Is esophageal dilatation easily carried out as an outpatient procedure?
O. Ekberg (Malmö)
Balloon dilatation is an established method in the treatment of esophageal stricture. Dilatation can be made both endoscopically and/or under fluoroscopic control. Overall success rates have been reported to be 67-98%, and rupture rates have been 0-9% in prior studies [1-5]. Using a balloon during dilatation, such esophageal ruptures are virtually eliminated. There are reduced shearing forces for the balloon compared with bougies in vivo and this increases the margin of safety . Balloon dilatation is done with intravenous sedation and/or analgesics and is basically an
Figure IA-C. .Severe GERD in a 53 year old male. A) There is a stricture in the distal esophagus (arrow). B) Balloon dilatation was uneventful and a postprocedure gastrografin swallow showed patency of the esophageal lumen. C) The patient was admitted to the hospital 48 h later, with chest pain, shortness of breath and dysphagia. A CT examination of the lower thorax showed a large abcess (arrow) adjacent to the esophagus.
Figure ID-E. .Severe GERD in a 53 year old male. D) A new gastrografin study showed a leak (arrow) from the proximal area of the dilated stricture and the left thoracic cavity. A percutaneous drainage catheter (open arrow) had been placed under ultrasound guidance. E) After 6 months the patient had recovered. A barium swallow showed only mild narrowing of the distal esophagus. There is, however, aspiration of barium into the airways. The latter was probably not related to the balloon dilatation or its complications.
outpatient procedure. The patient is observed in the recovery area in approximately 4-6 h and then discharged if there is no evidence of chest pain or dysphagia. A postprocedure barium swallow may be added, but is probably not mandatory. However, when major complications occur, i.e., esophageal rupture, prompt and adequate treatment including tracheotomy may be necessary.
Minor complications during the procedure are bleeding and chest pain. There may also be respiratory depression from oversedation. Such minor complications can be handled with the patient in an outpatient setting. Major complication basically means rupture of the esophagus. Such rupture can occur immediately during the procedure, when the patient usually experiences sharp and persistent pain. The symptoms, however, can be insidious and therefore many prefer to regularly do a barium or gastrografin swallow after dilatation. However, the insidious course also includes the possibility of late ruptures. In these patients the rupture may occur hours or even days
after the dilatation [7,8]. Therefore, it is necessary to be sure that the patient understands instructions to return immediately when symptoms like chest pain, shortness of breath, and dysphagia occur after dilatation. There does not seem to be any relation between symptoms during the dilatation and whether or not a late rupture will occur, i.e., it is not those patients who had experienced severe pain during the dilatation that will present with late rupture. However, it has been shown that early and late esophageal ruptures do predominantly occur in patients who had undergone several dilatations. Many patients experience immediate symptom relief, i.e., they can eat normally. However, the patient should be instructed to take liquids and only soft food during the day after the procedure and return to solid food the morning after. Some patients get reflux of material cranially to the dilated stenosis. Such reflux of acid material can give heartburn that can be difficult to distinguish from pain due to rupture. Many of these patients, however, are on H2-blockers and therefore do not experience such heartburn.
Dilatation of peptic strictures of the esophagus is an outpatient procedure that can be safely done in a cooperative patient, who has been carefully instructed about possible late complications and who can reach his physician easily during the next few days after the procedure.
1. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SC Radiologically guided balloon dilatation of gastrointestinal strictures. Part I. Technique and factors influencing procedural success. Radiology 1987;165:35-40.