What are the types of aero digestive tract fistulas?

Tracheo-oesophageal fistula (TOF)

Broncho- oesophageal fistula (BOF)

Oesophageal-lung parenchyma fistulas (rare)

What are the causes of these fistulas?

• These fistula’s develops either because of direct tumor invasion and subsequent perforation or after radiation, laser therapy, chemotherapy or pre-existing stents (primarily, oesophageal stents), or a combination of these.

• Approximately 77% of MTOF are related to oesophageal cancer, whereas approximately 16% originate from a primary lung neoplasm.

• Other tumours like malignant mediastinal nodal disease, thyroid, laryngeal cancer etc causes MTOF rarely

How common is it?

It develops in approximately 5%–15% of patients with an oesophageal malignancy and in less than 1% of those with bronchogenic carcinoma

What are the symptoms?

Intractable cough and repeated aspirations.

Autopsy data indicate a higher incidence of fistulas, thus suggesting that fistulas are more common in patients than is usually diagnosed.  A history of repeated coughing associated with eating, drinking, or both, with an increase in dysphagia and dyspnea are highly suggestive of a fistula. Endoscopic findings are sometimes inadequate in demonstrating a fistula, in which case a water contrast swallow is required.

Lung abscess is the most frequent and severe complication of oesophageal-lung parenchyma fistulas. In this particular type of aero digestive fistula, stent placement may worsen the infectious problem by impairing natural drainage of the abscess.

In one study, lung abscesses decreased in size, but persisted even after stent placement. Concomitant abscess drainage procedures should thus be considered. Thus, oesophageal stent remains the accepted treatment for oesophageal-lung parenchyma fistulas (with percutaneous drainage of the abscess)

What is the prognosis?

Once a fistula (stage T4) develops, the tumour is incurable. The treatment is palliative to alleviate symptoms. Treatment should be begun immediately after the diagnosis is confirmed since the usual cause of death in these patients is pulmonary sepsis resulting from chronic aspiration through the fistula. In two, large series reports (4, 5), mean patient survival was reported to be 3.1-3.4 months. The usual causes of death are: massive bleeding, pneumonia or malnutrition

What are the treatment options?

Therapy is mainly directed to palliate symptoms and maintain quality of life.

• Unfortunately, at the time of diagnosis, the patient’s performance and disease status usually precludes aggressive palliative surgical therapy (oesophageal bypass using a gastric bypass and cardiostomy)

• Radiation therapy and chemotherapy are generally contraindicated due to the concern regarding fistula enlargement caused by tumor necrosis.

• Oesophageal or tracheobronchial stenting or both is the treatment of choice.

• Gastrostomy: Stenting however achieves better palliation of respiratory symptoms with a better quality of life.

Discuss selection of stent?

Several kinds of covered oesophageal stents are available (i.e., Ultraflex stent, Wallstent, and Z stent). However, there are no randomized or controlled trials to compare the outcomes of any of these stents when used to treat malignant aero digestive fistulas

Discuss the stenting area?

The selection guide for determining the stenting area could be summarized as follows:

• oesophageal stent placement if a patient has a stricture in the oesophagus,

but with no or only mild airway stricture since an oesophageal stent can successfully treat both oesophageal stricture and a fistula;

• airway stent placement if a patient has no or only mild stricture in the oesophagus, or has moderate to severe stricture in the airway, since an oesophageal stent migrates well when oesophageal stricture is absent or mild, and an airway stent can treat an airway stricture; or
• both the airway and oesophageal stent placement when a patient has moderate to severe stricture involving both the oesophagus and the airway, since both the airway and oesophageal stents are necessary to treat a stricture involving both the oesophagus and the airway.
• In case of a high (fistula at 18-20cm from incisor) tracheo-oesophageal fistula –oesophageal stent may be undesirable and a tracheal stent is the better option.

NB: Airway stent is preferred in malignant fistula developing after Ivor Lewis

Oesophagectomy (the replaced stomach or colon shows a large lumen compared

with the lumen of the original oesophagus). The larger lumen makes oesophageal stent migration (and hence uncovering fistula) easier.

Discuss double stenting i.e. both oesophageal and Tracheobronchial stent insertion?

Double stenting appear to provide more benefits than either oesophageal or respiratory stents alone in terms of palliation and safety. Double stenting is definitely indicated when fistula occlusion is not achieved by the oesophageal or airway stent alone. In cases of double stenting, airway stent should be placed first in order to avoid tracheal or bronchial compression secondary to the oesophageal stent.

Mechanical friction between the oesophageal and airway stents may cause pressure necrosis of the interposed tissue between the two stents, thereby possibly resulting in a fatal haemorrhage. Thus, parallel stenting should only be performed after thoroughly reviewing a patient’s clinical indications.

Discuss the success of oesophageal stenting?

• Oesophageal stenting is technically feasible in the majority.

• Oesophageal stent completely seals off the fistula in 60-100% of cases. Incomplete closure of the fistula caused by spillage of material through a gap between the proximal stent margin and the oesophageal wall (‘funnel phenomenon’). This is difficult to manage despite the insertion of additional stents or glue injection to seal the gap. An additional airway stent is usually required. Thus, a contrast swallow is obtained immediately after stent insertion to confirm the sealing of the fistula and subsequently allow a patient to eat a soft diet. If there is persistent leakage through the fistula, resulting from an incomplete stent expansion, a follow-up contrast swallow should be obtained 2-3 days after stent placement in order to confirm stent expansion before food intake is resumed.

• The fistulas may reopen/recur in 0-20% of cases. The reported causes of reopening following stent placement were stent occlusion (caused by tumor overgrowth or in growth, food impaction, or granulation tissue formation), stent migration, and stent covering disruption.

Does stenting have a survival advantage?

A recent study (3) compared treatment of MTEF in three groups:  oesophageal stent group, gastrostomy group and control group (refused both stenting and gastrostomy).

There was no statistical difference in survival time (Average survival time for stent group was 93 days with a range of 44-165 days, gastrostomy group- 62 days, range 41-111 days and control group survival time was 66 days- range 20-119 days).

In two, large series reports (4, 5), mean patient survival was reported to be 3.1-3.4 months. In one of these reports (4), the survival benefit was significant in patients in the stenting group (3.4 months) compared with the gastrostomy group (1.1 months), and the supportive management group (1.3 months).

NB: It is very important to carefully evaluate the airway stenosis with CT scans or

bronchoscopy prior to oesophageal stent placement, since it is possible to develop tracheal compression caused by expanding oesophageal stents. Further, for airway

stenting, reconstructed CT images are very useful for measuring the distance between the fistula and a carina or vocal cord, in the determination optimal stent length.

References:

1.Rodriguez AN, Diaz-Jimenez JP. Malignant respiratory-digestive fistulas. Curr Opin Pulm Med. 2010 Jul;16(4):329-33.

2. Shin JH et al. Interventional management of esophagorespiratory fistula. Korean J Radiol. 2010 Mar-Apr; 11(2):133-40.

3. Hu Y et al. Comparative study of different treatments for malignant tracheoesophageal/bronchoesophageal fistulae. Dis Esophagus. 2009;22(6):526-31.

4. Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008;34:1103-1107

5. Shin JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004;232:252-259

1. The basic principle of achalasia dilatation
2. The common devices used
3. How to actually do it
4. Aftercare

Choosing the correct patient

1. If you cannot pass the endoscope beyond the narrowing at GOJ , reconsider your diagnosis and consider pseudo-achalasia
2. A thorough endoscopic examination is important, with particular attention given to the GOJ, where malignancy can simulate achalasia (pseudoachalasia).
3. It is very important that your diagnosis of achalasia is quite firm  ideally with endoscopic, Barium swallow and manometry findings.
4. Quite high risk procedure (5% chance of perforation)- so discussion in the clinic with the patient is important while discussing the alternatives (Laparoscopic cardiomyotomy)
5. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
6. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the dilation
   

Procedure

Choice of balloon

1. A 30 mm balloon is used for a first dilatation. Subsequent dilatation may involve larger balloon- 35 and 40cm.
   This are quite big sized balloon compared to standard stricture dilatation balloons- the idea being to rupture the muscle fibres.
2. Inflate the  balloon before use to check for any leaks
3. We  describe the  OTW ( over the wire) achalasia balloon from Rigiflex™ II ( Boston Scientific)


Picture1: RigiflexII achalasia dilatation balloon: Courtesy Boston Scientific

4. Another frequently used balloon is Wilson-Cook


Picture2 and 3: Wilson-Cook achalasia dilatation balloon and the inflation and luminal port

5. Another alternative is reusable balloon (shown below)


Picture4 and 5: Reusable achalasia dilatation balloon with the pressure gauge: the endoscope goes through the top end of the yellow tube and comes out below the balloon

Positioning the balloon across the LOS

1. A guidewire is passed through the biopsy channel of the endoscope into the stomach and the scope is withdrawn to the GOJ.
2. Note the distance between the incisors and the GOJ along the length of the scope.
3. The endoscope is then removed (taking care to maintain the position of the guidewire in the stomach- push/pull technique).
4. As an aid in initial placement, a marker (such as a paper tape/ tippex) can be placed on the shaft of the dilating catheter to correspond to the previously noted distance from the incisors to the GOJ.
5. This distance should be measured from the middle of the balloon on the dilating catheter.
6. The balloon and tip of the shaft is lubricated and passed over the previously placed guide wire until the marker is in place at the incisors- that means the midpoint  of the balloon is now at GOJ.
   

Actual dilatation

1. Using fluoroscopy, the balloon is then gradually inflated with air, noting the position of the developing waist.
2. Inflation is achieved with a 50ml syringe attached to the balloon port with a 3 way stopcock ( one end to catheter, second to syringe and third port to the pressure gauge)
3. The balloon is inflated with air
4. Small adjustments usually have to be made in the position (deflating the balloon each time) to ensure that the waist occupies the centre of the balloon- balloon will slip downwards if you are too down and then you will have to exert a pull upwards and vice versa- called the cone effect
5. After a satisfactory position is obtained, the balloon is fully inflated (usually requiring about 120 mL of air).
6. The required pressure will be specified on the moulded junction- average 7-15 PSI
7. The balloon is kept inflated for 60 seconds, during which patients may be very  uncomfortable- give pethidine or fentanyl 2 minutes before the dilatation
8. After the 60 seconds are over, the balloon is rapidly deflated.
9. Sudden disappearance of the waist is very suspicious of rupture
10. Thereafter, perform another full inflation for 60 seconds and again note the pressure required to obliterate the waist. This is usually less than the initial pressure
11. Another alternative is reusable balloon-
    • The scope here is passed through the balloon and then the scope is introduced beyond GOJ- a J manoeuvre confirms part of the balloon beyond the GOJ ( see picture)
    • The side catheter containing the inflation port is attached straight to a inflation device with a pressure gauge ( see picture)
    • Pressure of 200mm kept for 2minutes and then release

Aftercare:

1. The patient is observed for the next five to six hours during which serious complications, such as perforation would be obvious
2. Routine post procedure CXR is advisable
3. Follow up in clinic to assess response

Here is the link for achalasia dilatation video

Acknowledgement/Bibliography:

1. Khan AA et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of balloon distention time. Am J Gastroenterol 1998; 93:1064-1067
2. Kadakia SC et al.Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary achalasia. Am J Gastroenterol 1993; 88:34-38
3. Barkin JS et al.Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990; 36: 123-125
4. Product guide of the respective companies- Wilson-Cook and Boston Scientific

1. How to determine the location of the foreign body
2. How urgently the endoscopy needs to be done
3. How to use an overtube
4. How to grab the FB
5. When can you wait and watch
6. Food bolus obstruction

Location of the foreign body:

1. Two important questions-What is it and Where  is it ( Pharynx/Larynx/trachea/oesophagus etc)
2. Take history and get an x-ray of neck/CXR /AXR depending on the history and clinical suspicion
3. Remember -Bones may not show on x-ray
4. Get both coronal and sagittal views- if in doubt
5. Beware of airway compromise

How urgent is the need for an endoscopy?

1. Immediate if
   • Complete obstruction
   • Sharp – up to 35% perforate
   • Battery – burn within 2 hours and can perforate within 6 hours
2. Everything else within 24hours


Picture1: An overtube
How to use and overtube

3. Use overtube- prevents repeated intubation and protect airway and mucosa
4. Thoroughly lubricate the inside and the outside of the overtube
5. Pass the endoscope through the overtube- the thicker and corrugated end remains outside the oral cavity – then intubate and advance the gastroscope
6. Keep the tip of the overtube in the lower oesophagus while you find the foreign body as it immediately deflates the stomach and view will be compromised
7. Once FB is viewed and position located – do a J manoeuvre and advance the overtube – note the tip protruding through the GOJ- both overtube and the scope is black but scope has got white ring marking
8. Next withdraw the overtube just within the GOJ and inflate the stomach again
9. Find the foreign body and grasp it – use Roth net for battery, for razor blade use stent grabber- anything sharp – you need to grab it along its axis and not across
10. Pull the scope very close to GOJ
11. Advance the overtube OVER the scope to cover the sharp object – we find it more convenient than to pull the scope into the overtube
12. Immediately the whole field will look black
13. Withdraw the endoscope and FB together keeping the overtube in place
14. Can go back again if more FB is to be picked
15. Remove the overtube at the end

How to grab the FB

1. Tool kit- snare/triprongs/Roth net/Suction cap/biliary basket/Rat toothed forceps


Picture2: Capuchon hood

2. Capuchon hood is another device which can be used instead of overtube in selected cases- it is fitted at the tip of the endoscope and looks like a rubber skirt which invaginates itself once the scope is withdrawn into the GOJ and then covers the FB
3. Dry run outside the patient with similar objects- ensure the size of the FB is compatible with the holding size of your device
4. Move with pointed end trailing
5. If both ends pointed cover one with forceps
6. For razor blades rat toothed forceps ( stent grabbers) are probably best as with other devices you can catch it across which is problematic
7. If perforation- conservative management only in highly selected cases (endoclips or covered stents)- most require operation

When can you wait and watch

1. If the patient is
   • Asymptomatic
   • Blunt FB
   • Inert FB
   • Not>5cm
   • Healthy gut
2. Warn to report symptoms
3. Check X-Ray

Food bolus obstruction:

1. If complete obstruction with saliva drooling urgent OGD
2. Once visualised one can either
   • Pull- Forceps/snare/net/grasper
   • Push it down in to the stomach by using
     • Air insufflations
     • Gentle pressure
     • Fragment and gentle pressure
3. Success 97%
4. Remember to take oesophageal biopsy particularly if young male to exclude Eosinophilic oesophagitis
5. If narrowing is seen once the bolus is gone- e.g. benign stricture, web, schatzki’s ring or malignant stricture – that needs to be addressed then or later depending on the pathology.

Here is the link for foreign body extraction video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Alhaji M et al. Razor blade removal from the stomach utilizing a novel modification of the overtube. Endoscopy. 2009;41 Suppl 2:E166. Epub 2009 Jul 23.
2. Webb WA et al.Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology. 1988 Jan;94(1):204-16.
3. Stack LB et al. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. 1996 Aug;14(3):493-521.

1. When to use balloon dilatation
2. What is a TTS balloon
3. How to assess the length of the stricture
4. How to set it up
5. Which size of balloon to choose
6. How to actually use it once it is set up
7. Situation when stricture is impassable with scope- the need for screening
8. Aftercare
9. Titbits

When to use balloon dilatation

• It is normally used to dilate benign oesophageal strictures- eg peptic stricture, post operative stricture, post radiotherapy stricture, corrosive injury related stricture.
• This is not used for dilatation of achalasia – a separate Achalasia balloon is used.
• Malignant strictures are treated with self expanding metal stents rather than by dilatation as risk of oesophageal perforation is high.

What is a TTS balloon

1. CRE ™ ( controlled radial expansion ) wire guided Balloon Dilatation Catheter (Boston Scientific)  is  commonly called TTS ( Through the scope) balloon
2. It is capable of being inflated to three distinct and progressively larger size diameters depending on the inflation pressures.
   
   Picture1 and 2: Higher ATM will produce greater dilatation: ATM is shown on the outer dial
3. It is designed to pass through the working channel of an endoscope and accept a guide wire through it’s lumen
4. Standard sizes are
   • 8-9-10mm
   • 10-11-12mm
   • 12-13.5-15mm
   • 15-16.5-18mm
5. Usually length of balloon is 5cm and is same for different balloons and they differ only in the post inflation diameters.
6. While choosing the size, remember a standard gastroscope tip is 10mm diameter and if cannot pass the stricture then oesophageal lumen is less than 10mm.
7. It will come with a guide wire is situ
   • Confirm the blue guide wire tip is positioned inside the transparent catheter tip and move the locking device switch to ON position. This will prevent guide wire movement during the scope introduction.
     
     Picture3 and 4: The blue guide wire is visible just inside the tip of the balloon: The guide wire is seen protruding from guide wire port; the white lock is on, so that wire will not move
   • Once endoscope is in position if you want to use the guide wire make sure the locking device switch is in OFF position and then you can advance the guide wire through the stricture.
   • But very often, a separate jagwire is used rather than the guide wire supplied, particularly in impassable strictures when the lumen is not clearly visible distal to the stricture ( radiological screening is mandatory in these cases)
   • The balloon hub of the catheter is attached to an integrated inflation system such as ALLIANCE™ or other 60cc inflation device with a gauge to monitor the balloon pressure.


Picture5 and 6: The Alliance single use syringe/Gauge assembly: The actual inflation device- blue knob to green arrow will allow inflation, blue knob to red arrow allow deflation while if it is vertical the piston moves freely either way- position when you initially fix the filled syringe to the inflation device

8. And during the passage of the balloon through the biopsy channel spray the outside of the catheter with silicone gel and suck the balloon in.
9. Do not test the balloon- it might not pass through the channel then.
10. Bougies use shearing force rather than radial force and are infrequently used for dilatation.

How to assess the length of the stricture

1. If you can pass the stricture it is easy to calculate.
2. If not- to get an idea about the length of the stricture – under fluoroscopy measure the distance between the tip of the endoscope (keep it the level of the stricture) and the stomach air shadow. The diameter of the normal gastroscope tip is 10mm
3. It is better to squirt some contrast above the stricture and delineate the whole length.
4. It is unusual for the benign strictures to be very long.
5. Remember the length of balloon is fixed and is 5cm and is same for different balloons and they differ only in the post inflation diameter.

What do you need

1. You will need different sized CRE balloons
2. The inflation device
3. The Alliance single use syringe/Gauge assembly ( it includes a 50ml syringe to be filled with water ( or contrast if screening is needed)

Which size of balloon to choose

1. Remember the tip of a normal endoscope is roughly 10mm- if it does not pass start with a 8-9-10mm CRE TTS balloon
2. Although unless you inflate to the manufacturer’s recommended pressure 3ATM for 8mm dilatation, 5.5ATM for 9mm dilatation and 9ATM for 10mm dilatation the balloon diameter will not be what you are hoping
3. However most gastroenterologists stay below the limit. Be guided by the radiological waist ( how much of the ‘predilatation waist’ is gone) and repeat the procedure at a later date rather than be aggressive.

How to actually do it

1. Pass the endoscope up to the point of stricture
2. Pass the CRE balloon catheter through the biopsy channel after spraying the outside with silicone gel and sucking the balloon flat.
3. The assistant will prepare the device by
   • Aspirating  water in the syringe up to the red mark and fit in the inflation device
   • Connect the balloon port of the catheter to  the inflation device
4. Pass the half of the length of the balloon through the stricture
5. Keep the guide wire locked in and make sure it is inside the tip of the balloon- it is quite stiff and gives the balloon some stiffness.
6. Once the balloon is across the stricture you can remove the wire after sliding the white locking device to off position
7. The assistant will inflate the balloon with water by squeezing  the inflation device repeatedly
8. Blue knob to green arrow will allow inflation, blue knob to red arrow allow deflation while if it is vertical the piston moves freely either way- position when you initially fix the filled syringe to the inflation device
   
   Picture7: Before you start inflating the blue knob to be turned to green arrow
9. Maintain the endoscopic view of the balloon all the time
10. At first fill it only partially to make sure the balloon is sitting across the stricture i.e.  to catch the stricture
11. Then increase the pressure gradually noting the manometer reading.
12. This is the time when the balloon might slip- called cone effect.
13. The balloon will slip  upwards if the major portion of the balloon happens to be above the stricture( then maintain inward push on the balloon catheter  )
14. The balloon will slip downwards if the major portion of the balloon happens to be below the stricture (then you need to exert outward pull)
15. Each balloon will pass through 3 different diameter depending on inflation
16. Remember not to dilate it too much in one endosocpy session
17. Keep the pressure on for 60 secs – if pressure falls ( say from 3 ATM to 2ATM as the stricture dilates ) –and increase it back to the pressure of 3 ATM.
18. After successful dilatation try to go through the stricture and have a careful look. Minor mucosal tear and slight bleeding is expected.

Situation when stricture is impassable with scope- the need for screening

1. When the stricture is impassable but it is a very short segment stricture and you can clearly see the lumen distally – you can proceed as above
2. Other than that the dilatation needs to take place under radiological screening according to the following steps
3. Here you might need an additional three way tap and a 20ml syringe filled with contrast solution and use it as follows
4. Introduce the scope up to the point of stricture
5. Introduce a white tube/ ERCP cannula through the biopsy channel so that it’s tip rests just above the stricture
6. Pass the guide wire through the white tube/ERCP cannula and then through the stricture
7. Advance the white tube over the guide wire
8. Remove the guide wire and inject contrast and screen to make sure the white tube is in the stomach
9. Reintroduce the guide wire and withdraw the endoscope and the white tube by pull/push technique leaving the guide wire in.
10. Introduce the TTS balloon over the guide wire and simultaneously introduce the endosocpe along side up to point of stricture
11. Advance the balloon through the stricture
12. Inflate the balloon with contrast after catching the stricture with the balloon – two ways it can be done- either normally by the inflation device or better in the following way
    • Inflate the balloon with contrast by inflating from the 20ml syringe fitted to the TTS balloon catheter via a three way tap
    • In this way the balloon will catch the stricture easily rather than by the slow inflation with the inflation device
    • Once you think you got the stricture, change the three way tap to the inflation device and start inflating again
13. Rest is similar to the procedure without the screening but here you keep a careful eye on the screen and look for the stricture and gradual dilatation. Sometime a residual waist will remain in first attempt at dilatation for very tight strictures.
14. If dilatation is successful it is expected that you will see blood and minor mucosal laceration
15. Inject contrast proximal to the stricture and look for any leak

Aftercare:

1. CXR after 2-4hrs to exclude oesophageal perforation- this is not routine practice particularly if straightforward procedure and post dilatation visual check and contrast check is ok but is a safe practice.
2. If OK patient can eat and drink
3. Admit the patient if subcutaneous emphysema, persistent or worsening pain and evaluate for perforation
4. Follow up in clinic to assess the response- prefer to calculate a dysphagia score pre and post procedure

Titbits:

1. Previously Eder-Peustow dilatation olives or Savary-Gillard dilators ( Wilson-Cook) was standard- which exerts an unnecessary longitudinal shear force on top of radial dilatation force but has the advantage of tactile sensation of the feeling of resistance which acts as a safeguard- no good evidence that these are more dangerous or less effective than the TTS dilator.


Picture8 and9: Eder-Peustow dilatation olives on flexible shaft

Picture 10: Savary-Gillard PVC dilators

2. The TTS balloon dilatators are standard these days but these does not provide any tactile feedback.
3. With these dilators the rule of 3 is- do not more than three consecutive dilatation at 1mm increment
4. Remember 1F=0.3mm eg 7F=2.1mm
5. Lumen of 13mm is enough to relieve the symptom of dysphagia

Here is the link for Oesophageal stricture dilatation video:

Acknowledgement/Bibliography:

1. Tytgat GN. Dilation therapy of benign esophageal stenoses. World J Surg 1989; 13:142-148
2. Marks RD et al. Peptic strictures of the esophagus. Am J Gastroenterol 1993; 88:1160-1173
3. Scolapio JS et al. A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc 1999; 50: 13-17
4. Product guide of the respective companies- Boston Scientific

1. What do you need
2. Assessment of the stricture- choosing the length of stent
3. Basic principles
4. Choosing the stent
5. How to choose the diameter of the stent
6. How to deploy
7. Aftercare
8. Complications
9. Titbits

What do you need

1. Stent
2. ERCP cannula and long guidewire (450cm)
3. Lipoidol contrast
4. Injector needle or simple paper clip attached to adhesive tape
5. Paediatric gastro/colonoscope if  available for impassable stricture

Assessment of the stricture and choosing the length of the stent:

• Ideally assess the length and anatomy of the stricture by direct vision if possible.
  • Most centres that does frequent oesophageal stenting will have a paediatric endoscope.
  • Paediatric gastroscope is usually 3mm diameter and paediatric colonoscope 7mm diameter and most of the strictures will allow these paediatric scopes to pass.
• You have to leave at least 2-3 cm above the top of the stent and the upper oesophageal sphincter ( cricopharyngeal )
• How to estimate the length of the stricture, if the stricture is impassable:
  • Under fluoroscopy measure the distance between the tip of the endoscope (keep it the level of the stricture) and the stomach air shadow. The tumour normally then can be all the way down to the GOJ but more commonly a few centimetres only ( be guided by the CT Scan findings )
  • Other techniques that can be used
    • Once you opacify the stomach rugal fold by injecting the contrast through the ERCP cannula- withdraw while injecting and as it passes through the stricture it delineates the stricture.
    • Inflate a biliary dilatation balloon 15mm and withdraws until it is stuck where the stricture begins.
• Mark the top end of the stricture with
  • A metal clip taped to the bare skin at the proximal end of the stricture (fluroscopically)
  • Or inject contrast intramucosally at the top of the stricture
  • Put an endoclip at the top end of the stricture
• If you under estimate the length of the tumour then you might have to dove tail another stent through the first stent-so if  in doubt go for the longer stent in the first instance.
• Stent should be 3-4cm more than the stricture length – 2cm above and 2cm below the stricture plus the stricture length, so for a stricture of 5cm the stent length would be 5+2+2= 9cm

How to assess the diameter of the stent

If adult gastroscope cannot pass the stricture , the diameter of the stricture is less than 10mm
Choose the diameter which is 1-4mm larger than the largest reference oesophageal diameter, to achieve secure placement
Standard stent is of 18mm diameter but if the scope can pass the stricture bigger diameter may be needed e.g. 22mm

Basic principles

When you can pass the stricture with the gastroscope

• Measure the actual length of the stricture with paediatric/adult gastroscope and whether the GOJ is involved
• If using adult gastroscope inject Lipoidol contrast to tattoo the top and bottom of the stricture (for tattooing the lower end of the stricture you will have to do J manoeuvre )
• If using a paediatric scope to measure then introduce adult gastroscope to tattoo only the top of the stricture as it cannot take a injector needle through it’s biopsy channel
• After tattooing pass a jagwire into the stomach ( no need for white tube/ERCP cannula or injecting contrast into stomach)
• Some centres do not mark the lower end of the stricture with contrast if they can go through the stricture and some centres mark the top end with other  devices ( see above)

If you cannot go through the stricture

• Mark the top of the stricture/tumour with Lipoidol contrast tattoo at the top only  on two opposite walls ( or use other devices – see above)
• Pass a ERCP cannula  first through the scope ( with a Jagwire through it with the soft tip) up to the beginning of the stricture- do not push the ERCP cannula through the stricture at this stage – it can perforate
• Push guide wire gently into the stomach under fluoroscopic screening
• Learn to identify the stomach shadow and the diaphragm on the fluoroscopy
• Push the cannula  over the guide wire into the stomach under screening
• Inject contrast in the stomach to make sure you are in stomach- you might have to withdraw the cannula if it hits the gastric rugal folds.
• Keep injecting contrast as you withdraw the cannula until you delineate the whole stricture.
• Take ERCP cannula out keeping the jagwire in – pull/push exchange
• Once you are sure that the jagwire is in the stomach/duodenum take the scope out while pushing the guide wire in simultaneously ( left hand pulling out the scope holding the knob and right hand pushing the guide wire in
• The assistant at head end supports  the end of the scope as it comes out the mouth so that it does not suddenly drop causing the jagwire to dislodge and when the scope is out of mouth , assistant will secure the jagwire and then remove  the scope completely

Choosing the stent

• Type- covered and non-covered: advantage of non-covered stent is there is less chance of stent migration but more chance of stent blockage because of tumour ingrowth. Most gastroenterologists use partially covered i.e. non-covered at the end flanges or a sleeve of non-covered segment around the covered midsection (e.g. Niti-S)
• Top/proximal release or bottom/distal release: Most use bottom release but in case of high tumour top release may be preferable as it can be deployed with direct endoscopic visualization ( most companies produce both variety).
• Dimension – varies from 15-18-22mm diameter and 70-100-120mm length. Most common diameter used is 18mm. End flanges are wider and normally 23mm. Choosing the length has already been discussed above.
• Removable or non-removable – when chemo/radiotherapy shrinks the tumour size obviating the need for the stent. Most companies produce both the types but non-removable is the one most commonly used. Removable stent will have a string at the proximal end which can be grasped with a forceps and the stent can be pulled out.
• Different makes from different companies are available:
  1. Pyramed: Niti-S
  2. Alveolus Inc: Alimaxx-E
  3. Boston Scientific: Ultraflex and newer wallflex
• Other variables like foreshortening, radial force, delivery system diameter ( Pyramed’s Niti-S is 16F whereas Boston’s ultraflex is 18F) and flares also come into consideration but beyond the scope of our discussion.
• Recently biodegradable stents are being used to treat benign oesophageal strictures which require frequent dilatations ( SX-ELLA stent)
• Also Pyramed has come up with a TTS oesophageal stent which will be available in very near future.

How to deploy

Picture1and 2: The top green marker in Alveolus stent: The stent has just began to open

• Jelly on the stent tip
• Hold the tip of the stent with the left hand and glide it over the guide wire while holding the guide wire with the other hand
• Screen- the proximal, midpoint and the distal end of the stent is marked with radio-opaque marker. The proximal end will also have a coloured marker for most stent if you are using scope alongside technique.
• Stop when the middle marker of the stent is at the mid-point of the stricture- you might have to zoom out to see all the three markers of the stent
• Or stop when the top of the stent assembly  is 2cm above the top tattoo ( if under direct endoscopic vision see the top marker – eg. Green marker  in Alimax-E)
• Once you start to deploy ( slight variation of actual technique depending on which company you are using, but principle is same)- remember about halfway there is a period of no return for most of the stent ie you can resheath and reposition before you cross this point if you are too far in or out and redeploy again. But once you cross this point you cannot resheath.
• Remember the cone effect-
  • The stent will slip  upwards if the major portion of the stent happens to be above the stricture at the time of deployment( then maintain inward push on the stent assembly  )
  • The stent will slip downwards if the major portion of the stent happens to be below the stricture (then you need to exert outward pull)
• Some gastroenterologists pass the endoscope along side again after passing the stent assembly through the stricture over the guide wire and then pull or push the stent under endoscopic view to keep 2cm of stent above the stricture- advantage is that you are 100% sure that top of the stent is opening above the stricture. Another advantage of the scope alongside technique is that you don’t have to mark the top end of the stricture.
• Throughout the deployment monitor the screen and endoscopic view ( if the scope is alongside) to ensure the waist is developing at the centre of the stent
• Go back with the endoscope and squirt some contrast just at the top of the stent and ensure contrast passes freely into the stomach and there is no contrast leak to suggest any perforation.

Alimaxx-E stent ( Alveolus Inc)

• Pull the white flange of the handle to white flange first
  
  Picture3 and 4: This phase is reversible and stent is half open
  
  Picture5: This is completion and stent is irreversibly deployed
• On screening you will see the stent opening up from below
• Look for flaring of the bottom end – if it does not, the lower end might not have passed the stricture- particularly when you estimated the length of the stricture because it was impassable
• This half is reversible and you can re-sheath the stent
• Then pull the  blue  flange  to the white flange
• This is  irreversible
• Continuously pull outwards as the stent deploys otherwise the stent will slip into the stomach as it opens from below
• Look for the shoulder and flaring above and below the shoulder- the shoulder corresponds to the area of the stricture

Niti-S ( Pyramed)

• Unlock the valve of the Y connector handle once the stent is in position for deployment, by rotating the screw counter clockwise
  
  Picture 6 and 7: Niti-S oesophageal stent- the Y connector handle and the inner shaft: the stent opening at the bottom
• Hold the end ( hub on the inner shaft) and keep it fixed while withdrawing  the outer sheath by holding at the locking screw  ( in contrast to push the inner shaft)
• Visualize the stent fluoroscopically to verify full deployment
• The stent opens from bottom ( if using a top release stent – deployment technique is reverse i.e. push the inner shaft rather than pull the outer sheath)

Ultraflex ( Boston)

• Proximal release covered stent can be deployed under endoscopic method
• After passing the stent assembly over the guide wire pass the endoscope up to the stricture and position the endoscope along the delivery system immediately above the visual marker band ( tight black suture area at the proximal end of the stent- we use TIPPEX to make it even more prominent before passing the stent in)
• Hold the delivery catheter stationary with one hand and using the other hand , grasp the finger ring attached to the handle and pull the finger ring to release and unravel the suture.
• Monitor the stent release fluoroscopically and or  endoscopically.
• Keep the delivery system between the identified stricture margin.

Aftercare

• Liquid diet for 24 hrs and consider a CXR in 2 hours  to check for stent position and exclude perforation.
• PPI, if the stent traverses the GOJ
• Eating advise to patients
  • Even after the stent insertion patient can not eat normal diet – must be blenderized or semisolid or THOROUGHLY chewed
  • Eat upright
  • Frequent sips of liquid during and following the meal

Complications:

• Tumour overgrowth: Options are treatment with Laser followed by re-stenting through the existing stent ( dove tailing)
• Bottom end not opening – balloon dilatation or dove tailing if under estimation of stricture length.
• Stent migration into stomach: migrated stents are very often left alone in teh stomach ( intestinal obstruction with the stent is a possibility). However, you can snare one end of the stent and close to make that end to make a cone and pull out carefully.

Titbits:

• For duodenal or colonic stents principles are the same
• Standard duodenal stents are 20mm and colonic 22mm
• All non covered to prevent migration
• TTS type only
• Use inflated biliary balloon pull back technique to identify the distal end of the stricture.

Here is the link for oesophageal stent insertion  video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Knyrim K et al.A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-1307
2. Austin AS et al.Placement of oesophageal self-expanding metallic stents without fluoroscopy. Gastrointest Endosc 2001; 54:357-359
3. Siersema PD et al.Self-expanding metal stents for complicated and recurrent oesophagogastric cancer. Gastrointest Endosc 2001; 54: 579-586
4. Product guide of the respective companies- Alveolus, Pyramed and Boston Scientific

1. What is BOTOX
2. When to use BOTOX
3. How to make up the solution and ready the device
4. How to actually use it once it is set up

What is BOTOX

BOTOX contains Clostridium botulinum type A neurotoxin complex.

Botulinum toxin injected into the Lower Oesophageal Sphincter (LOS) of patients with achalasia/or pylorus poisons the excitatory acetylcholine-releasing neurons thereby producing a therapeutic decrease in LOS/pylorus pressure

Picture1: BOTOX Allergan 100units, powder for solution for injection Containing Clostridium botulinum type A neurotoxin complex

When to use BOTOX

1. Achalasia- ONLY TO treat elderly or infirm patients for whom pneumatic dilation and surgical myotomy has unacceptable risks. The long-term safety and efficacy remain uncertain
2. Gastroparesis- not very good evidence.

How to make up the solution and ready the device

1. Equipments
   • Injector needle
     
     Picture2: Injector needle
   • Botox (100units)
   • 2ml syringe to calculate needle volume
   • 5ml syringe to draw up after Botox powder has been diluted
2. Dose:
   • Achalasia: 100 units (25units in four sectors) in the GOJ
   • Gastroparesis (idiopathic or diabetic): 100 units (25units in four sectors) in the pylorus
     
     Picture3 and 4: Needle volume is 2ml-1ml=1ml
3. Making up the BOTOX
   • The botox in the vial is almost invisible
   • To determine how much water to dissolve it into first determine the volume of normal saline you need to prime the injection needle
   • Standard injection needle volume is 1ml ( as shown above to see the water drop from the tip you push from 2ml to 1ml)- but always check your needle dead space volume before actual start
   • Then inject 4ml of NS into the vial and gently swirl it without agitation (agitation inactivates botox) and withdraw it into the 5ml syringe.
   • Each ml=25units
   • If your needle volume is more say 1.5ml then dissolve the powder with four times the needle volume so that one fourth of the solution  will have 25units

How to actually use it once it is set up

1. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
2. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the injection
3. After the completion of diagnostic OGD come back to GOJ
4. It is easier to inject on a retroflexed view ( J manoeuvre in the fundus)
5. Prime the injection needle with 1ml of Botox solution
6. When ready say ‘advance needle’ and then Inject 1ml =25U in sector 1 and when finished say ‘ needle back’
7. Similarly inject in sector 2 and 3
8. In sector 4 inject 1ml of NS   which will push the remaining Botox from the injection needle channel.
9. For treatment of gastroparesis inject 25 units in 4 sectors in the pylorus.
10. Make sure the needle is in the muscle layer rather than submucous layer.
    
    Picture6: Fundal retroflexed view:Actual injection needle in use
    
    Picture5: After the GOJ injections

Acknowledgement/Bibliography:

1. Storr M et al.Treatment of achalasia: the short-term response to botulinum toxin injection seems to be independent of any kind of pretreatment. BMC Gastroenterol. 2002; 2: 19.
2. Pasricha PJ et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med. 1995 Mar 23;332(12):774-8.
3. Fishman VM et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. Am J Gastroenterol. 1996 Sep;91(9):1724-30.
4. Product guide of the respective companies- Allergen

What is GORD?

GORD is a condition that develops when the reflux of gastric content causes troublesome symptoms or complications. Heartburn and regurgitation are the characteristic symptoms of GORD. Heartburn is defined as a burning sensation in the retrosternal area. Regurgitation is defined as the perception of flow of refluxed gastric contents into the mouth or hypopharynx.GORD can also cause episodes of chest pain that resemble ischemic cardiac pain, without accompanying heartburn or regurgitation. Epigastric pain can also be the major symptom of GERD

GORD symptoms may occur when upright or supine or both. Symptoms occurring when supine may cause sleep disturbance. Physical exercise may induce troublesome symptoms of GERD in patients who have no/minimal symptoms at other times (exercise-induced gastroesophageal re?ux)

Discuss the mechanism of GORD?

• OG junction incompetence- due to
  • Transient LOS relaxation. There may not be increased frequency of non swallow related relaxation of LOS in pts with GORD but they have higher frequency of acid reflux (as opposed to gas reflux) during LOS relaxation. LOS is relaxed by fat, chocolate, ethanol, peppermint, drugs (nitrates, CCB, theophylline, morphine, diazepam).
  • LOS hypotension without anatomic abnormality.
  • Anatomic distortion of the OG junction inclusive of but not limited to, hiatus hernia
• Delayed oesophageal acid clearance- due to impaired oesophageal emptying and impaired salivary function.

Discuss the diagnosis of GORD?

The typical reflux syndrome can be diagnosed on the basis of the characteristic symptoms, without diagnostic testing.

What are the complications of GORD?

Reflux oesophagitis, haemorrhage, stricture, Barrett’s oesophagus, and adenocarcinoma.
There is no increased risk of Barrett’s or oesophageal cancer with non erosive reflux disease. However 10-15% of NERD progress to erosive disease in US and Europe.

What is the role of endoscopy?

Endoscopy is a poor diagnostic test. Most patients (>50%) with GORD have no visible evidence of oesophagitis at endoscopy, making endoscopic appearance a poor guide to diagnosis and management of GORD. Further, the correlation between endoscopy findings and symptom severity is poor.
Endoscopy may be requested in patients with:

• Long-standing (> 5years) symptoms (to diagnose Barrett’s oesophagus)
• Symptoms unresolved by PPI
• Presence of alarm features like vomiting, gastrointestinal bleeding or anaemia, abdominal masses or unexplained weight loss, and progressive dysphagia

Discuss the endoscopic grading for severity of oesophagitis?

The severity of erosive oesophagitis on endoscopy is usually graded using the Los Angeles classification:
Grade A- One or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds
Grade B- One or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds
Grade C- Mucosal breaks that extend between the tops of two or more mucosal folds, but which involve less than 75% of the oesophageal circumference
Grade D-Mucosal breaks which involve at least 75% of the oesophageal circumference

What is the role of pH monitoring?

Indicated primarily for the investigation of atypical or persistent symptoms despite appropriate therapy

Discuss the management of GORD?

• Mild and infrequent symptoms- antacids or H2RA on a prn basis
• More severe symptoms- PPI once a day. PPIs are superior to H2RA for the reduction of symptoms and healing of oesophagitis with equivalent safety. Standard once daily doses of PPI are esomeprazole 40mg, lansoprazole 30 mg, omeprazole 20mg, pantoprazole 40mg and rabeprazole 20 mg.
• Twice daily PPI is generally not required as initial therapy for typical GORD symptoms. However twice daily standard dose PPI may be used for patients who have severe oesophagitis (LA grade C or D). Twice daily PPI is also used in patients with NCCP or extra oesophageal manifestations of GORD.
• Prokinetic agents are not recommended either alone or in combination with antisecretory agents for the routine initial treatment of GORD

How long to continue the PPI?

The PPI may be discontinued after a period of 4-8 weeks to confirm the need for ongoing therapy. However, the risk of recurrent endoscopic erosions is extremely high without maintenance therapy. Thus long term therapy is recommended for erosive oesophagitis with the aim of preventing recurrent oesophageal injury, in addition to complications such as stricture, haemorrhage, ulceration or Barrett’s epithelium. Currently there is no evidence that PPI therapy prevents the development or progression of Barrett’s epithelium.
Long term maintenance therapy is given at the lowest dose and frequency that is sufficient to achieve optimal control of the patient’s symptoms. Half dose PPI therapy is sufficient to maintain endoscopic remission in about 35% to 95% of patients with erosive oesophagitis. On demand therapy may also be acceptable because oesophagitis recurrence, in the absence of symptoms, occurs in fewer than 9% of patients

What is the role of supplementary night time H2RA therapy?
Supplementary nighttime H2RA therapy is not generally recommended for individuals who have responded incompletely or have failed to respond to standard dose or double dose PPI therapy of adequate duration.

Discuss H. Pylori and GORD?

H. Pylori testing is not necessary before starting treatment for typical symptoms of GORD. Further, it is not necessary to test routinely for H Pylori in a patient taking long term PPI therapy for GORD symptoms.

Eradication of H. Pylori has no clinically relevant adverse effect on the long term outcome of GORD

Background to this debate- There were concerns that the progression of H. pylori gastritis to metaplasia and gastric carcinoma might be hastened by long term PPI therapy for GORD. There is no evidence that PPI is an additional risk factor or that H. Pylori eradication affects the risk of gastric cancer in presence of PPI therapy.
In addition, eradication does not alter the therapeutic dose of PPI or cause an increase in reflux symptoms

What are the indications for antireflux surgery?

• Regurgitation-dominant or volume related reflux symptoms (although there is no proven superiority for surgery for this indication)
• Persistent or recurrent symptoms despite PPI therapy
• Dissatisfaction at continuing long term PPI
• Poor compliance (for example due to costs of PPI)
• Presence of large hiatus hernia

Limitations of surgery
Relapse needing repeat surgery
PPI may be needed after a period
Absence of documented benefit in preventing Barrett’s oesophagus

Prerequisites before surgery
Typical reflux symptoms and erosive oesophagitis on endoscopy or evidence of reflux on pH study

Discuss the extra oesophageal manifestations of GORD?
There is a significant association between GORD and cough, laryngitis, asthma, and dental erosions. Important features:

• These syndromes are usually multifactorial with GORD as one of the several potential aggravating cofactors
• In the absence of heartburn or regurgitation, unexplained asthma and laryngitis are unlikely to be related to GORD
• Medical and surgical treatment trials aimed at improving presumed GORD related extra oesophageal symptoms by treating GERD are associated with uncertain and inconsistent treatment effect.
• A therapeutic trial of a PPI in twice daily dose is indicated in such patients. This trial should be for four months, as a symptomatic response may be delayed. (BSG)
• Potential causal mechanisms of reflux cough, reflux laryngitis, and reflux asthma syndromes include direct (aspiration) or indirect (neurally mediated) effects of gastroesophageal reflux Experimental evidence has demonstrated reflex stimulation of bronchospasm and cough as a response to oesophageal acidification

It is unclear whether gastroesophageal reflux is a significant causal or exacerbating factor in the pathogenesis of sinusitis, pulmonary fibrosis, pharyngitis, or recurrent otitis media

It is unclear whether gastroesophageal reflux plays a role in triggering apnoeic episodes in patients with obstructive sleep apnoea

Discuss the approach to a patient with GORD and non response to twice daily PPI?

Step 1- Check compliance. Exclude contributory causes like alendronate, NSAIDS, KCL, doxycycline etc
Step 2- Consider other diagnoses:

• Look for skin changes- some skin diseases can affect oesophagus like epidermolysis bullosa acquisita, bullous pemphigoid, cicatricial pemphigoid and lichen planus. Lichen planus of oesophagus present with nodules. The diagnosis may be difficult as the skin disease may not be active when their oesophageal disease is problematic.  Oesophageal biopsy from the uninvolved areas usually helps in the diagnosis. These patients require very aggressive immunosuppressive therapy.
• ZES- about 60% patients with ZE syndrome will have associated esophageal complaints.
• Eosinophilic oesophagitis.
• Functional heartburn- A normal 24 hr pH study in the presence of symptoms raises the possibility

Ref

1. The Montreal De?nition and Classi?cation of Gastroesophageal Re?ux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol 2006; 101:1900–1920
2. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults- Update 2004. Can J Gastroenterol Vol 19 No 1 2005
3. The British Society of Gastroenterology Guidelines for oesophageal manometry and pH
4. Monitoring.

What are the causes of oesophageal stricture?

The majority of oesophageal strictures are reflux related. Other causes are malignancy, anastomotic, sclerotherapy, radiation, medication, and corrosive induced strictures, and rings and webs.
Eosinophilic oesophagitis is a recently described emerging cause of oesophageal stricture.

Discuss the role of barium swallow as the first investigation in the diagnosis of dysphagia?

Patients with proximal dysphagia may have a pharyngeal pouch, post cricoid web etc which increases the risk of perforation on endoscopy. Barium swallow may be considered as an initial investigation for investigation of proximal dysphagia, however an endoscopy is safe as an initial test in experienced hands.

Discuss the contraindications to oesophageal dilatation?

• Active perforation
• Severe cardio respiratory disease is a relative contraindication
• The risk is increased in patients with a pharyngeal or cervical deformity or a large thoracic aneurysm.
• Concurrent radiotherapy is not a contraindication for dilatation

Discuss the preparation for dilatation?

• Stop warfarin or convert to low molecular weight heparin (if high risk)
• Aspirin or NSAIDs can be continued
• Antibiotic prophylaxis is not needed

Discuss the types of oesophageal dilators?

Two types of oesophageal dilator are available:

• Mechanical (push dilator or bougie like Maloney dilator or Savary-Gilliard dilators)
• Balloon dilator

Mechanical dilators exert a longitudinal and radial force whereas balloon dilators deliver radial force only. Balloon dilators are widely used and may be passed through the scope. Both mechanical and balloon dilatators are safe and efficacious. The principal disadvantage of balloon dilators is their cost.

What is the diameter to which the obstruction should be dilated?

Dysphagia occurs when the oesophageal diameter is less than 13 mm. Thus a diameter of 13-15mm is generally accepted as the end point of dilatation. A few patients will require greater diameters for symptom relief. Large calibre dilators (16–20 mm) are also advised in the treatment of patients with Schatzki’s rings

Discuss the size of the balloon to be used for first dilatation?

Stricture diameter can be estimated by comparing the stricture to the outer diameter of the endoscope (outer diameter is around 9 mm for diagnostic scopes and 11 mm for therapeutic scopes). A 12 mm balloon can be used for stricture diameter of 5mm or more. A 10 mm balloon should be used for tighter strictures.

How quickly dilatation should be achieved?

No more than three consecutive dilatations should be performed in one session (‘rule of three’).  3X1mm increments- i.e. the luminal diameter should be increased by no more than 2 mm.
Weekly dilatation until 15mm dilatation is a common strategy. As a general rule, the last balloon size in the previous session can be used first.
In some patients symptoms tend to recur rapidly following dilation to adequate diameter of 14-15 mm. Such patients require more frequent dilations based upon symptoms.

Discuss the role of radiological screening?

This is not essential when the anatomy is well defined and the wire passes easily (with wire guided mechanical dilators) into the stomach.   Through the scope balloon dilatation is performed under direct endoscopic visualisation.  Fluoroscopy is not needed if the passage of the balloon into the stomach is clearly visible or if the patient has undergone prior endoscopy (assuring that there is no unexpected pathology or an anatomical variant distal to the stricture)

Radiographic screening is useful when the stricture is tortuous or complex or associated with a large hiatus hernia or diverticulae. It may also be of value when the
guidewire or the balloon meets with resistance during passage through the
stricture.

Discuss the role of CXR or contrast swallow post dilatation?

These investigations are not essential but should be performed urgently in patients who develop pain, breathlessness, fever, or tachycardia.
A chest x ray may show pneumomediastinum, pneumothorax, air under the diaphragm, or a pleural effusion but normal appearances do not exclude
perforation and, if there is any clinical suspicion, a water soluble contrast study should be performed.

Discuss the complications of oesophageal dilatation?

• Perforation (benign- 1.1%, malignant- 6.4%)
• Pulmonary aspiration
• Bleeding

Discuss the safety of mucosal biopsy before dilatation?

Biopsies, if needed, are taken after dilatation, although there is no evidence that pre dilatation biopsy is harmful

Discuss the management of benign refractory strictures?

Options to prevent stricture recurrence:

• Consider 24 hour pH monitoring on PPI therapy to check on adequacy of acid suppression. Consider increased PPI or anti-reflux surgery as needed.
• Intralesional injection of steroid may reduce stricture recurrence following dilatation.  Prior to dilatation, 0.5 ml of triamcinolone acetonide (40mg/ml diluted 1:1 with saline) is injected in four quadrant in the stricture.
• Temporary placement of non metal expandable stents can be effective. Further studies are needed

Ref

1. The British Society of Gastroenterology Guidelines on the use of oesophageal dilatation in clinical practice

Oesophageal dysmotility is defined as motility that differs significantly from accepted normal variations. The clinical significance of this is unknown. With the exception of achalasia, the relationship between the manometric patterns and clinical symptoms remain controversial. Oesophageal dysmotility could be primary or secondary to systemic diseases like scleroderma, diabetes, Chagas disease, chronic GORD and chronic idiopathic intestinal pseudo obstruction.

Discuss the clinical features of oesophageal dysmotility?

Dysphagia and chest pain

Classify oesophageal motility disorders?

3 types- hypercontracting, hypocontracting, and discoordinated motility. Hypocontracting motility disorder may be caused by GORD

Discuss the manometric findings of motility disorders?

Discuss the management of motility disorders?

There are no effective treatments as the pathophysiology and the relation of the motility findings to symptoms remain obscure.

Calcium channel blockers (diltiazem 180-240 mg/day) or tricyclic antidepressant (trazodone 100-150 mg/day or imipramine 25-50 mg/day) may provide symptomatic relief.

There are anecdotal reports of use of nitrates, botulinum toxin, bougie dilatation etc.

What are the clinical features of oesophageal candidiasis?

The hallmark of oesophageal candidiasis is dysphagia or odynophagia. However, the patients may be asymptomatic too. It often occurs together with oral thrush; however absence of thrush does not preclude a diagnosis of oesophageal candidiasis.

What is the causative organism?

C. albicans is almost always the infecting organism. Symptomatic infections caused by C. glabrata and C. krusei alone have been described

What are the risk factors for oesophageal candidiasis?

• HIV infection- oesophageal candidiasis is an AIDS defining illness and occurs with CD4 counts less than 200/microL.
• Haematological and non-haematological malignancies
• Chemotherapy or use of broad spectrum antibiotics
• Use of inhaled steroids

Discuss the diagnosis?

Diagnosis is made at endoscopy when white plaque like lesions is noted in the oesophagus. Brushings/biopsy of the lesions reveals presence of candida pseudohypahe

What is the treatment?

• Systemic antifungal therapy is always required for treatment. Oral fluconazole (200 to 400 mg daily for 14 to 21 days) is the drug of choice due to its lack of toxicity and cost. Symptoms improve within 7 days.
• For ?uconazole-refractory disease, itraconazole solution at a dosage of 200 mg daily, posaconazole suspension at a dosage of 400 mg twice daily, or voriconazole at a dosage of 200 mg twice daily administered intravenously or orally for 14– 21 days is recommended.
• Intravenous ?uconazole at a dosage of 400 mg (6 mg/kg) daily, Amphotericin B at a dosage of 0.3–0.7 mg/kg daily, or an echinocandin (caspofungin, micafungin and anidulafungin) should be used for patients who cannot tolerate oral therapy.
• Suppressive therapy with ?uconazole at a dosage of 100–200 mg 3 times weekly is recommended for recurrent infections

Discuss the role of presumptive treatment?
The presence of oropharyngeal candidiasis and dysphagia or odynophagia is predictive of oesophageal candidiasis. A therapeutic trial with ?uconazole for patients with presumed oesophageal candidiasis is a cost-effective alternative to endoscopic examination. If symptoms fail to improve within 7 days of treatment, endoscopy must be performed to exclude other causes of symptoms

Discuss side effects of azole therapy?

Azole therapy can be associated with gastrointestinal upset; prolonged administration can cause hepatotoxicity.
Azoles are teratogenic and are thus contraindicated in pregnancy. Amphotericin B is the recommended treatment for candidiasis in pregnancy.
Pic 1 Oesophageal candidiasis

?Ref

1. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America