilation 2-4x, appropriate pressure maintained 30 sec
N patients
N procedures
Success
Complications
53
182
49
0
Conclusions: safe and effective.
Anderson SHC et al. Gastrointest Endosc 2004;59:28-32
Dilation of cervical web of esophagus
Savary-Gilliard
N
Success
Recurrence
Minimal (self limited)
hematemesis
16
100 %
0
3 (18%)
Conclusions: simple, safe, effective.
Sreenivas DV et al. Hepato-Gastroenterol 2002;49:188-190
Factors influencing application of endoscopic
balloon dilatation for benign esophageal strictures
TTS, CRE, 1-1.5 minutes, ↑3mm→15mm (rule of three)
Effective treatment – solid or semisolid diet was sustained for more
thatn 12 months
Groups
N
Stricture length
Success
11
2.6±1.1
Relapse
11
5.7±3.4
Failure
3
8<
Mild complications:(oozing (self limited) bleeding, chest pain only
Conclusions: Diameter and length of the stricture are predictive factors.
Chiu YC et al. Endoscopy 2004;36:595-600
Temporary placement of an expandable polyester
silicone-covered stent for treatment of benign
esophageal strictures
Polyflex stent, polyvinyl dilation prior stenting, etiology caustic
5, radiotherapy 4, surgery 3
N
Mean N of dilations
Success
Complications
15
9.5
100%
0
Conclusions: enormously safe and effective.
Repici A et al. Gastrointest Endosc 2004;60:513-519.
Endoscopic treatment of benign esophageal
stenosis with electrocautery
Esophagojejunostomy due gastric carcinoma, sphincterotomy,
six radial incisions
N/succeess
Complications
6/6
0
Brandimare G et al. Endoscopy 2002;34:399-401
Dysphagia without evident disease: dilate?
TTS, 0.5-1 min
Dilation
N
6 months improvement
Complications
43
84%
0%
Sham
40
73%
0%
Conclusions: Results do not support empiric dilation
without evident cause of dysphagia.
Scolapio JS et al. Am J Gastroenterol 2001;96:327-330
Evaluation of three interventional procedures in achalasia
Fluoro control
Dilation
N
Dysphagia relaps, 12 m
Dysphagia relaps, 36 m
Pain
Reflux
Bleeding
60
60%
90%
50%
26.7%
10%
Stent
Un/covered Partially/temporary
8
50%
66.7%
62.5%
62.5%
37.5%
65
9.2%
14.5%
40%
20%
12.3%
Conclusions: Temporary partially covered metal stent was the best method.
Complications were not characterized.
Cheng Y-S et al. World J Gastroenterol 2003;9:2370-2373.
Botulinum toxin vs. balloon dilation for
treatment of achalasia
Witzel dilation
N
Remission, 1 y
Additional dilation
Perforation
Dilation
Botulotoxin
18
89%
16
38%
9
2
Conclusions: Both methods had excellent immediate relief,
but much better long-term outcome after dilation.
Bansal R et al. J Clin Gastroenterol 2003;36:209-214.
Botox Czech experience: N 49, long-term response 41 %
Martínek J… Špičák J. Diseases of Esophagus 2003;16:204-209
Balloon dilation in achalasia
Author
Year
N
Success
West
2002
125
→ 50%
Sabharwal
Cheng
2002
2003
76
60
89%
40→ 10%
Dobrucali
2004
43
79→ 54%
Karamanolis
2005
260
88→ 66%
Boztas
2005
50
83%
Gockel
IKEM
2005
2006
64
> 100
83%
Complications
perforations 2
surgery 7
0
pain 50%
reflux 26%
bleeding 10%
perforation 1
reflux 4
perforation 1
tears 9 (4.2%)
surgery 13%
immediate 0
reflux 12
surgery 5
NR
perforations 3
surgery 2
clipps 1
esophagitis easy to control
Balloon dilation in achalasia
9 12 → hours fasting
9 Sedation, air ways protection
9 Fluoro/endo control
9 30-mm balloon, 1-2 minutes
9 Further sessions: on demand, according to manometry?
9 Contrast, endoscopy, to exclude perforation
9 Perforation treatment: ATB, fasting, surgery, clipps?
Pyloroduodenal peptic stenosis
TTS
N 19
Symptoms improvement
Stenosis resolution
Scintigraphy confirmed improved gastric emptying
Artifon EL et al. Surgical Endosc 2006;20: 243-248
Dilation of gastric outlet obstruction with/without
Hp infection
TTS, , CRE, 3 minutes, 12→16 mm
N 33, immediate dilation success 76%, recurrence 36% within 2 years
2 perforations after 16-mm balloon perforation
Conclusions: Results better in Hp eradicated patients, in Hp negative
and recurrent patients the surgery should be the first choice.
Lam YH et al, Gastrointest Endosc 2004;60:229-233
Strictures following laparoscopic
Roux-en-Y gastric bypass (LRYGB) for obesity
Pneumatic balloons, Savary-Gilliard bougies
LRYGB
Anastomotic stricture
Stricture resolution
Microperforation
369
19 (5.1%)
90%
1
Conclusions: symptoms free at a mean follow-up 21 months.
Goiten D et al. Surg Endosc 2005;19:628-632
Colonoscopic balloon dilation of Crohn´s
strictures
Baloon dilation: 3 minutes, 18 mm
N
Success
> 2 sessions
Surgery (unsuccess)
Complications
22
16
15
6
0
Dear KLE et al. J Clin Gastroenterol 2001;33: 315-318
Colonoscopic balloon dilation of Crohn´s
strictures
TTS dilation
N patients/procedures
Recurrence/surgery
Complications
Perforation – surgery
Fever
Hematochezia
Pain
38/53
43%
5 (9.4%)
1
2
1
1
Conclusions: Safe, dilation can avoid or postpone surgery.
Sabaté JM et al. Aliment Pharmacol Ther 2003
Ileal pouch strictures
Through-scope-balloons
N patients
Inlet/outlet strictures
Mean sesseions p/p
Complications
19
14/14
1.74
0
Conclusions: safe and effective
Shen B et al. Am J Gastroenterol 2004;99: 2340-2347
Stenosis after stapled colorectal anastomosis
N
Stenosis
Endoscopic dilation
Relaps
179
8
5/8
1
Conclusions: early stenosis is often asymptomatic and
disappears spontaneously. Dilation is a method of choice.
Bannura GC et al. World J Surg 2004;28:921-925
Colorectal stricture after low anterior resection
Prospective controlled trial, two balloon types,
TTS, OWB, 24-months follow-up
N
Mean N of sessions
Response, mean, days
TTS
OWB
15
2.6
294.2
15
1.6
560.8
Conclusions: Better results with OWB.
Di Giorgio P et al. Gastrointest Endosc 2004;60:347-350
Stenosis after stapled colorectal anastomosis
9 Incidence depends on the criteria
9 Clinically relevant in < 5%
9 Stenosis is often asymptomatic and can disappear
9 Dilation – excellent choice
Colorectal cancer - stenting-dilation-perforation
Summary metaanalysis – perforation rate 3%
Early / delayed
71 / 19%
Stenting and dilation
With
Without
N
Perforation
65
14%
718
2.6%
EST - consequences
9 Bacterial colonization of bile ducts
9 Increased rate of primary choledocholithiasis
9 Increase risk of bile duct tumor
9 Clinical relevancy?
Histological analysis of the papilla after
endoscopic dilation
N patients balloon dilation
Histology
Muscle disruption
Architectural distortion
Inflammation
Fibrosis
467
10
1
1
9
9
Kawabe T et al. Hepato-Gastroenterology 2003;50:919-923
Influence of papillary dilation and sphincterotomy
on sphincter Oddi function
Pure bile collection: Before, 1 week, 1 year after the procedure
No difference in pancreatic enzymes before and after procedures
Both dilation and sphincterotomy preserve sphincter Oddi function
Takezawa M et al. Endoscopy 2004;36:631-637.
Balloon dilation of the sphincter of Oddi
- increased risk of pancreatitis?
N
Stones removal
Mechanical lithotripsy
Early complications
Pancreatitis
Hyperamylasemia
EBD
EST
93
88%
31%
17%
8%
23%
87
93%
13%*
22%
8%
8%
Conclusions: No difference in pancreatitis, hyperamylasemia
in EBD may indicate more irritation.
Bergman JJGHM et al. Endoscopy 2001;33:416-420
Balloon dilation for common bile duct stones
A metaanalysis: Velavinous, Fujita, Arnold, Minami, Bergman,
Ochi, Natsui, Yasuda
Stones removal
Complications, total
Bleeding
Pancreatitis
Severe
Death
Lithotripsy need
EBD
EST
94.3
10.5
7.4%
5
1
20.9%
96.5
10.3
2.0%*
4.3%*
2
1
14.8%
Conclusions: EBD should be preferred in coagulopathy only.
Baron TH et al. Am J Gastroenterol 2004;99:1455-1460
Balloon dilation of the sphincter of Oddi
N
Success
Complications, total
Severe
Pancreatitis
Deaths
EBD
EST
117
97.4%
17.9%
6.8%
15.4%
2
120
92.5%
3.3%
0
0.8%
Conclusions: dilation is unsafe.
DiSario JA et al. Gastroenterology 2004;127: 1291-1299
Stent placement in the pancreatic duct prevents pancreatitis
after dilation
Stent removed 3 days later (38/40)
N
Pancreatitis (mild)
Stent
Controls
40
0
92
6
Conclusions: pancreatitis and hyperamylasemia was prevented by
pancreatic stent insertion.
Aizawa T et al. Gastrointest Endosc 2001;54:209-213
Papillary balloon dilation from percutaneous approach
Fragments after lithotomy removal
N
Stones removal (one session)
Complications
16
12
0
Conclusions: simple and effective
Moon Jong Ho et al. Gastrointest Endosc 2001;54: 232-236
Endoscopic balloon dilation
for specific indications only
9 Coagulopathy
9 Anatomy – B II
Endoscopic treatment of patients with PSC
Author
Johnson
Craig
Gaing
Lee
Van Milligen
Wagner
Petersen
Baluyut
Stiehl
Year
1987
1992
1993
1995
1996
1996
2001
2001
2002
Stent
11
16
15
22
21
0
37
32
5
Dilation
24
18
6
31
0
12
34
140
210
Enteroscopic balloon dilatation
of hepaticojejunostomy after liver transplantation
9 7-year-old boy, 6 years after OLT
9 Double-balloon-enteroscopy
9 Successful dilation (2-years follow-up)
Haruta H et al. Liver transplantation 2005;11:1608-10
Dilation - risk factors
Stricture
Etiology
Long
Caustic
Irregular
Achalasia
Hard
Malignancy
Bowel/esophageal wall involved,
Radiation
scaring
Conclusions - complications - how to prevent
9 Patients selection (vs. other techniques)
9 Equipment cannot be significantly improved
9 To avoid unadequate overpressure
9 Most of complications are not reported, they are caused by
incorrect approach
9 Declared guidelines will not be principally changed,
the goal is to respect them