Journal of Gastroenterology and Hepatology (1992) I, 520-523
ALIMENTARY TRACT AND PANCREAS
Long-term follow-up of dilatation treatment of oesophageal strictures A. G. FRASER AND G. I. NICHOLSON
Department of Gastroenterology, Auckland Hospital, Auckland, New Zealand
Abstract A review of the endoscopy records of 100 consecutive patients with oesophageal strictures was undertaken to determine the effectiveness of endoscopic dilatation therapy. The follow-up period from presentation ranged from 6 to 72 (mean 39 months) and the symptom-free period after the last dilatation ranged from 3 to 66 months (mean 29 months). Three hundred and fifty procedures were performed with no perforations and minimal morbidity. Eighty-one patients who had been followed for at least 12 months since their last dilatation were free of significant dysphagia. Of these 81 patients, 77% became symptom-free within 1 year, and 88% within 2 years. Only 35 patients required more than three dilatations; 30 patients required one dilatation and 35 required two to three dilatations. Age, sex, the presence of Barrett’s oesophagus, or the oesophageal lumen diameter at presentation was not significantly correlated with outcome.
Key words: Barrett’s oesophagus, dilatation, long-term follow-up, oesophageal stricture, peptic oesophagitis.
INTRODUCTION Endoscopic dilatation is now the recommended therapy for benign oesophageal strictures.’ There have been few reports of the long-term results and these have principally reviewed the results of dilatation with bougies.2-6Because newer techniques using Eder-Peustow olives, Celestin dilators and hydrostatic balloons have substantially changed the practice of oesophageal dilatation we have reviewed our results and compared them with earlier series.
METHODS The case notes and endoscopy records of 100 consecutive cases of benign oesophageal strictures presenting to the Gastroenterology Unit, Auckland Hospital during 1984-88 were reviewed. Patients with malignant strictures, achalasia, Schatzki’s rings and oesophageal webs were excluded. Fourteen patients who had previous dilatations under general anaesthetic and were subsequently referred for outpatient dilatation under sedation were included in the review. Patients were either given regular follow-up in the gastroenterology clinic, or were instructed to return for dilatation as soon as dysphagia recurred.
Dilatation was performed using Eder-Peustow olives and Celestin dilators over a guidewire throughout the period of review. Hydrostatic balloons passed through the scope were used from 1988. The procedures were performed on outpatients using intravenous benzodiazepine sedation and overnight admission was only recommended for persisting symptoms of chest discomfort or haematemesis. Dilatation to 18 mm (54 F) was attempted for most strictures unless the stricture was very tight, in which case a smaller diameter (usually 42 F) was accepted for the initial procedure. Patients with tight strictures often had elective repeat dilatations whereas those with less severe strictures had the interval between dilatations determined by the recurrence of symptoms. Patients with erosive oesophagitis were treated either with H,-receptor antagonists or, more recently, with omeprazole. Patient groups were compared by the Mann-Whitney U test or Student’s t-test and P values < 0.05 were considered significant.
RESULTS There were 56 males and 44 females in the study; mean age was 70 years (range 25-87 years) and 60% were over 70 years. All patients presented with dysphagia; two patients presented with bolus obstruction and total dysphagia. Three patients also had duodenal ulceration. The
Correspondence: Dr A. G. Fraser, Clinical Research Fellow, University Department of Medicine, Royal Free Hospital School of Medicine, London NW3 2QG. Accepted for publication 25 April 1992.
Dilatation of oesophageal strictures
521
Table 1 Pathogenic factors for oesophageal stricture Previous surgery Anti-reflux procedure Partial gastrectomy Oesophago-jejunal anastomosis Highly selective vagotomy Thoracotomy for VSD Barrett's epithelium High strictures (upper 113) Scleroderma Caustic injury Naso-gastric tube
Table 2 Mean follow-up, symptom-freeperiod after last dilatation and results
11 2 1
No. dilatations
No. patients
1
30
2 3 4-6 6
23 12 23
1 1 9 10 5 1 1
Follow-up from presentation (months)
Symptom-free period after last dilatation (months)
40
37
48/53
37
22**
33/47
12 ~~
~
majority of strictures were due to reflux oesophagitis. Other pathogenic factors are listed in Table 1. There were 16 post-surgical cases, 11 of which were anti-reflux procedures. Only one patient had an anastomotic stricture; a partial gastrectomy was considered to be relevant in promoting bile reflux in two patients. One patient developed a stricture at the gastro-oesophageal junction after a highly selective vagotomy. Barrett's epithelium was identified endoscopically in nine patients. Patients with strictures in the upper third of the oesophagus were considered to have a non-peptic aetiology; medicationinduced ulceration was identified as an aetiological factor in some of these patients. Strictures in patients with scleroderma were not usually severe, but they often had significant dysphagia because of the associated motility disorder. One patient with scleroderma developed a squamous cell carcinoma 12 years after first presentation with dysphagia. Patients were followed for a mean period of 39 months from first presentation (range 6-72 months), and the mean symptom-free period after the last dilatation was 29 months (range 3-66 months). A total of 350 procedures were performed on 100 patients. No perforations were recorded and there was no procedure-related mortality. There were three technical failures because of: intolerance of procedure under benzodiazepine sedation; difliculty with intubation because of previous pharyngeal surgery; and failure to pass a guidewire through the stricture. Two of these patients had further successful outpatient procedures and the patient with total occlusion underwent surgery. The procedure-related complication rate was 1.4%. Two patients had a haematemesis which required their admission and three other patients required overnight observation because of chest discomfort or excessive sedation. Thirty patients required only one dilatation, 35 required two or three dilatations, 23 required four to six dilatations and 12 required more than six dilatations (Table 2). A satisfactory outcome, defined as requiring no further dilatations 12 months after the last dilatation, was achieved in 81 patients. The duration of treatment (from presentation to last dilatation) for these patients was less than 1 year in 779'0, and less than 2 years in 88%. Figure 1 shows the intervals between dilatations and the duration of treatment for 38 patients who required three or more dilatations (excluding the patients who had dilatations under general anaesthetic before endoscopic dilatation were excluded from Fig. 1). Only 12 patients
Good result*
100
39
29
81/100
Defined as requiring no further dilatation after 12 months follow-up. ** P < 0.01 compared with patients requiring 1-2 dilatations. The shorter follow-up in patients with three or more dilatations may have resulted in an underestimateof their total requirement for dilatations.
Year 1
2
3
4
5
1
2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
'
. ' '
Figure 1 Follow-up for patients requiring three more dilatations. Each dilatation after the initial dilatation is marked by the solid bars. The patients who have been followed for less than 12 months since their last dilatation are indicated by an asterisk.
A. G. Fraser and G. I. Nicholson
522
Table 3 Relationship of number of dilatations to oesophageal lumen diameter Oesophageal lumen diameter (mm)
1-3 dilatations ("0)
> 11 < 11
68 44
> 3 dilatations (YO) 32 56
14 patients with previous dilatations under GA excluded because lumen diameter at presentation unknown. 'l = NS.
continued to require dilatations 2 years after their initial dilatation. The sex, age and oesophageal lumen diameter at presentation, of the patients who required three or more dilatations were not significantly different from those patients who required 1-2 dilatations. There was a non-significant trend for patients with a lumen diameter of less than 11 mm to require more dilatations (Table 3), and similarly, the 10 patients with Barrett's oesophagus required more dilatations (mean 3.9; range 1-8) but this trend was not significant.
DISCUSSION This review confirms that the endoscopic technique of dilatation is effective. A satisfactory outcome can be achieved in the majority of patients within an acceptable period of time and without the need for multiple dilatations. There was a small group of patients (12%) who required multiple dilatations over more than 2 years (Figure l), but almost all of these patients did eventually get long-term relief of their dysphagia, demonstrating that dilatation therapy is definitive treatment rather than simply palliation. Despite the widespread acceptance of dilatation treatment of benign oesophageal strictures, there have been few reports of the long-term results, and these have mainly described the results with mercury bougies only. This study describes the long-term result using the
combination of Celestin, Eder-Peustow olives and hydrostatic balloon techniques that are now in common use. The results of this study are compared with previous studies in Table 4. Comparison with earlier series is difficult because of the considerable variation in methods of treatment, assessment of outcome and duration of follow-up; only one other study describes the duration of follow-up after completion of dilatation^.^ A satisfactory outcome achieved in 81% of patients with minimal morbidity and no procedure related mortality compares favourably with other studies. Only 35 patients required more than three dilatations despite a conservative approach to the initial dilatation of tight strictures. Wesdorp et al. achieved a higher success rate using a more intensive programme of dilatations at the expense of an increased incidence of perforations at 8%.5 Dilatation to 18 mm (54 F) appears to improve results without resulting in an increased rate of perforations (Table 4). Comparison of the effectiveness of the different techniques was not possible in this retrospective review. Hine et al. showed that Celestin dilators and Eder-Peustow olives were equally effective,' while hydrostatic balloons may be marginally less effective than a combination of Celestin dilators and Eder-Peustow olives.* T h e recently available Savary-Guillard dilators were found to be as effective as balloon dilatation in a short-term comparison involving 60 patient^.^ Some centres advocate routine endoscopic follow-up of all strictures because very tight stenoses might develop and make dilatation technically very difficult. This problem has not been encountered when patients are instructed to return as soon as the 'dysphagia recurs. Comparison of our series with a similar review of 100 consecutive cases reported in 1970 by Raptis and MearnsMilne illustrates the change in the management of oesophageal strictures." Half of the patients were treated surgically and, while a good result was achieved in the majority of patients treated surgically, 25% required further oesophageal dilatations. Other reviews of surgical procedures have similarly reported good results with either surgical resection or the more conservative approach of performing an anti-reflux procedure after pre-operative dilatation.''*" In one surgical series, there
Table 4 Comparison of follow-up studies of dilatation treatment Lama ( 1978)
Method
bougies/EP to 44Ft
No. Follow-up from 1st dilatation (months) Follow-up from last dilatation Perforations Mean no. of dilatations Percentage requiring only 1 dilatation Satisfactory outcome*
71 21 0 2.6 42 75
Glick (1 982)
Patterson (1 983)
Wesdorp (1983)
bougies/EP to 44Ft 76 21 -
bougies/EP
bougies/EP to 54F
154* 26 -
100 40 8 6.7 88
1
5
7.5 35 -
4.9 43 63
* Defined as requiring no further dilatation 12 months after the last dilatation (Patterson - 6 months follow-up only) Eder-Peustow olives
* Follow-up for only 101 patients
Fraser (1 992)
EP/Celestin to 54F 100 39 28 0 3.5 30 81
Dilatation of oesophageal strictures
was a need for further dilatation in 38% of the patients13. Eleven patients in our series presented with dysphagia several years after an anti-reflux surgical procedure. There has been some renewed interest in the surgical management of gastro-oesophageal reflux with the refinement of surgical techniques, but there are few definitive indications for surgical management of oesophageal strictures. Conservative management is preferable to surgical resection as these patients are usually elderly and have associated medical conditions; the elderly in our series did not require more dilatations compared with younger patients. The severity of the stricture at presentation, while possibly influencing the number of dilatations required, is not a predictor of a poor result. The patients with Barrett’s epithelium had an equally good result with endoscopic dilatation therapy. This complication of longstanding reflux should not be considered an indication for surgery. Atkinson et al. have also reported equally good results with conservative management of strictures related to Barrett’s epithe1i~m.l~ Patients with a Schatzki’s ring were excluded from our study, but surprisingly, there is often a requirement for repeat dilatations. In one series, 63% developed recurrent dysphagia; 71% of these patients required a total of 1-3 dilatations and 29% required more than three dilatations.” The widespread use of H,-antagonists in the community has not altered the frequency of presentation of patients with oesophageal strictures during the past 6 years (approximately 20 new cases per year). This may be explained by the significant number of patients (up to 35%) who present without an antecedent history of heartburn.6.’6 Further studies are required to determine whether the better healing rates for reflux oesophagitis obtained with omeprazole will decrease the need for repeated dilatations. It is concluded that conservative management of benign oesophageal strictures is effective and has minimal morbidity involving an acceptable number of procedures within a limited duration.
ACKNOWLEDGEMENT The authors thank the nursing staff of the Gastroenterology Unit, Auckland Hospital for technical assistance.
REFERENCES 1. TYTGAT G. N. Dilatation therapy of benign oesophageal stenoses. WorldJ. Surg 1989; 13: 142-8.
523 2. LANZAF. L. & GRAHAM D. Y. Bougienage is effective therapy for most benign oesophageal strictures. JAMA 1978; 240: 844-7. 3. OCILVIE A. L., FERCUSON R. & ATKINSONM. Outlook with
conservative treatment of peptic oesophageal stricture. Cur 1980; 21: 23-5. 4. GLICKM. E. Clinical course of oesophageal stricture managed by bougienage. Dig. Dis. Sci. 1982; 27: 884-8. 5. WESDORP I. C., BARTELSMAN J. F., DEN HARTOGJACER F. C., HUIBREGTSE K. & TYTCAT G. N. Results of conserva-
tive treatment of benign oesophageal strictures: A follow-up study in 100 patients. Gastroenrerology 1982; 82: 487-93. 6. PATTERSON D. J., GRAHAM D. Y., SMITHJ. L. et al. Natural history of benign oesophageal stricture treated by dilatation. Casrroenrerology 1983; 85: 346-50. 7. HINEK. R., HAWKEY C. J., ATKINSON M. & HOLMES G. K.
Comparison of the Eder-Peustow and Celestin techniques for dilating benign oesophageal strictures. Gut 1984; 25: 1100-2. 8. Cox J. G., WINTER S . C., MASLINR. K. et af. Balloon or
bougie for dilatation of benign oesophageal stricture? An interim report of a randomised controlled trial. Gur 1988; 29: 1741-7. 9. SHEMESH E. & CZERNIAK A. Comparison between Savary-
10.
11.
12.
13.
14.
Gillard and balloon dilatation of benign oesophageal strictures. World J. Surg. 1990; 14: 518-21. RAPTISS. & MEARNS MILNED. A review of the management of 100 cases of benign stricture of the oesophagus. Thorax 1972; 27: 599-603. HOLLENBECK J. I. & WOODWARD E. R. Treatment of peptic oesophageal stricture with combined fundic patch - fundoplication. A n n . Surg. 1975; 182: 472-7. HILLL. D., GELFAND M. & BAVERMEISTER D. Simplified management of reflux oesophagitis with stricture. A n n . Surg. 1970; 172: 638-46. HENDERSON R. D., GELFAND M. & BAVERMEISTER D. Simplified management of reflux oesophagitis with stricture. Ann. Surg. 1970; 172: 638-46. ATKINSONM. & ROBERTSON C. S. Benign oesophageal stricture in Barrett’s columnar epithelialised oesophagus and its responsiveness to conservative management. Gur
1988; 29: 1721-4. 15. GROSKREUTZ J. L. & KIMC. H. Schatzki’s ring: long-term
results following dilatation. Gasrroinresrinal Endoscopy 1990; 36: 479-81. 16. WILLIAMSON R. C. The management of peptic oesophageal stricture. Br. J. Surg. 1975; 62: 448-54.
ALIMENTARY TRACT AND PANCREAS
Long-term follow-up of dilatation treatment of oesophageal strictures A. G. FRASER AND G. I. NICHOLSON
Department of Gastroenterology, Auckland Hospital, Auckland, New Zealand
Abstract A review of the endoscopy records of 100 consecutive patients with oesophageal strictures was undertaken to determine the effectiveness of endoscopic dilatation therapy. The follow-up period from presentation ranged from 6 to 72 (mean 39 months) and the symptom-free period after the last dilatation ranged from 3 to 66 months (mean 29 months). Three hundred and fifty procedures were performed with no perforations and minimal morbidity. Eighty-one patients who had been followed for at least 12 months since their last dilatation were free of significant dysphagia. Of these 81 patients, 77% became symptom-free within 1 year, and 88% within 2 years. Only 35 patients required more than three dilatations; 30 patients required one dilatation and 35 required two to three dilatations. Age, sex, the presence of Barrett’s oesophagus, or the oesophageal lumen diameter at presentation was not significantly correlated with outcome.
Key words: Barrett’s oesophagus, dilatation, long-term follow-up, oesophageal stricture, peptic oesophagitis.
INTRODUCTION Endoscopic dilatation is now the recommended therapy for benign oesophageal strictures.’ There have been few reports of the long-term results and these have principally reviewed the results of dilatation with bougies.2-6Because newer techniques using Eder-Peustow olives, Celestin dilators and hydrostatic balloons have substantially changed the practice of oesophageal dilatation we have reviewed our results and compared them with earlier series.
METHODS The case notes and endoscopy records of 100 consecutive cases of benign oesophageal strictures presenting to the Gastroenterology Unit, Auckland Hospital during 1984-88 were reviewed. Patients with malignant strictures, achalasia, Schatzki’s rings and oesophageal webs were excluded. Fourteen patients who had previous dilatations under general anaesthetic and were subsequently referred for outpatient dilatation under sedation were included in the review. Patients were either given regular follow-up in the gastroenterology clinic, or were instructed to return for dilatation as soon as dysphagia recurred.
Dilatation was performed using Eder-Peustow olives and Celestin dilators over a guidewire throughout the period of review. Hydrostatic balloons passed through the scope were used from 1988. The procedures were performed on outpatients using intravenous benzodiazepine sedation and overnight admission was only recommended for persisting symptoms of chest discomfort or haematemesis. Dilatation to 18 mm (54 F) was attempted for most strictures unless the stricture was very tight, in which case a smaller diameter (usually 42 F) was accepted for the initial procedure. Patients with tight strictures often had elective repeat dilatations whereas those with less severe strictures had the interval between dilatations determined by the recurrence of symptoms. Patients with erosive oesophagitis were treated either with H,-receptor antagonists or, more recently, with omeprazole. Patient groups were compared by the Mann-Whitney U test or Student’s t-test and P values < 0.05 were considered significant.
RESULTS There were 56 males and 44 females in the study; mean age was 70 years (range 25-87 years) and 60% were over 70 years. All patients presented with dysphagia; two patients presented with bolus obstruction and total dysphagia. Three patients also had duodenal ulceration. The
Correspondence: Dr A. G. Fraser, Clinical Research Fellow, University Department of Medicine, Royal Free Hospital School of Medicine, London NW3 2QG. Accepted for publication 25 April 1992.
Dilatation of oesophageal strictures
521
Table 1 Pathogenic factors for oesophageal stricture Previous surgery Anti-reflux procedure Partial gastrectomy Oesophago-jejunal anastomosis Highly selective vagotomy Thoracotomy for VSD Barrett's epithelium High strictures (upper 113) Scleroderma Caustic injury Naso-gastric tube
Table 2 Mean follow-up, symptom-freeperiod after last dilatation and results
11 2 1
No. dilatations
No. patients
1
30
2 3 4-6 6
23 12 23
1 1 9 10 5 1 1
Follow-up from presentation (months)
Symptom-free period after last dilatation (months)
40
37
48/53
37
22**
33/47
12 ~~
~
majority of strictures were due to reflux oesophagitis. Other pathogenic factors are listed in Table 1. There were 16 post-surgical cases, 11 of which were anti-reflux procedures. Only one patient had an anastomotic stricture; a partial gastrectomy was considered to be relevant in promoting bile reflux in two patients. One patient developed a stricture at the gastro-oesophageal junction after a highly selective vagotomy. Barrett's epithelium was identified endoscopically in nine patients. Patients with strictures in the upper third of the oesophagus were considered to have a non-peptic aetiology; medicationinduced ulceration was identified as an aetiological factor in some of these patients. Strictures in patients with scleroderma were not usually severe, but they often had significant dysphagia because of the associated motility disorder. One patient with scleroderma developed a squamous cell carcinoma 12 years after first presentation with dysphagia. Patients were followed for a mean period of 39 months from first presentation (range 6-72 months), and the mean symptom-free period after the last dilatation was 29 months (range 3-66 months). A total of 350 procedures were performed on 100 patients. No perforations were recorded and there was no procedure-related mortality. There were three technical failures because of: intolerance of procedure under benzodiazepine sedation; difliculty with intubation because of previous pharyngeal surgery; and failure to pass a guidewire through the stricture. Two of these patients had further successful outpatient procedures and the patient with total occlusion underwent surgery. The procedure-related complication rate was 1.4%. Two patients had a haematemesis which required their admission and three other patients required overnight observation because of chest discomfort or excessive sedation. Thirty patients required only one dilatation, 35 required two or three dilatations, 23 required four to six dilatations and 12 required more than six dilatations (Table 2). A satisfactory outcome, defined as requiring no further dilatations 12 months after the last dilatation, was achieved in 81 patients. The duration of treatment (from presentation to last dilatation) for these patients was less than 1 year in 779'0, and less than 2 years in 88%. Figure 1 shows the intervals between dilatations and the duration of treatment for 38 patients who required three or more dilatations (excluding the patients who had dilatations under general anaesthetic before endoscopic dilatation were excluded from Fig. 1). Only 12 patients
Good result*
100
39
29
81/100
Defined as requiring no further dilatation after 12 months follow-up. ** P < 0.01 compared with patients requiring 1-2 dilatations. The shorter follow-up in patients with three or more dilatations may have resulted in an underestimateof their total requirement for dilatations.
Year 1
2
3
4
5
1
2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
'
. ' '
Figure 1 Follow-up for patients requiring three more dilatations. Each dilatation after the initial dilatation is marked by the solid bars. The patients who have been followed for less than 12 months since their last dilatation are indicated by an asterisk.
A. G. Fraser and G. I. Nicholson
522
Table 3 Relationship of number of dilatations to oesophageal lumen diameter Oesophageal lumen diameter (mm)
1-3 dilatations ("0)
> 11 < 11
68 44
> 3 dilatations (YO) 32 56
14 patients with previous dilatations under GA excluded because lumen diameter at presentation unknown. 'l = NS.
continued to require dilatations 2 years after their initial dilatation. The sex, age and oesophageal lumen diameter at presentation, of the patients who required three or more dilatations were not significantly different from those patients who required 1-2 dilatations. There was a non-significant trend for patients with a lumen diameter of less than 11 mm to require more dilatations (Table 3), and similarly, the 10 patients with Barrett's oesophagus required more dilatations (mean 3.9; range 1-8) but this trend was not significant.
DISCUSSION This review confirms that the endoscopic technique of dilatation is effective. A satisfactory outcome can be achieved in the majority of patients within an acceptable period of time and without the need for multiple dilatations. There was a small group of patients (12%) who required multiple dilatations over more than 2 years (Figure l), but almost all of these patients did eventually get long-term relief of their dysphagia, demonstrating that dilatation therapy is definitive treatment rather than simply palliation. Despite the widespread acceptance of dilatation treatment of benign oesophageal strictures, there have been few reports of the long-term results, and these have mainly described the results with mercury bougies only. This study describes the long-term result using the
combination of Celestin, Eder-Peustow olives and hydrostatic balloon techniques that are now in common use. The results of this study are compared with previous studies in Table 4. Comparison with earlier series is difficult because of the considerable variation in methods of treatment, assessment of outcome and duration of follow-up; only one other study describes the duration of follow-up after completion of dilatation^.^ A satisfactory outcome achieved in 81% of patients with minimal morbidity and no procedure related mortality compares favourably with other studies. Only 35 patients required more than three dilatations despite a conservative approach to the initial dilatation of tight strictures. Wesdorp et al. achieved a higher success rate using a more intensive programme of dilatations at the expense of an increased incidence of perforations at 8%.5 Dilatation to 18 mm (54 F) appears to improve results without resulting in an increased rate of perforations (Table 4). Comparison of the effectiveness of the different techniques was not possible in this retrospective review. Hine et al. showed that Celestin dilators and Eder-Peustow olives were equally effective,' while hydrostatic balloons may be marginally less effective than a combination of Celestin dilators and Eder-Peustow olives.* T h e recently available Savary-Guillard dilators were found to be as effective as balloon dilatation in a short-term comparison involving 60 patient^.^ Some centres advocate routine endoscopic follow-up of all strictures because very tight stenoses might develop and make dilatation technically very difficult. This problem has not been encountered when patients are instructed to return as soon as the 'dysphagia recurs. Comparison of our series with a similar review of 100 consecutive cases reported in 1970 by Raptis and MearnsMilne illustrates the change in the management of oesophageal strictures." Half of the patients were treated surgically and, while a good result was achieved in the majority of patients treated surgically, 25% required further oesophageal dilatations. Other reviews of surgical procedures have similarly reported good results with either surgical resection or the more conservative approach of performing an anti-reflux procedure after pre-operative dilatation.''*" In one surgical series, there
Table 4 Comparison of follow-up studies of dilatation treatment Lama ( 1978)
Method
bougies/EP to 44Ft
No. Follow-up from 1st dilatation (months) Follow-up from last dilatation Perforations Mean no. of dilatations Percentage requiring only 1 dilatation Satisfactory outcome*
71 21 0 2.6 42 75
Glick (1 982)
Patterson (1 983)
Wesdorp (1983)
bougies/EP to 44Ft 76 21 -
bougies/EP
bougies/EP to 54F
154* 26 -
100 40 8 6.7 88
1
5
7.5 35 -
4.9 43 63
* Defined as requiring no further dilatation 12 months after the last dilatation (Patterson - 6 months follow-up only) Eder-Peustow olives
* Follow-up for only 101 patients
Fraser (1 992)
EP/Celestin to 54F 100 39 28 0 3.5 30 81
Dilatation of oesophageal strictures
was a need for further dilatation in 38% of the patients13. Eleven patients in our series presented with dysphagia several years after an anti-reflux surgical procedure. There has been some renewed interest in the surgical management of gastro-oesophageal reflux with the refinement of surgical techniques, but there are few definitive indications for surgical management of oesophageal strictures. Conservative management is preferable to surgical resection as these patients are usually elderly and have associated medical conditions; the elderly in our series did not require more dilatations compared with younger patients. The severity of the stricture at presentation, while possibly influencing the number of dilatations required, is not a predictor of a poor result. The patients with Barrett’s epithelium had an equally good result with endoscopic dilatation therapy. This complication of longstanding reflux should not be considered an indication for surgery. Atkinson et al. have also reported equally good results with conservative management of strictures related to Barrett’s epithe1i~m.l~ Patients with a Schatzki’s ring were excluded from our study, but surprisingly, there is often a requirement for repeat dilatations. In one series, 63% developed recurrent dysphagia; 71% of these patients required a total of 1-3 dilatations and 29% required more than three dilatations.” The widespread use of H,-antagonists in the community has not altered the frequency of presentation of patients with oesophageal strictures during the past 6 years (approximately 20 new cases per year). This may be explained by the significant number of patients (up to 35%) who present without an antecedent history of heartburn.6.’6 Further studies are required to determine whether the better healing rates for reflux oesophagitis obtained with omeprazole will decrease the need for repeated dilatations. It is concluded that conservative management of benign oesophageal strictures is effective and has minimal morbidity involving an acceptable number of procedures within a limited duration.
ACKNOWLEDGEMENT The authors thank the nursing staff of the Gastroenterology Unit, Auckland Hospital for technical assistance.
REFERENCES 1. TYTGAT G. N. Dilatation therapy of benign oesophageal stenoses. WorldJ. Surg 1989; 13: 142-8.
523 2. LANZAF. L. & GRAHAM D. Y. Bougienage is effective therapy for most benign oesophageal strictures. JAMA 1978; 240: 844-7. 3. OCILVIE A. L., FERCUSON R. & ATKINSONM. Outlook with
conservative treatment of peptic oesophageal stricture. Cur 1980; 21: 23-5. 4. GLICKM. E. Clinical course of oesophageal stricture managed by bougienage. Dig. Dis. Sci. 1982; 27: 884-8. 5. WESDORP I. C., BARTELSMAN J. F., DEN HARTOGJACER F. C., HUIBREGTSE K. & TYTCAT G. N. Results of conserva-
tive treatment of benign oesophageal strictures: A follow-up study in 100 patients. Gastroenrerology 1982; 82: 487-93. 6. PATTERSON D. J., GRAHAM D. Y., SMITHJ. L. et al. Natural history of benign oesophageal stricture treated by dilatation. Casrroenrerology 1983; 85: 346-50. 7. HINEK. R., HAWKEY C. J., ATKINSON M. & HOLMES G. K.
Comparison of the Eder-Peustow and Celestin techniques for dilating benign oesophageal strictures. Gut 1984; 25: 1100-2. 8. Cox J. G., WINTER S . C., MASLINR. K. et af. Balloon or
bougie for dilatation of benign oesophageal stricture? An interim report of a randomised controlled trial. Gur 1988; 29: 1741-7. 9. SHEMESH E. & CZERNIAK A. Comparison between Savary-
10.
11.
12.
13.
14.
Gillard and balloon dilatation of benign oesophageal strictures. World J. Surg. 1990; 14: 518-21. RAPTISS. & MEARNS MILNED. A review of the management of 100 cases of benign stricture of the oesophagus. Thorax 1972; 27: 599-603. HOLLENBECK J. I. & WOODWARD E. R. Treatment of peptic oesophageal stricture with combined fundic patch - fundoplication. A n n . Surg. 1975; 182: 472-7. HILLL. D., GELFAND M. & BAVERMEISTER D. Simplified management of reflux oesophagitis with stricture. A n n . Surg. 1970; 172: 638-46. HENDERSON R. D., GELFAND M. & BAVERMEISTER D. Simplified management of reflux oesophagitis with stricture. Ann. Surg. 1970; 172: 638-46. ATKINSONM. & ROBERTSON C. S. Benign oesophageal stricture in Barrett’s columnar epithelialised oesophagus and its responsiveness to conservative management. Gur
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