World J. Surg. 14, 518--522, 1990

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World Journal of Surger7 9 1990 by the Soci›233

Internationale d e Chirurgie

Comparison between Savary-Gilliard and Balloon Dilatation of Benign Esophageal Strictures Eliahou Shemesh, M.D., and A b r a h a m Czerniak, M.D. Departments of Gastroenterology and Surgery, The Chaim Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel The efl9 and safety of the 2 most commonly used endoscopic dilators, Savary-Gilliard and pressure balloons, were compared in 2 groups, each including 30 patients, with benign esophageal strictures. Four additional patients with tight and tortuous cervical esophageal strictures were initially managed by baUoon dilatation followed by Savary-Gilliard dilatation. These patients could not be dilated by eaeh of the methods alone. Sixty patients [35 males and 25 females with a mean age of 52 years (range, 4-91)] underwent 165 esophageal dilatations. The etiologies of strictures included reflux esophagitis (65 %), caustic damage (18.3%), and postoperative (anastomotic, or post-Nissen operation) in 16.7%. Dysphagia improved in ail patients; however, 2 patients (1 from each group) with hard postoperative anastomotic stricture eventually underwent surgieal resection of stricture. There were no major complications or mortality related to the dilatations. Both methods were highly effective and weil tolerated, yet Savary-Gilliard dilators were slightly more effective and simpler to use than balloons. Nevertheless, tortuous cervical strictures and multiple close|y-placed strictures were more effectively managed by initial use of bailoon followed by Savary dilators.

Endoscopic dilatation of benign esophageal stricture (EDBS) is safe and highly effective in relieving dysphagia [1, 2]. Due to progress in endoscopic technique and to the introduction of improved dilators, EDBS has become a simple (mainly outpatient) procedure requiring light sedation [2]. Fluoroscopic control is not routinely needed during dilatation, and surgical repair of esophageal strictures is rarely indicated [2]. Two main methods of dilatation are available--axial (push through of rigid dilators) and radial (balloon infation). Various types of axial and balloon dilators are used and, sometimes, the combination of the 2 types of dilators was recommended [2]. Nevertheless, the exact indications for each method have not been fully established. The aire of the present study was to compare prospectively the efficiency, safety, and patient tolerance of the 2 most commonly used dilators for EDBS--Savary-Gilliard and balloon dilators. Reprint requests: Eliahou Shemesh, M.D., Gastroenterology Department, The Chaire Sheba Medical Center, Tel Hashomer 52621, TelAviv, Israel.

Material and Methods

From January, 1985 to December, 1988, a total of 64 patients (37 males, 27 females; mean age, 52 years, range 4-91) underwent endoscopic dilatation of benign esophageal strictures. The diagnosis was based on typical radiologie and endoscopic appearance and on negative biopsies for malignancy. SavaryGilliard dilators were used in 30 patients and balloons in 30 patients. Four additional patients, all with long and tortuous cervical strictures, could be dilated only by the combination of balloons and Savary dilators. The study was prospective and randomized. The patients' clinical data are listed in Tables 1 and 2. Ail patients had dysphagia (a sensation of difficulty in the passage of food through the esophagus when swallowing) [3]. Dysphagia was graded into mild (intermittent arrest of solid food), moderate (steady arrest of solids and intermittent for liquids), and severe (steady arrest of solids and liquids). Seventeen patients presented with acute food bolus impaction. The strictures in the 2 main groups were due to reflux esophagitis in 65% (including scleroderma in 6.7%), caustic in 18.3%, and postoperative in 16.7% of patients. Esophagitis was graded as previously detailed [4]. All patients underwent standard barium meal study [4]. The diameter and length of strictures were measured from barium and endoscopic studies [5, 6]. Ail patients received maintenance antireflux combined medical treatment. Treatment in each patient included metoclopramide (or domperidone) 10 mg 3-4 times per day, free use of antacids, H2-receptor blockers (cimetidine 800-1,200 mg/day, or ranitidine 300-450 mg/day), and when symptoms were still marked, a combination of sucralfate 1 g 3 times a day and ranitidine 300 mg at bedtime was used. Both groups received antireflux medical treatment according to the same rules. All patients were also instructed to elevate the head of their beds, to eat smaller meals at more frequent intervals, and to avoid sleeping horizontally immediately after eating. Esophagoscopy was performed using the Olympus type gastroscopes GIF XQI0 & 20 and P2 after light intravenous sedation (Demerol | and diazepam). Biopsies were taken from mucosa inside the stricture. The first dilatations were done during hospitalization, and subsequent dilatations were usually performed as outpatient procedures.

E. Shemesh and A. Czerniak: Esophageal Strictures

519

Table 1. Clinical data of patients with esophageal strictures dilated

Table 3. Results of endoscopic dilatation.

by 2 methods of endoscopic dilatation.

No. of patients No. of dilatations a Mean age (range): Yr Male:Female Mean duration of symptoms (range): Mo Location of stricture Upper Middle Lower Esophagitis Severe Moderate Mild Mean diameter of stricture (range): mm Multiple (2 or more) esophageal strictures Mean length of stricture (range): mm

SavaryGilliard

Balloon

Balloon and SavaryGilliard

30 81 51 (4-91) 18:12 17 (12-31)

30 84 53 (4-86) 17:13 15 (10-42)

4 10 51 (10-89) 2:2 12 (6-30)

4 5 21

3 6 21

4 0 0

15 8 7 5 (2-7)

14 10 6 5 (3-7)

2 2 0 5 (3-6)

3 22 (10-70)

2 25 (10-90)

2 35 (25-50)

y Until an 18-mm size balloon or 17-mm Savary dilator could be easily passed. Table 2. Causes of esophageal stricture.

Reflux esophagitis ` Caustic Postoperative Anastomotic b Post-Nissen procedure Total

SavaryGilliard

Balloon

19a 6 5 3 2 30

20a 5 5 3 2 30

Balloon and SavaryGilliard 0 4 0 4

a Including 2 patients with scleroderma in each group. 87Esophagogastric anastomosis.

Savary-Gilliard dilatations were started by passing a flexible guidewire through the endoscope beyond the stricture into the stomach, and with withdrawal of the endoscope, leaving the guidewire in place. The position of the guidewire in the stomach was documented by fluoroscopy. A series of Savary-Gilliard dilators (from 6 to 17 mm in diameter) were pushed through the stricture. Dilatations were stopped when a significant resistance was reached. Balloons (Rigiflex TTS | Microvasive, Inc., Milford, Massachusetts, U.S.A.) of 6 to 18 mm in outer diameter were pushed beyond the stricture (guided by their flexible tip) and then pulled back until their proximal mark was located above the stricture. Balloons were inflated with a 35-60 Psi filling pressure, as specified by the manufacturer for each individual balloon, and held inflated in the stricture for 1 minute. In 4 patients, with long, tortuous strictures located in the cervical esophagus, a combination of the 2 methods of dilatation was used, as previously reported [2]. The aim of dilatation was to easily pass an 18-mm baUoon or a 17-mm Savary dilator through the stricture. A water-soluble contrast

SavaryGilliard

Balloon

p value

No. of patients 30 30 Mean no. of dilatations 2.7 (1-4) 2.8 (2-4) (range)" Success rate (%) 96.7 96.6 Surgery: No. of patients 1 1 Mean follow-up (range): Mo 13 (6--24) 15 (6-30) Recurrence of dysphagia b No. of patients (%) 11 (36.7) 17 (58.6) Not significant Not significant Mean time interval (mo) 11 6 % successful dilatation 100 100 a Until the stricture diameter was >9 mm on barium meal. b Within 12 months.

medium swallow study was performed immediately after the procedure whenever pain was severe or protracted following the dilatation. Barium meal was performed electively 1-2 months following a full series of dilatations in ail patients to monitor the success of dilatations by comparing the size of the stricture after dilatations. Ail patients underwent repeated endoscopy within 7-14 days following initial treatment and dilatation was repeated if needed (based on endoscopic appearance or persistence of stricture waist in radiology). Thereafter, clinical evaluation was repeated every 1-2 months for 6 months, and then every 3 months for 2 years. Endoscopy and dilatation were repeated when dysphagia had recurred or increased. Statistical analysis of results was performed using chi square analysis and Fischer exact tests as suitable. Results

The results of the study are presented in Table 3. Eighty-one dilatations were performed with the Savary-Gilliard dilators (2.7 per patient) and 84 dilatations with balloon dilators (2.8 per patient). Dilatations were continued until at least a 17-mm dilator could be passed through the stricture. Both groups of patients were matched for age, sex, and the etiologies of esophageal stricture.

Radiologic and Endoscopic Findings Most strictures were located in the lower (70%) or middle (18.3%) thirds of the esophagus. Cervical strictures were found in 11.7% of patients; ail were either due to caustic damage or postoperative. The length of strictures was 10-30 mm in 86.7% of patients, 4-6 cm in 4 patients, and 7-11 cm in 4 patients. Four patients had multiple (2 or 3) strictures; ail were due to caustic damage. The mean diameter of strictures was 4 mm (range, 2-7). Esophageal p l i was less than 4 in ail patients. Esophagitis (based on endoscopy and histology) was present in ail patients: severe in 49%, moderate in 29%, and mild in 22%.

Dilatations Ail patients had an immediate relief of dysphagia after the first dilatation although esophageal p l i remained unchanged following the procedure. The mean diameter of strictures after dila-

520

tation was 13 mm (range, 10-16), an increase of 9 mm in mean diameter. Esophagitis has improved to varying degrees in all patients after dilatation. Two patients (l from each group) underwent surgical resection of hard strictures which recurred early after dilatations and persisted. One patient died postoperatively and the other recovered.

Technical Difficulties Technical difficulties were regarded in relation to location, duration, diameter, and type of stricture. High, tortuous cervical strictures and postoperative anastomotic strictures were the most difficult to dilate. In our experience, an initial dilatation with a 6-10-mm diameter balloon creates a funnel facilitating the introduction of a guidewire through such strictures. Thereafter, Savary-Gilliard dilators were easier to use in these strictures. Longstanding strictures did not cause unusual technical difficulty during dilatations. Five of our patients had strictures for 3-38 years with failed prior dilatations. Both methods of dilatation were successful and well tolerated both in infants and in adults.

Relative Effectiveness of Both Methods The Savary-Gilliard dilator was slightly more effective and simpler to use than the balloon dilator in achieving both an increase in diameter and in duration of improvement; however, balloon dilators were more helpful in long, tortuous strictures and in multiple, closely-placed strictures mainly in the cervical esophagus.

Complications and Mortality There were no major complications or mortality related to the procedure; however, 6 patients with tight hard strictures had local pain for 3--6 days following dilatation which was alleviated by analgesics. Repeat endoscopy has not detected specific pathology.

Follow- Up Patients were followed up for 6--36 months (mean, 16) after dilatation. Dysphagia recurred during follow-up in 36.7% and 58.6% after Savary-Gilliard or balloon dilatations, respectively. There were 20% more recurrences after balloon dilatations, but this did not reach statistical significance. The interval until recurrence of dysphagia was longer after Savary-Gilliard dilatation as compared to balloon dilatation. Dysphagia was relieved in ail patients by a repeat dilatation. Discussion

The present study, again, demonstrates the effectiveness and Safety of EDBS [1, 2]. Although both studied methods of dilatation were highly effective in relieving dysphagia, the Savary-Gilliard method was siightly more effective in achieving a wider diameter and a longer duration. Yet, in our experience, a Combination of Savary-Gilliard and balloon dilators was beneficial in long, tortuous cervical strictures or in multiple,

World J. Surg. Vol. 14, No. 4, July/Aug. 1990

closely-located strictures where the passage of a guidewire is hazardous [7]. Peptic esophageal strictures occur mainly in old and frail patients [8], while caustic damage is more frequent in young patients [9]. Benign esophageal strictures are initially treated by a forceful dilatation and, when symptomatic stricture persists, surgical resection or bypass of stricture is undertaken. Due to recent technical progress and to the development of improved dilators, EDBS has become a simple, well-tolerated, highly effective procedure, and surgery is rarely indicated [2]. The Savary-Gilliard dilators produce an axial force on the stricture during dilatation, white balloon dilators execute a radial force directed to the stricture waist. High cervical strictures [2] and hard postoperative anastomotic strictures frequently require the combination of both methods and are the most difficult strictures to dilate [7]. EDBS is usually performed as an outpatient procedure [10], and may also be performed during diagnostic endoscopy, resulting in an early relief of symptoms [1]. Savary-Gilliard and balloon dilators are the most commonly used dilators in recent years. Both methods are safe and cost-effective in both adults and children [11-15]. Esophageal dilatation does hOt alter the amount and duration of acid reflux to the esophagus [5] and, therefore, a prolonged treatment with H2 blockers is needed after the procedure. These methods, in experienced hands, are associated with very low complication rates compared to a rate of about 8% of perforations by earlier bougies [16-18]. EDBS is safe and effective due to 2 main reasons--the use of a guidewire (balloons have an elongated tip to guide them), and the use of gradually increasing dilators. In our experience, caustic strictures (even longstanding) were the easiest to dilate. In contrast, postoperative, anastomotic strictures were hard and the most difficult to dilate. Fluoroscopic control during EDBS was not routinely needed. EDBS was not influenced by the number of strictures, presence of esophagitis, etiology, location, diameter, length, or duration of strictures. The 2 patients who were operated had hard, postoperative anastomotic strictures with a partial response to dilatation. Both methods of treatment were safe, without associated mortality or complications. We conclude that both methods of dilatation are highly effective and well tolerated. Nevertheless, Savary-Gilliard dilators are slightly more effective and easier to use than balloons as an initial method of dilatation. Balloon dilators are effective mainly in long and tortuous strictures, and in multiple, closelyplaced strictures in the cervical esophagus. R›233

On a compar› l'efficacit› et l'inocuit› des 2 dilatateurs endoscopiques le plus souvent utilis› bougies de Savary-Gilliard et sondes ” baltonnets, chez 2 groupes comprenant chacun 30 patients ayant une st› oesophagienne b› On a trait› › 4 patients ayant une st› oesophagienne cervicale sinueuse et serr› d'abord par dilatation avec ballonnets puis par dilatation avec des bougies de Savary-Gilliard. Ces patients n'ont pu œ dilat› par une seule des 2 m› Soixante patients [35 hommes et 25 femmes, –233 en moyenne de 52 ans (ages extrš de 4 ” 91)] ont eu une dilatation oesophagienne par une seule m› Les › de la st› › les

E. Shemesh and A. Czerniak: Esophageal Strictures

suivantes: oesophagite peptique (65% des cas), l› caustique (18.3%), ou postop› (anastomotique, ou suivant une op› de Nissen) (16.7%). Chez tous les patients la dysphagie s'est am›233 Toutefois, 2 patients (1 de chaque groupe) ayant une st› anastomotique postop› serr› ont eu par la suite une r› chirurgicale de leur st› Il n'y a eu ni complications graves ni mortalit› imputables aux dilatations. Les 2 m› se sont av›233 trš efficaces et bien tol›233 encore que les dilatateurs Savary-Gilliard soient l›232 ement plus efficaces et plus faciles ” utiliser que les sondes ” ballonnet. N› les st› cervicales sinueuses et les st› multiples proches les unes des autres, ont ›233trait› au mieux par l'emploi d ' a b o r d des ballonnets puis des dilatateurs de Savary.

Resumen

Se efectu6 la comparaci6n de la seguridad y la eficacia de los 2 dilatadores endosc6picos mas utilizados, el dilatador de Savary-Gilliard y el bal6n de presi6n, en 2 grupos, cada uno de 30 pacientes con estenosis benignas del es6fago. Cuatro pacientes adicionales con estenosis severas y tortuosas del es6fago cervical fueron manejados inicialmente con dilataciones con bal6n seguidas de dilataciones con el dilatador de Savary-Gilliard. Estos pacientes no pudieron ser dilatado mediante uno s61o de los 2 m› Sesenta pacientes [35 hombres y 25 mujeres, con edad promedio de 52 afios (rango de 4 a 91)], recibieron 165 dilataciones esofagicas. Las etiologias de las estenosis incluyeron la esofagitis de reflujo (65%), la lesi6n caustica (18.3%), y la estenosis postoperatoria (anastom6tica o postoperaci6n de Nissen) en 16.7%. La disfagia mejor6 en la totalidad de los pacientes. Sin embargo, 2 casos (1 en cada grupo) con estenosis anastom6tica fibr6tica eventualmente fueron sometidos a resecci6n quirfirgica de la estenosis. No se presentaron complicaciones mayores ni mortalidad relacionada con las dilataciones. Ambos m› probaron ser altamente efectivos y bien tolerados, aunque los dilatadores de Savary-Gilliard aparecieron ligeramente mas efectivos y mas faciles de usar que los balones. Sin embargo, las estenosis tortuosas del es6fago cervical asi como las estenosis mtiltiples y cercanas unas de otras, pudieron ser mas efectivamente manejadas mediante el uso inicial de balones, seguido de dilatadores de Savary.

Invited Commentary James H.F. Shaw, M.D. University Department of Surgery, Auckland Hospital, Auckland, New Zealand This article is a useful addition to the surgical literature as it underlines a number of important concepts regarding the contemporary management of benign oesophageal strictures

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References

1. Hine, K.R., Hawkey, C.J., Atkinson, M., Holms, G.K.T.: Comparison of the Eder-Puestow and Celestin techniques for dilating benign oesophageal stricture. Gut 24:1100, 1984 2. Webb, W.A.: Esophageal dilation: Personal experience with current instruments and techniques. Am. J. Gastroenterol. 83:471, 1988 3. Ouyang, A.: Chest pain, esophageal spasm, and othcr functional disorders of the esophagus. In Functional Disorders of the Gastrointestinal Tract, S. C0hen, R.D. Soloway, editors, New York, Churchill Livingstone, 1987, pp. 1-16 4, Blackston•, M.O.: Esophagitis. In Endoscopic Interprr M.O. Blackstone, editor, New York, Raven Press, 1988, pp. 19-22 5. Penagini, R., Dabbagh, A.L., Misiewicz, J.J., Evans, P.F., Trotman, I.F.: Effect of dilatation of peptic esophageal strictures on gastroesophagcal reflux, dysphagia, and stricture diameter. Dig. Dis. Sci. 33:389, 1988 6. Blackstone, M.O.: Esophageal strictures. In Endoscopic Interpretation, M.O. Blackstone, editor, New York, Raven Press, 1988, pp. 36-37 7. Whitworth, P.W., Richardson, R.L., Larson, G.M.: Balloon dilation of anastomotic strictures. Arch. Surg. 123:759, !988 8. Ahtaridis, G., Snape, W.J., Cohen, S.: Clinical and manometric findings in benign peptic strictures of the esophagus. Dig. Dis. Sci. 24:858, 1979 9. Loeb, P.M., Eisenstein, A.M.: Caustic injury to the upper gastrointestinal tract. In Gastrointcstinal Diseasc, 3rd edition, M.H. Sleisenger, J.S. Fordtran, editors, Philadclphia, W.B. Saunders, 1983, pp. 148-155 10. Bradpiece, H.A., Galland, R.B., Murray, J., Spencer, J.: Esophageai dilation as an outpatient procedure. Surg. Gynec01. Obstet. 167:45, 1988 11. Starck, E., Paolucci, V., Hcrzer, M., Crummy, A.B.: Esophageal stenosis: Treatment with balloon catheters. Radiology 153:637, 1984 12. Sato, Y., Frcy, E.E., Smith, W.L., Pringle, K.C., Soper, R.T., Franken, Jr., E.F.: Balloon dilatation of esophageal stenosis in children. Ara. J. Roentgeno|. 150:639, 1988 13. LaBergc, J.M., K•lan, Jr., R.K., Pogany, A.C., Ring, E.J.: Esophageal rupture: Complication of balloon dilatation. Radiology 157: 56, 1985 14. Maynar, M., Guerra, C., Reycs, R., Mayor, J., Garcia, J., Facal, P., Castaneda-Zuniga, W.R., Letourneau, J.G.: Esophageal strictures: Balloon dilation. Radiology 167:703, 1988 15. Dupin, B., Meric, B., Dumon, J.F.: Techniques, rcsults and complications of oesophageal dilatation. Bailliere's Clin. Gastroenterol. 1:809, 1987 16. Wcsdorp, I.C.E., Bartelsman, J.F.W.M., Van den Hartog Jager, F.C.A., Huibregtse, K., Tytgat, G.N.: Results of conservativc treatment of benign esophageal stricture: A follow-up study in 100 patients. Gastroentr 82:487, 1982 17. Kozarek, R.A.: Hydrostatic balloon dilation of gastrointestinal stenoses: A national survey. Gastrointest. Endosc. 32:15, 1986 18. Kozarek, R.A.: Endoscopic gruntzig balloon dilation of gastrointestinal stenoses. J. Clin. Gastroenterol. 6:401, 1984

(BOS). The main causes of BOS are peptic, caustic burn to the esophagus, congenital webs and bands, and surgery to the esophagus. As the authors describe, most BOS can be managed medically (less than 10% of patients require surgical correction), and morbidity and mortality rates should be low (rates of less than 0.1% are widely reported [1]). In most patients, single or repeat dilatation results in satisfactory relief of dysphagia, and surgery is reserved for patients with severe strictures who respond in a suboptimal manner or when the frequency for dilatation becomes excessive [2].

Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures.

The efficiency and safety of the 2 most commonly used endoscopic dilators, Savary-Gilliard and pressure balloons, were compared in 2 groups, each incl...
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