Download PDF
ads:
1
FUNDAÇÃO FACULDADE FEDERAL DE CIÊNCIAS MÉDICAS DE
PORTO ALEGRE
PROGRAMA DE PÓS-GRADUAÇÃO EM MEDICINA:
CIÊNCIAS MÉDICAS
DILATAÇÃO ENDOSCÓPICA DE ESTENOSES ESOFÁGICAS
BENIGNAS SEM O AUXÍLIO DE FLUOROSCOPIA: EXPERIÊNCIA
EM 2750 SESSÕES
RICARDO PARIZZI RAYMONDI
Porto Alegre, Rio Grande do Sul
2006
ads:
Livros Grátis
http://www.livrosgratis.com.br
Milhares de livros grátis para download.
2
FUNDAÇÃO FACULDADE FEDERAL DE CIÊNCIAS MÉDICAS DE PORTO
ALEGRE
PROGRAMA DE PÓS-GRADUAÇÃO EM MEDICINA:
CIÊNCIAS MÉDICAS
DILATAÇÃO ENDOSCÓPICA DE ESTENOSES ESOFÁGICAS BENIGNAS SEM
O AUXÍLIO DE FLUOROSCOPIA: EXPERIÊNCIA EM 2750 SESSÕES
RICARDO PARIZZI RAYMONDI
Orientador: Prof. Dr. Júlio Carlos Pereira Lima
Co-orientador: Prof. Dr. Cláudio A. Marroni
Dissertação apresentada ao Programa de Pós-Graduação em Medicina da
Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, como
requisito parcial à obtenção do título de Mestre em Medicina, área de
concentração: Ciências Médicas
Porto Alegre
2006
ads:
3
R267d Raymondi, Ricardo Parizzi
Dilatação endoscópica de estenoses esofágicas benignas sem o
auxílio de fluoroscopia: experiência em 2750 sessões / Ricardo
Parizzi Raymondi; orient. Júlio Carlos Pereira- Lima; co-orient.
Cláudio Augusto Marroni. Porto Alegre: FFFCMPA, 2005.
xx f.: tab.
Dissertação (Mestrado) – Fundação Faculdade Federal de
Ciências Médicas de Porto Alegre. Faculdade de Medicina. Curso de
Pós-Graduação em Medicina. Área de concentração: Ciências
Médicas.
1. Esôfago. 2. Estenose benigna. 3. Dilatação endoscópica. 4.
Fluoroscopia. I. Pereira -Lima, Júlio Carlos. II. Marroni, Cláudio
Augusto. III. Título.
CDD 6l6.32
Ruth B.F. Oliveira/Bibliotecária
CRB10/501
4
AGRADECIMENTOS
Um trabalho como este, no qual foram revisados dados coletados nos últimos 13
anos, é fruto do esforço de um número de pessoas tão grande que se torna tarefa quase
impossível abranger a todos nesse espaço. Muitas dessas pessoas, com certeza, nem
conheci, já que freqüento as dependências físicas do Serviço de Gastroenterologia de nosso
hospital há pouco mais de 7 anos.
Aos residentes e alunos, que realizaram os procedimentos e incansavelmente
preencheram o protocolo do estudo (e nisso humildemente me incluo); aos funcionários,
que dioturnamente se postaram prontos a prestar seu valoroso e imprescindível suporte às
atividades do setor de Endoscopia; aos pacientes, que – com o perdão da redundância –
pacientemente se submeteram às filas, demoras, contratempos; aos professores, pela
orientação, apoio, estímulo; e, finalmente, a Deus, por tornar tudo isso possível, meus mais
profundos e sinceros agradecimentos. Espero que meu esforço tenha sido à altura.
Não poderia deixar de fazer um agradecimento especial ao professor Dr. Júlio C.
Pereira-Lima, por sua perspicácia, sua objetividade, sua disponibilidade total dentro das
possibilidades dos dias de hoje, e seu interesse sincero pelo desenvolvimento do nosso
estudo. Agradeço também ao professor Dr.Cláudio A. Marroni, que durante a residência,
por diversas vezes, foi para mim um pai.
Finalmente, um muito obrigado a minha família pela compreensão e estímulo
irrestritos.
5
SUMÁRIO
Abstract ………………………………………………..............................................5
Resumo...........................................................................................................................6
Introdução………………………………………………...........................................7
Referências da Introdução……………………………….....................................…16
Artigo Científico………………………………..........................................…..........20
Abstract…………………………………….………………………….……….20
Key words……………………………………………………………….……..20
Introduction…………………………………………………………………….21
Patients and Methods…………………………………………………………..21
Results……….…………………………………………………………………23
Discussion……………………...………………………………………………27
Appendix.………………………………………………………………………34
References……………………...………………………………………………46
6
ABSTRACT
Background and study aims: We report our experience on a large series of patients with
benign esophageal stricture from different etiologies who underwent endoscopic dilation
without the aid of fluoroscopy.
Patients and methods: Between 1992 and 2005, we performed 2,750 dilation sessions on
321 patients. The grade of dysphagia, cause and location of the stricture and diameter of the
inserted bougies were recorded in every session. Clinical response was considered to be
achieved when dysphagia disappeared or remained in a mild grade.
Results: Three hundred twenty-one patients were followed-up for a mean of 18.8 months.
Stricture’s etiology was postsurgical in 204 patients, peptic in 60, caustic in 13,
postradiotherapy in 13, and from other causes in 31. Clinical response was achieved in 92%
of the postsurgical patients; 84% of the patients with caustic injury; 81% of the peptic
patients; and 58% of the patients with radiation injury (p<0.05). Absence of dysphagia was
obtained in 68, 38, 67 and 27% of them, respectively (p<0.05). All groups showed a
significant improvement in dysphagia score, and 98% of patients in whom a 45 F catheter
was inserted achieved clinical response. There were six perforations, with two deaths.
Conclusions: Endoscopic dilation for benign esophageal strictures without the aid of
fluoroscopy is a safe and effective method. Postsurgical patients show excellent results to
dilation, and caustic and post-radiotherapy strictures have the worst response to therapy. A
diameter of 45 F is a satisfactory end-point to therapy in the vast majority of the cases.
Key Words: Benign esophageal strictures; Endoscopic dilation; Fluoroscopy
7
RESUMO
Introdução/Objetivo: Reportamos nossa experiência em uma grande série de pacientes com
estenoses esofágicas benignas de diferentes etiologias os quais foram submetidos à
dilatação endoscópica sem o auxílio de fluoroscopia.
Pacientes e Métodos: Entre 1992 e 2005 foram realizadas 2.750 sessões de dilatação em
321 pacientes. O grau de disfagia, a causa e localização da estenose e o diâmetro dos
dilatadores inseridos foram registrados a cada sessão. Considerou-se haver resposta clínica
quando houve desaparecimento da disfagia ou a mesma se manteve em grau leve.
Resultados: Trezentos e vinte e um pacientes foram seguidos por uma média de 18,8
meses. A etiologia da estenose foi pós-operatória em 204 pacientes, péptica em 60, cáustica
em 13, actínica em 13, e de outras causas em 31. Resposta clínica foi atingida em 92% dos
pacientes pós-cirúrgicos; 84% dos pacientes com lesão cáustica; 81% dos pacientes com
doença péptica; e em 58% dos pacientes com lesão actínica (p<0.05). Ausência de disfagia
foi obtida em 68, 38, 67 and 27% dos pacientes, respectivamente (p<0.05). Todos os grupos
demonstraram um melhora significativa no grau de disfagia, e 98 % dos pacientes nos quais
se introduziu um cateter de 45 Fr atingiram resposta clínica. Houve seis perfurações, com
duas mortes.
Conclusões: A dilatação endoscópica de estenoses esofágicas benignas sem o auxílio
fluoroscópico é um método seguro e efetivo. Pacientes pós-cirúrgicos demonstram
excelentes resultados à dilatação, e estenoses por lesões cáusticas e actínicas têm a pior
resposta à terapia. O diâmetro de 45 Fr é um ponto de corte satisfatório na vasta maioria
dos pacientes.
Palavras-chave:
Estenose esofágica benigna; Dilatação endoscópica; Fluoroscopia
8
INTRODUÇÃO
A estenose benigna do esôfago é entidade que traz consigo significativo impacto
negativo na qualidade de vida dos pacientes e pode acarretar importantes
complicações tais como desnutrição, perda de peso e aspiração, além da presença do
sintoma disfágico. A doença do refluxo gastro-esofágico, a ingesta de agentes
cáusticos, a cirurgia do esôfago e a radioterapia estão entre as causas mais freqüentes
de estenose esofágica benigna. Dentre causas menos freqüentes estão os anéis,
membranas, retrações pós-escleroterapia de varizes esofágicas, uso prolongado de
cateter nasogástrico, acalasia, pós-operatório de cirurgia para acalasia, esclerodermia
e lesões por medicamentos, entre outros (1,2, 3, 4, 5, 6).
Fisiopatologicamente, a estenose (termo definido por Dorland como um
“estreitamento de um ducto ou canal”) é resultado de intensa lesão da mucosa do
órgão, com conseqüente espessamento de suas camadas mucosa, submucosa e
muscular, evoluindo então para fibrose, retração e, por fim, diminuição da luz
esofágica (7).
A dilatação endoscópica é considerada a terapia inicial de escolha para pacientes
com estenoses esofágicas benignas (1,2). Existem diversas técnicas para se proceder à
mesma, entre elas a introdução de velas dilatadoras por passagem às cegas (tipo Hurst
e Maloney), o uso de olivas metálicas (Eder-Puestow) e velas de polivinil (Savary-
Gilliard) guiadas por fio-guia posicionado endoscopicamente, o uso de balões
dilatadores, ou até mesmo a inserção de próteses auto-expansíveis temporárias (1, 8).
Os dilatadores de Hurst e Maloney são constituídos de borracha e preenchidos por
mercúrio, para permitir sua visualização por fluoroscopia. Sua diferença está na
9
ponta, que é arredondada nos de Hurst e afilada nos de Maloney. A técnica de
dilatação empregada com tais sondas envolve a transposição da estenose pelo peso
das próprias sondas, portanto o procedimento é efetuado com o paciente sentado, e a
introdução dos dilatadores é realizada às cegas, com ou sem o auxílio fluorocópico.
Como em diversas outras técnicas de dilatação, é sempre respeitada a “regra dos três”,
ou seja, a utilização de no máximo três dilatadores consecutivos (de diâmetros
crescentes) por sessão de dilatação (9, 10, 11, 12).
As olivas metálicas de Eder-Puestow são confeccionadas em tamanhos de 21 a 53
Fr, e são fixadas por uma haste de metal - isoladamente ou em grupo de três - e
introduzidas através de fio-guia posicionado endoscopicamente momentos antes da
dilatação. Tais dispositivos, hoje em dia, raramente constituem a terapêutica de
escolha no tratamento das estenoses benignas de esôfago (13).
Os dilatadores termoplásticos de Savary-Gilliard, por sua vez, são velas
constituídas de material plástico semi-rígido de polivinil dotadas de um canal coaxial
fino por onde se introduz o fio-guia de aço, como nas velas de Eder-Puestow. Tais
dilatadores apresentam-se em vários diâmetros, possuem a ponta afilada e vêm se
tornando os instrumentos mais comumente utilizados nos procedimentos de dilatação
tendo-se em vista a praticidade e simplicidade com que se dá seu manejo (14, 15, 16,
17).
Outra alternativa para se proceder à dilatação esofágica é fazer uso de balões
dilatadores hidrostáticos ou pneumáticos. Tais dispositivos ganharam popularidade
por teoricamente serem mais seguros e possibilitarem que o procedimento seja
realizado sob visão direta, o que no entanto não se confirmou em estudos (11, 14, 17).
10
O emprego de próteses auto-expansíveis temporárias de poliéster recobertas com
silicone foi recentemente avaliado em uma série de casos de estenoses de difícil
manejo, e se mostrou uma alternativa eficaz e com baixa morbidade para o tratamento
de tais pacientes (8).
Apesar do fato de ser a dilatação endoscópica a principal causa da mais temida
complicação de uma endoscopia digestiva alta, a perfuração esofágica, a dilatação
endoscópica do esôfago segue sendo considerada como o método mais seguro, e
talvez o mais eficiente, de aliviar parcial ou completamente a disfagia e a má-nutrição
causada por uma estenose benigna de esôfago (18, 19). A melhor técnica e o melhor
tipo de dilatador para a realização do procedimento, no entanto, permanecem a ser
definidos.
Na análise final de estudo comparativo prospectivo com duração de 1 ano entre
duas técnicas de dilatação, Cox et al (12) concluiram que os dilatadores de Eder-
Puestow passados através de fio-guia posicionado endoscopicamente produziram um
maior aumento no diâmetro do lúmen esofágico ao final do seguimento, um maior
alívio na disfagia e uma menor taxa de redilatação em relação à técnica de dilatação
não-endoscópica por balão. Por outro lado, Scolapio et al (14) não encontraram
diferenças entre o uso de dilatadores rígidos ou balões em relação ao alívio imediato
da disfagia ou à necessidade de redilatação ao cabo de 1 ano. Dilatadores do tipo
Celestin (dilatadores de neoplex os quais apresentam diâmetros de 4 mm na ponta e
que gradualmente aumentam de diâmetro em direção à sua extremidade proximal, em
intervalos de 2 mm, com canal central para passagem de fio-guia) apresentariam a
vantagem teórica de proporcionar dilatação em níveis satisfatórios com maior rapidez
em comparação aos dilatadores de Savary-Gilliard e Eder-Puestow. Em um estudo
11
indiano, 100% dos pacientes com estenoses pépticas submetidos ao uso de dilatadores
do tipo Celestin foram dilatados com sucesso (i.e., tornaram-se assintomáticos e um
cateter de 18 mm – 54 Fr – foi inserido) com uma média de 1,62 sessões (20).
Entretanto, no único estudo comparativo entre dilatadores do tipo Celestin e Eder-
Puestow, não se encontrou diferença em relação ao alívio dos sintomas a longo prazo
(21).
Cada estenose esofagiana parece ter suas próprias características, e alguma
variação individual na técnica de dilatação pode ser necessária para que o tratamento
tenha êxito. Dilatadores do tipo Maloney funcionam bem em estenoses curtas, mas
são de difícil emprego em lesões mais complexas (10, 11). Em uma comparação entre
as taxas de perfuração esofágica por dilatadores do tipo Maloney, Savary e balões, tal
complicação ocorreu mais freqüentemente durante a passagem às cegas dos
dilatadores do tipo Maloney em estenoses consideradas complexas (3,9 % dos casos)
(11). Em oposição, em estudo prévio onde todos os pacientes portavam estenoses
consideradas “leves”, nenhuma perfuração ocorreu e a taxa de sucesso encontrada foi
alta, demonstrando que tais dilatadores podem proporcionar boas respostas quando
bem indicados (10). As olivas metálicas de Eder-Puestow foram amplamente
abandonadas em favor das velas de Savary-Gilliard na maioria dos serviços de
endoscopia em todo o mundo, no entanto nenhum estudo comprovou haver vantagens
em termos de segurança e eficácia das velas em relação às olivas dilatadoras (1, 2).
De fato, diferenças nos resultados do tratamento endoscópico são, em grande parte,
operador-dependentes, e apesar de diretrizes para o uso das diferentes técnicas
estarem disponíveis, variações inter-operadores irão provavelmente resultar em viéses
12
individuais entre endoscopistas e tenderão a favorecer o uso de um tipo de dilatador
em relação a outro (22).
O uso de controle fluoroscópico para se proceder à dilatação endoscópica também
é fonte de controvérsia (2). Alguns autores e guidelines recomendam o uso da
fluoroscopia ao menos nas sessões iniciais de dilatação (23, 24, 25). A Associação
Americana de Gastroenterologia, contudo, não faz referência ao uso do controle
fluoroscópico em suas recomendações oficiais para o tratamento de pacientes com
enfermidades benignas do esôfago distal (1). Diversos estudos têm reportado a
segurança em se realizar a dilatação endoscópica sem o auxílio da fluoroscopia (21,
26, 27, 28). Kadakia et al em uma série de 138 pacientes submetidos a 748 dilatações
individuais com velas de polivinil sem controle fluoroscópico, não registraram
nenhuma complicação significativa relacionada ao procedimento (15), assim como
Wang et al em série de 401 dilatações também usando velas de Savary (16). Salienta-
se que nesta série mais da metade dos pacientes portavam estenoses de origem
maligna, as quais teoricamente acarretam maior chance da ocorrência de perfurações.
Nos casos de estenoses muito estreitas ou com muita tortuosidade - tais como as
produzidas pela ingesta de substância cáustica ou câncer - o uso de um fio-guia mais
flexível (como os utilizados em endoscopia biliar) proporciona um meio seguro de
“negociar” com essas estenoses, uma vez que sua ponta é atraumática (16, 29). Além
disso, o uso de fluoroscopia na rotina diária consome tempo, resulta em exposição à
radiação, e o equipamento radiológico não é disponível na maioria dos serviços de
endoscopia tendo em vista seu alto custo.
Quanto às contra-indicações ao procedimento de dilatação, a presença de
perfuração aguda ou não curada completamente constitui contra-indicação absoluta ao
13
tratamento endoscópico. Entre as contra-indicações relativas, inclui-se os distúrbios
de coagulação, doença pulmonar grave, infarto agudo do miocárdio recente, cirurgia
esofágica recente, deformidades faríngeas e cervicais, laparotomia recente, e
aneurisma de aorta de grandes proporções. Radioterapia concomitante não constitui
contra-indicação à dilatação esofágica (2).
Dentre as possíveis complicações, inclui-se a perfuração, a aspiração pulmonar e o
sangramento. Dor torácica transitória é comum durante a dilatação de estenoses de
alto grau ou neoplásicas. Dor persistente ou aparecimento de febre requerem
avaliação imediata para exclusão de complicações. Taxas de perfuração em torno de
0,3 % por procedimento são esperadas, e o risco para ocorrência da mesma é maior
em estenoses complexas, ou seja, estenoses mais longas, estreitas e anguladas (1, 2,
11).
Fator que influencia diretamente a resposta à terapêutica de dilatação é a etiologia
causadora da estenose. Uma estenose benigna de esôfago não é essencialmente uma
doença, mas sim uma complicação de uma enfermidade de base. Portanto, diferentes
mecanismos fisiopatológicos de agressão produzirão lesões com história naturais
diversas (3, 4, 5, 20, 28, 30, 31). Pacientes com estenoses de origem péptica
costumam apresentar melhor resposta em relação ao grupo dos “não-pépticos” (20,
30). Já pacientes com lesões causadas por substâncias cáusticas via de regra são de
difícil tratamento, uma vez apresentarem extenso comprometimento tanto no sentido
crânio-caudal como também em relação à profundidade da lesão esofágica, que
costuma ser transmural (4, 20, 28, 31).Tal aspecto já foi inclusive demonstrado em
estudo por análise tomográfica, onde pacientes com espessura da parede esofágica
superior ou igual a 9 mm necessitaram de um número significativamente maior de
14
sessões para obter resultado satisfatório em relação àqueles com diâmetro inferior a 9
mm (5). O uso de injeções de corticóide para melhorar a resposta à terapêutica de
dilatação em tais doentes tem sido defendido por alguns autores. Tal técnica poderia
levar a uma diminuição na freqüência das sessões de dilatação ou promover a
obtenção de diâmetros esofágicos maiores, como sugerido em alguns estudos (32, 33).
Ainda em relação aos pacientes pépticos, o uso de medicações anti-refluxo é
variável que, conforme já demonstrado na literatura, altera o desfecho do tratamento
endoscópico nesse grupo de pacientes. Em estudo onde se comparou o uso de
omeprazol com o uso de ranitidina na prevenção de recorrência de estenoses pós-
dilatação, verificou-se que o grupo usuário dos inibidores de bomba de prótons
apresentou melhor resposta em relação ao grupo que fez uso dos bloqueadores de
receptores H2, enaltecendo a importância do controle do refluxo gastro-esofágico para
obtenção de respostas satisfatórias em pacientes pépticos (34). Em nosso estudo,
tendo-se em vista o baixo nível econômico da população estudada, possivelmente o
uso de tais medicações foi aquém do indicado, levando tais pacientes a apresentarem
uma pior resposta, conforme comentado em nosso artigo. Outros fatores recentemente
identificados como sendo de risco para recidiva dos sintomas relacionados à estenose
nos pacientes com doença péptica foram a persistência de pirose durante o
seguimento (apesar do uso de inibidores de bomba) e a presença de hérnia hiatal,
sendo que as duas variáveis se mostraram independentes quando submetidas à análise
multivariada (30) .
Os casos de estenoses pós-operatórias são bastante escassos na literatura,
geralmente perfazendo pequenas frações da amostra (2%, em determinado estudo
norte-americano) (30). Tal escassez faz com que haja poucos dados disponíveis em
15
relação a como se comportam tais pacientes quando submetidos à dilatação. Em nosso
estudo, porém, tais casos são responsáveis por mais de 60 % da amostra, o que
confere à nossa série um perfil bastante diverso daquele encontrado na maioria das
séries publicadas na literatura internacional. As razões para tal discrepância serão
exploradas em nosso artigo.
Em um dos raros estudos em que se acompanharam pacientes cirúrgicos, no caso
submetidos à esofagectomia transhiatal com interposição de tubo gástrico e
conseqüente anastomose cervical, 42 % da amostra desenvolveu estenose durante o
seguimento, com boas respostas à dilatação (resposta em 80 % dos casos). Tal estudo,
no entanto, difere do nosso por não ter realizado a comparação das taxas de resposta
com casos de outras etiologias. De qualquer maneira, em relação aos fatores de risco
para o desenvolvimento de estenoses na amostra estudada, os achados sugeriram
como relevantes a presença de cardiopatia isquêmica, de fístula pós-operatória e do
uso de staplers na confecção da anastomose. A extremidade cervical do tubo gástrico
é área sujeita à circulação sanguinea deficiente pela própria natureza da cirurgia em
questão. Somando-se a isso a presença de vasculopatia – no caso identificada por
serem os pacientes cardiopatas isquêmicos – realmente se faz plausível a idéia de que
vasculopatas estejam sob maior risco de desenvolver estenoses, secundárias à
irrigação sanguinea insuficiente durante o processo de cicatrização. Para explicar o
uso dos staplers como fator de risco - em comparação à sutura manual - os autores
levantaram a hipótese de que, como o intervalo entre os pontos de sutura seria maior
com o uso de tais dispositivos, haveria maior presença de cicatrização por segunda
intenção, o que leva ao surgimento de tecido de granulação e conseqüente fibrose.
16
Quanto à fístula pós-operatória, a presença da mesma por si só já acarreta importante
processo inflamatório adjacente e fibrose subsequencial (35).
Aspecto de discussão na literatura é o diâmetro ideal a ser atingido para que a
resposta à dilatação endoscópica seja considerada satisfatória. Não há consenso em
quanto dilatar seja suficiente, e a idéia de “quanto mais melhor” não encontra suporte
na literatura (3). Este é outro assunto que também será abordado em nosso estudo.
O objetivo de nosso estudo é, portanto, relatar nossa experiência em uma série de
2.750 sessões de dilatação endoscópica sem o auxílio de fluoroscopia, e relacionar
entre si dados como diâmetro das estenoses, etiologia das mesmas, grau de disfagia
pré e pós-tratamento, resposta clínica ao tratamento e dados epidemiológicos, no
intuito de chegar a conclusões que tenham, fundamentalmente, aplicabilidade no dia-
a-dia do endoscopista digestivo.
17
REFERÊNCIAS BIBLIOGRÁFICAS
1 Spechler JS. American Gastroenterological Association Medical Position
Statement on Treatment of Patients With Dysphagia Caused by Benign
Disorders of the Distal Esophagus. Gastroenterology 1999; 117: 229-32
2 American Society for Gastrointestinal Endoscopy Guideline. Esophageal
dilation. Gastrointest Endosc 1998; 48: 702-4
3 Saeed ZA, Graham DY. Treatment of benign esophageal strictures. Where do
we go from here? Dig Dis Sci 1994; 39: 2099-101
4 Broor SL, Ragu GS, Bose PP, et al. Long term results of endoscopic dilation for
corrosive oesophageal strictures. Gut 1993; 34: 1498-501
5 Lahoti D, Broor SL, Basu PP, et al. Corrosive esophageal strictures: Predictors
of response to endoscopic dilation. Gastrointest Endosc 1995; 41: 196-200
6
Sreenivas DV, Kumar A, Mannar R, et al. Results of Savary-Gilliard Dilatation
in the Management of Cervical Web of Esophagus. Hepat Gastroenterol 2002;
49: 188-190
7 Earlam R, Cunha-Melo JR. Benign oesophageal strictures: historical and
technical aspects of dilation. Brit J Surg 1981; 68:829-36
8 Repici A, Conio M, De Angelis C, et al. Temporary placement of an expandable
polyester silicone-covered stent for treatment of refractory benign esophageal
strictures. Gastrointest Endosc 2004; 60: 513-19
9 Sakai P, Pinotti HW, Gama-Rodrigues JJ, et al. Endoscopic treatment of benign
post-anastomotic anular stricture of cervical esophagus. Int Surg 1982; 67: 115-
8
10 Ho SB, Class O, Katsman RJ, et al. Fluoroscopy is not necessary for Maloney
dilation of chronic esophageal strictures. Gastrointest Endosc 1995; 41: 11-4
11 Hernandez JL, Jacobson JW, Harris MS. Comparison among the perforation
rates of Maloney, balloon, and Savary dilation of esophageal strictures.
Gastrointest Endosc 2000; 4: 460-2
12 Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilatation of
benign esophageal stricture? Dig Dis Sci 1994; 39: 776-81
18
13
Rago E, Boesby S, Spencer J. Results of Eder-Puestow dilation in the
management of esophageal peptic strictures. Am J Gastroenterol 1983; 78: 6-8
14
Scolapio JS, Pasha TM, Christopher JG, et al. A randomized prospective study
comparing rigid to balloon dilators for benign esophageal strictures and rings.
Gastrointest Endosc 1999; 50: 13-7
15 Kadakia SC, Parker A, Carrougher JG, et al. Esophageal dilation with polyvinyl
bougies, using a marked guidewire without the aid of fluoroscopy: an update.
Am J Gastroenterol 1993; 88: 1381-6
16 Wang YG, Tio TL, Soehendra N. Endoscopic dilation of esophageal stricture
without fluoroscopy is safe and effective. World J Gastroenterol 2002; 8: 766-8
17 Saeed ZA, Winchester CB, Ferro PS, et al. Prospective randomized comparison
of polyvinyl bougies and through-the-scope balloons for dilation of peptic
strictures of the esophagus. Gastrointest Endosc 1995; 41: 189-95
18 Clouse RE. Complications of endoscopic gastrointestinal dilation techniques.
Gastrointest Endosc Clin N Am 1996; 6: 323-41
19 Pasricha PJ, Fleischer D, Kaloo AN. Endoscopic perforations of the upper
digestive tract: A review of their pathogenesis, prevention and management.
Gastroenterology 1994; 106: 787-802
20 Duseja A, Chawla YK, Singh RP, et al. Dilatation of benign oesophageal
strictures: 10 years’ experience with Celestin dilators. J Gastroenterol Hepatol
2000; 15: 26-9
21 Hine KR, Hawkey CJ, Atkinson M, et al. Comparison of the Eder-Puestow and
Celestin techniques for dilating benign oesophageal strictures. Gut 1984; 25:
1100-2
22 Boyce HW. Hiatus hernia and peptic diseases of the esophagus. In: Sivak MV
(ed). Gastroenterologic endoscopy (CD-ROM). 2
nd
edn. Philadelphia: WB
Saunders, 1999: Chapter 44
23 Scheurlen CH, Sauerbruch T. Ösophaguserkrankungen. In: Sauerbruch T,
Scheurlen CH (eds). Leitlinien der deutschen Gesellschaft für Verdauungs-und
Stoffwechselkrankheiten (DGVS), Demeter Verlag, Balingen, 1997: 17-25
19
24
Tulman AB, Boyce HW. Complications of esophageal dilatations and guidelines
for their prevention. Gastrointest Endosc 1981; 27: 229-34
25
Webb WA. Esophageal dilation: Personal experience with current instruments
and techniques. Am J Gastroenterol 1988; 83: 471-5
26
Kadakia SC, Cohan CF, Starnes EC. Esophageal dilation with polyvinyl bougies
using a guidewire with markings without the aid of fluoroscopy. Gastrointest
Endosc 1991; 37: 183-7
27 Marshall JB, Afridi AS, King PD, et al. Esophageal dilation with polyvinyl
(American) dilators over a marked guidewire: Practice and safety at one center
over a 5-year period. Am J Gastroenterol 1996; 91: 1503-6
28 Pereira-Lima JC, Ramires RP, Zamin Jr. I, et al. Endoscopic dilation of benign
esophageal strictures: Report on 1043 procedures. Am J Gastroenterol 1999; 94:
1497-501
29 Vargas-Tank L, Ovalle L, Fernández C, et al. Use of a very flexible guidewire to
permit dilation of complex malignant strictures of the esophagus. Gastrointest
Endosc 1995; 41: 8-10
30 Said A, Brust DJ, Gaumnitz EA, et al. Predictors of early recurrence of benign
esophageal strictures. Am J Gastroenterol 2003; 98; 1252-6
31 Andreollo NA, Lopes LR, Inogutti R, et al. Tratamento conservador das
estenoses benignas do esôfago através de dilatações. Análise de 500 casos. Rev
Ass Med Brasil 2001; 47: 236-43
32 Kochhar R, Ray JD, Sriram PVJ, et al. Intralesional steroids augment the effects
of endoscopic dilation in corrosive esophageal strictures. Gastrointest Endosc
1999; 49: 509-13
33 Camargo MA, Lopes LR, Grangeia TAG, et al. O uso de corticosteróides após
dilatação esofágica em pacientes portadores de estenose por substâncias
corrosivas – estudo prospectivo, randomizado e duplo cego. Rev Ass Med Brasil
2003; 49: 286-92
34 Smith PM, Kerr GD, Cockel P, et al. A comparison of omeprazole and ranitidine
in the prevention of recurrence of benign esophageal stricture. Gastroenterology
1994; 107: 1312-8
20
35
Honkoop P, Siersema PD, Tilanus HW, et al. Benign anastomotic strictures after
transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and
management. Cardiovasc Surg 1996; 111: 1141-8
21
ARTIGO CIENTÍFICO
Title: Endoscopic Dilation of Benign Esophageal Strictures Without
Fluoroscopy: Report of a Series of 2,750 Procedures
ABSTRACT
Background and study aims: We report our experience on a large series of patients with
benign esophageal stricture from different etiologies who underwent endoscopic dilation
without the aid of fluoroscopy.
Patients and methods:
Between 1992 and 2005, we performed 2,750 dilation sessions on
321 patients. The grade of dysphagia, cause and location of the stricture and diameter of the
inserted bougies were recorded in every session. Clinical response was considered to be
achieved when dysphagia disappeared or remained in a mild grade.
Results: Three hundred twenty-one patients were followed-up for a mean of 18.8 months.
Stricture’s etiology was postsurgical in 204 patients, peptic in 60, caustic in 13,
postradiotherapy in 13, and from other causes in 31. Clinical response was achieved in 92%
of the postsurgical patients; 84% of the patients with caustic injury; 81% of the peptic
patients; and 58% of the patients with radiation injury (p<0.05). Absence of dysphagia was
obtained in 68, 38, 67 and 27% of them, respectively (p<0.05). All groups showed a
significant improvement in dysphagia score, and 98% of patients in whom a 45 F catheter
was inserted achieved clinical response. There were six perforations, with two deaths.
Conclusions: Endoscopic dilation for benign esophageal strictures without the aid of
fluoroscopy is a safe and effective method. Postsurgical patients show excellent results to
dilation, and caustic and post-radiotherapy strictures have the worst response to therapy. A
diameter of 45 F is a satisfactory end-point to therapy in the vast majority of the cases.
Key Words: Benign esophageal strictures; Endoscopic Dilation; Fluoroscopy
22
INTRODUCTION
Endoscopic dilation with or without fluoroscopy is considered the initial treatment
of choice for benign esophageal strictures [1, 2]. There are several techniques to achieve
esophageal dilation, including the use of mercury-weighted rubber blunt-tipped (Hurst
type) and tapered-tipped (Maloney type) bougies through blind passage, the use of wire-
guided polyvinyl bougies (Savary-Gilliard type) and wire-guided metal olives (Eder-
Puestow type), endoscopically oriented ballons, or even the placement of temporary self
expandable plastic stents [1, 3].
Despite the fact that endoscopic esophageal dilation is the main cause of the most
serious complication of an upper endoscopic procedure, that is, perforation, it remains
considered the safest, and may be the most efficient technique to achieve partial or
complete relief of dysphagia and improvement of the nutritional status in patients with
benign esophageal stenoses [4, 5]. In this study, we report our experience on a
prospectively assessed consecutive series of 321 patients who underwent 2,750 dilation
sittings without the use of fluoroscopy.
PATIENTS AND METHODS
Patients
A total of 352 patients with benign esophageal stricture were referred to our
Endoscopy Unit between May 1992 and February 2005. Two patients underwent dilation
with the aid of fluoroscopy in 1-2 sessions and were excluded from the study. Other 29
cases were lost to follow-up. Thus, 321 cases who were followed-up and underwent 2,750
dilation sessions entered the study. All patients presented with dysphagia of varying grades
and the benign etiology of the stricture was confirmed by means of endoscopy with
biopsies and by the clinical outcome.
23
Endoscopic Dilation
The dilation sessions were done as an outpatient procedure in almost the totality
of the patients. The endoscopic procedures were performed by the authors or
gastroenterology fellows under supervision. A barium esophagogram was performed before
the first dilation sitting only when the endoscopist suspected the existence of a tortuous
stenosis (e.g., all cases of caustic and some cases of peptic strictures). Dilation was done
using Savary-Gilliard dilators (Wilson Cook Medical Inc., Winston-Salem, NC) in the vast
majority of patients. Eder-Puestow dilators (Key Medical Inc., Essex. UK) were also used
in some few cases in 1992 and 1993. After sedation with midazolam 3-5 mg, bougies or
metal olives of increasing size were passed over a metal or biliary (teflon or with a floppy
tip) guide-wire, which has been positioned with the help of and endoscope (GIFXQ20, CV-
1, CV-100, CV-145 and CV-160 Video Endoscopes, Olympus, Corp., Tokyo, Japan). One
to four dilators were passed during each session, depending on patient tolerance and
stricture tightness. Fluoroscopic control of the procedure was never performed. Dilation
sessions were done on a weekly basis until a lumen size of 42 to 51 F (14 to 17 mm) was
obtained. Afterward, dilation was repeated whenever dysphagia recurred. Patients who had
strictures caused by peptic esophagitis were advised to use proton pump inhibitors, together
with other antireflux measures.
After each dilation session, patients were carefully observed for 3 hours. If
perforation was suspected, an urgent chest x-ray and an esophagogram using a water
soluble contrast medium were done. If perforation was confirmed, an immediate surgical
consultation was sought and the patient was put on intravenous fluids, parenteral
antiobiotics and was advised to take nothing by the oral route.
Response to Treatment
Response to treatment was judged on the basis of improvement in dysphagia, which
was graded as follows: 0, taking a normal diet, no dysphagia; 1, unable to swallow certain
solid foods (e.g., grilled beef); 2, able to swallow only semisolid soft foods; 3, able to
swallow just liquids; 4, unable to swallow liquids in adequate amounts.
Patients in whom the grade of dysphagia after endoscopic treatment was 0 or 1 were
considered to achieve clinical response to endoscopic treatment, while patients with a poor
24
response (grades 2, 3 or 4) after therapy were considered as “nonresponders”, even though
a catheter of 42 F or wider had been introduced through the stricture .
Treatment Follow-up
After adequate dilation (passage of at least a 42 F dilator catheter), patients were
instructed to return to our Endoscopy Unit for a control endoscopic examination 1 month
and 3 months after the last endoscopic procedure or whenever dysphagia recurred. One year
after the last dilation session, patients were contacted to assess response to treatment.
Statistics
Fisher’s exact test was applied to verify the significance of correlations between
categorical variables. To analyze correlations between categorical and quantitative
variables, T test or ANOVA was used (α set at 0.05). In the cases where a significant
association was found post hoc LSD test was used to specify which were the categories
with significant difference of means.
We also used Pearson’s coefficient to verify the presence of significant correlations
between quantitative variables and the Wilcoxon Signed Ranks Test to compare grades of
dysphagia before and after treatment.
This study was approved by the Ethical Review Board of our institution.
RESULTS
Three hundred twenty-one patients who underwent 2,750 dilations sittings (mean
8.57) were analyzed. Other 31 cases who did not wish to complete therapy, were lost to
follow-up or underwent fluoroscopy were excluded from the study. Two hundred eleven
were men (65.7%) and 110 were women, with a mean age of 56.2 years (median, 59 yr; age
range, 7 to 83). The causes of the esophageal strictures were divided in five groups and are
shown in Table 1. The mean follow-up was 18.8 (ranging from 1 to 166, median 11)
months.
25
There was a positive relationship between the number of dilation sessions and
clinical response (9.3 sessions in responders vs. 4.6 in non responders, p<0.01), as well as
between duration of treatment and clinical response (14.05 months in responders vs. 6.9 in
nonresponders, p<0.01) and, obviously, between duration of treatment and number of
sessions (p<0.001, r = 0.691).
Etiology
versus
Response to Treatment
The proportion of patients with clinical response (dysphagia after therapy graded as
0 or 1) according to the cause of the stricture is shown in Table 2. When comparing the
group as a whole, postoperative strictures patients obtained a higher clinical response rate,
while patients with postradiotherapy stenoses had more failures (84.7%, 92% and 58%,
respectively; p=0.001).
Comparing each group versus another, patients with postsurgical strictures had a
significantly better response to therapy in comparison with postradiotherapy and peptic
strictures (92% vs. 58% [p=0.003] and 92% vs. 81%[p=0.028], respectively). There were
no other statistically significant differences among the different groups.
When analyzing absence of dysphagia (grade 0) after therapy as an outcome,
patients with caustic and postradiotherapy stenoses had less successfully reached this end-
point in comparison with the rest of the studied population (38%, 27% and 64%,
respectively, p=0.009). Comparing each group versus another, we identified statistical
differences when confronting the postsurgical with the caustic and the postradiotherapy
groups (68% vs. 38%[p=0.037] and 68% vs 27%[p=0.009], respectively); the cases with
peptic strictures vs. the ones with postradiotherapy stenosis (67% vs 27%, p=0.019); and
there was also a trend towards better outcome when comparing the peptic versus the caustic
stricture group (67% vs 38%,p=0.065) (Table 2).
No correlations between the occurrence of complications and the cause of the
stricture were found (p=0.15).
The mean number of dilation sessions in the first two months for caustic,
postradiotherapy, postsurgical and peptic groups was, respectively, 4.23, 3.54, 3.53 and
2.75. Statistical differences were found between caustic and peptic stricture groups
(p=0.006) and between postsurgical and peptic cases
(p=0.003) (see Table 3).
26
Patients with caustic injury were significantly younger than patients in the peptic
and postsurgical groups (mean age: 45.3, 56.8 and 57.7 yr, respectively-p<0.01).
Diameter of the Inserted Catheter versus Response to Treatment
A 42 F or wider dilator was inserted in 237 of 321 (73.8 %) cases. The mean
maximum dilator diameter inserted in the group of patients with clinical response was 45.7
F, and among patients without response it was 36.8 F (p<0.000001).
Using a 45 F diameter as a cut-off, patients in whom this diameter was reached had a
significantly higher rate of clinical response than those in which this catheter size was not
inserted (98% vs 72%, p<0.000001). The absence of dysphagia (grade 0) after therapy was
also more frequent in the group in which a 45F catheter was introduced (80% vs 38%,
p<0.000001).
A 45 F catheter was more frequently inserted among postsurgical patients (64%)
than in caustic and postradiotherapy ones (31% for both, p=0.01).
No correlation was found between the maximum diameter of the inserted bougie
and the incidence of complications (p=0.24).
Analyzing the minimum diameter of the inserted bougie in the first session, we
found that the larger the minimum diameter of the bougie initially inserted, the better the
clinical response ( mean of 30.4 F in responders vs. 27.4 in nonresponders, p=0.017). A
positive correlation was also found between the minimum diameter of the inserted bougie
at the first session and the success in introducing 45 F catheter (mean of 32.3 F [group that
reached 45 F] vs. 27 F [group that did not reach 45 F], p<0.00001).
Wider bougie diameters were inserted in postoperative strictures patients, occurring
statistically significant differences in comparison with caustic and postradiotherapy cases
(45.3 vs. 41.6 F [p=0.03] and 45.3 vs. 39.3 F [p=0.001], respectively). In peptic stricture
patients the mean maximum diameter inserted was 44 F, showing a statistically significant
difference in relation to the postradiotherapy group (p=0.01). No significant differences
were found among the diameters of the initially inserted bougies (Table 3).
There was a trend to occur an inverse relation (p=0.058, r = -0.106) between the
width of the initial inserted bougie and the duration of therapy, i.e., the tighter the stricture,
the longer the treatment duration. An inverse correlation was also found between the
27
number of sessions in the first two months and during all the treatment period and the
diameter of the first inserted bougie (p<0.001, r= -0.342).
There was also a correlation between minimum and maximum diameter of the
inserted bougies, i.e., the wider the catheter introduced initially, the greater the diameter of
the final inserted dilator (p<0.00001, r = 0.376). The number of sessions in the first two
months also correlated positively with the total number of sessions (p<0.001, r = 0.283).
Dysphagia Grade versus Response to Treatment
The median pre-treatment grade of dysphagia of the analyzed sample as a whole
was 3, retroceding to zero after therapy (p<0.000001- Wilcoxon Signed Ranks Test). All
groups showed a significant improvement in the dysphagia score after dilation therapy (see
Table 4).
There was an association between dysphagia grade at presentation and total relief of
dysphagia. Absence of dysphagia after therapy (grade 0) was observed in 54% of the cases
with grade 4 before therapy and in 71% of the rest of the sample (grades 1, 2 and 3)
(p=0.001). The total number of sessions, the number of sessions in the first two months and
the minimum and maximum diameter of the inserted bougie according to pre treatment
grade of dysphagia are shown in Table 5. Patients with pre-treatment dysphagia grade 4
underwent more dilation sessions in comparison with patients who had initial grades 1,2 or
3 (p=0.004, 0.01 and 0.02). The number of sessions in the first two months was also higher
in the group with more severe symptoms.
As expected, the mean diameter of the stricture at presentation (measured indirectly
by observing the caliber of the first inserted bougie) had a straight relationship with the
grade of dysphagia, ranging from 25.9 F in grade 4 to 38.1 F in grade 1 (see Table 5-
statistical differences present in all comparisons, except between grades 1 vs. 2). The mean
diameter of the stricture after treatment (measured indirectly by the widest inserted bougie)
also showed a relationship with the initial grade of dysphagia, i.e., in patients who
presented initially with milder grades of dysphagia, there was a trend to be submitted to
dilation with wider bougies. However, a statistically significant difference was only found
between grades 1 vs. 4 (46.7 vs. 43.2 F, respectively; p=0.01).
28
Patients in whom absence of dysphagia (grade 0) was achieved showed wider
esophageal diameters after dilation therapy in comparison with all the other groups. These
patients had also wider stenotic diameter before treatment, indirectly measured by the
caliber of the inserted bougie (Table 6). In patients with dysphagia grade 1, catheters with
wider calibers were also inserted in a statistically significant fashion, in comparison with
patients with dysphagia grades 2, 3 and 4 (p<0.05 for all). No correlation between age and
intensity of dysphagia before or after therapy was found.
Complications
Five cases of esophagus perforation in two patients with peptic, two patients with
caustic and one patient with postoperative stricture were observed. One account of gastric
perforation due to guidewire injury in a patient with a postoperative stricture also occurred.
This represent 1.8 % of the patients, but 0.21 % of the sessions. We also observed one case
of brain abscess in a young woman with caustic injury who developed the infection few
days after a dilation session. The patient was treated with parenteral antibiotics and
endoscopic treatment with antibiotic prophylaxis was reinitiated after resolution of the
infection.
Four of the six patients with perforation were managed surgically, with two deaths
(0.6% of the cases, 0.07% of the sittings). No clinically overt hemorrhage occurred during
or after the sessions.
DISCUSSION
Although endoscopic dilation is considered the mainstay treatment for benign
esophageal strictures, the best technique and the best type of dilator to carry out the
procedure remains to be determined [1, 2].
In the final analysis of a 1-year prospective comparison of two dilation techniques,
Cox et al [6] found that Eder-Puestow dilators passed over an endoscopically placed
guidewire produced a greater increase in esophageal lumen size at the end of the follow-up,
a greater decrease in dysphagia grade at 5 months, and a lower redilation rate than did
29
nonendoscopic balloon dilation. On the other hand, Scolapio et al. [7] found no differences
between the use of rigid dilators or balloons with regard to immediate relief of dysphagia or
the need for repeating dilation at one year. Celestin dilators would have the theoretical
advantage of achieving optimum dilation with more rapidity than Savary-Gilliard and Eder-
Puestow dilators. In one study from India, 100% of the patients with peptic strictures were
successfully dilated (i.e., became asymptomatic and a 18 mm - 54 F - catheter was inserted)
with a mean number of sessions of 1.62 [8]. However, in the only comparative trial
between Eder-Puestow and Celestin dilators no difference in the long-term relief of
symptoms was found [9].
Every esophageal stricture seems to have its own characteristics and some
individualized variation in technique may be needed for a successful therapy. Maloney
dilators work well for short strictures, but are difficult to use in more complex cases [10,
11]. In a comparison among the perforation rates of Maloney, Savary-Gilliard and balloon
dilators [11], this complication occurred more often during the blind passage of Maloney
bougies into complex strictures (perforation rate with Maloney dilators = 3.9%). In
contrast, in one previous study where all patients had mild strictures, no perforations have
occurred and the rate of success was high, showing that this type of dilator can
proportionate a good response if well indicated [10]. Eder-Puestow metal olives have been
largely abandoned for Savary-Gilliard bougies in most endoscopic units around the world,
although no study have proved advantages in terms of safety and efficacy for the latter type
of dilator over the former one [1, 2]. Indeed, differences in the results of endoscopic
therapy is in a large measure operator-dependent, and although defined guidelines for the
use of these devices are available, interoperator variations in technique will likely result in
individual biases among endoscopists and will tend to favor one type of dilator over another
[1, 2, 12].
The use of fluoroscopic control is also a controversial issue [2]. In our series, we did
not use fluoroscopy to control guidewire and dilator position and path. Some authors and
guidelines have recommended the use of fluoroscopic guidance at least in the initial
dilation sessions [13, 14, 15]. The American Gastroenterological Association, however,
makes no reference to fluoroscopic control in its official recommendations on treatment of
patients with benign disorders of the distal esophagus [1]. Several studies have reported the
30
safety in performing esophageal dilation without the aid of fluoroscopy [10, 16, 17, 18].
Kadakia et al. in one series of 138 patients who underwent 748 individual dilations with
polyvinyl bougies without fluoroscopic control did not register any significant procedure-
related complication [19], as did Wang et al in one series of 401 dilations also using Savary
bougies [20]. It is noteworthy that in the latter series more than half of the patients had
malignant strictures, which theoretically would carry a higher risk of perforation. In cases
of tortuous or very tight strictures, as the ones produced by lye ingestion or cancer, the use
of a very flexible guidewire (like the ones used in biliary endoscopy) proportionates a safe
way in “negotiating with these strictures”, since its tip is atraumatic [20, 21]. Indeed, the
use of fluoroscopy on the daily routine is time-consuming, results to exposure to radiation,
and x-ray equipment is not available in most endoscopy units because of its expense. In our
opinion, fluoroscopy does not add safety to the vast majority of the procedures and even in
cases of tortuous strictures, blind guidewire passage can be performed safely, when
performed with care.
In our series we had a large number of patients in whom the cause of the stricture
was postsurgical, in opposition to other published series. The reason that could explain this
fact is that our hospital is a regional center for the surgical treatment of esophageal cancer
and, furthermore, our geographical region (Southern Brazil) presents as a region of high
incidence of this cancer [22].
Peptic stricture patients usually are the most amenable to respond to esophageal
dilation in comparison to the population of “non-peptic-stricture” patients [8, 23]. In our
series, however, we observed that peptic-stricture patients were not the best responders.
The reason for this finding may be the fact that the proportion of patients with caustic and
radiation injury was very low in comparison to postsurgical cases, and the latter responded
very well to endoscopic treatment in our series. In another series, e.g., the proportion of
patients with postsurgical strictures was only 2 % [23]. Possible explanations for the
finding of a better response in postsurgical cases may be the fact that this population
significantly underwent more dilation sessions in the first two months than did peptic
patients. Also, postsurgical lesions are very different than those secondary to radiation or
caustic exposure, since the former are shorter in length, more regular, and do not show the
extent of fibrosis that is found in the latter cases, in which important scarring is present
31
[27]. Furthermore, our series consisted of a population of low socioeconomic status, so the
use of proton pump inhibitors by patients with peptic disease was probably inadequate.
Once this kind of medication has already been proved to change the outcome of such
patients [24], this aspect may have contributed in worsening the response to dilation
therapy in the peptic esophagitis group. In addition, some patients with peptic disease could
present underlying motor disturbances which, of course, would not improve with dilation
therapy. Our study, however, was not designed to address this issue.
Absence of dysphagia - the ideal goal of therapy - was achieved in a large number
of patients with postsurgical and peptic stricture (68 and 67 %, respectively). Patients with
caustic or radiation injury, however, did not reach this end-point with the same frequency
(38 and 27 %, respectively), which shows that the latter cases are, in fact, more difficult to
treat, as demonstrated by other studies [8, 18, 25, 26]. The extent of fibrosis with
subsequent marked esophageal thickening in patients with corrosive injury as well as the
length of the lesion which usually compromises a large portion, if not all the esophagus, has
already been demonstrated in a previous series with CT analysis [27]. Thus, this kind of
injury produces strictures that are tight, long and often difficult to dilate, and also carrying a
higher risk of perforation. Perhaps these cases would be the ones in which the use of
fluoroscopy could significantly enhance the safety of the dilation procedure, and the use of
more flexible guidewires should be indicated more often. Moreover, some authors have
advocated the use of corticosteroid injections to improve the response to dilation therapy in
corrosive injuries, which might decrease the frequency of dilations [28] or promote an
improvement in esophageal diameters [29]. In our study, patients with caustic injury
underwent more dilations in the initial period of treatment than any other group, which
shows the difficulty to obtain satisfactory responses in this population.
In our series, patients who ingested corrosive substances were significantly younger
than patients of the other groups. The reason probably remains in the fact that the majority
of such cases corresponds to suicidal attempts, which tend to be more frequent in younger
individuals.
We observed that patients who presented the worst grade of dysphagia (unable to
swallow liquids in adequate amounts) had more difficulty to become asymptomatic, despite
they had underwent more dilation sessions in the first two months and during all the
32
treatment period - about half of the patients kept some degree of dysphagia. Patients with
milder grades of dysphagia at presentation became more often asymptomatic. Therefore,
patients with severe dysphagia at clinical presentation should be advised at the beginning of
endoscopic therapy that they will undergo an intensive treatment (more sessions) and, even
that, they will have a reasonable chance to keep some degree of dysphagia.
We found a positive relationship between the diameter of the bougie initially
inserted and the occurrence of clinical response. Such finding allow us to conclude that
strictures with wider diameters at presentation (measured indirectly by the diameter of the
catheter) have a higher chance to respond to therapy. Also, cases in which wider diameters
were obtained after dilation (postoperative and peptic groups) presented better responses in
comparison with the groups in which the diameter of the stricture at the end of therapy was
tighter (radiation and caustic lesions), as shown in Tables 2 and 3. And, as expected, the
initial and final grades of dysphagia also showed a straight correlation with the diameter of
the stricture, as shown in Tables 5 and 6. An inverse correlation was found between the
number of sessions in the first two months, total number of sessions and the diameter of the
first inserted bougie, which means, as expected, that tighter strictures demanded more
dilations sittings in the initial period of treatment and during all the follow-up period.
Nevertheless, the response to treatment of such strictures were worse than strictures with
wider diameters, as discussed above.
Ninety-eight per cent of patients in whom a 45 F bougie was inserted during
treatment reached clinical response, and 80% became free of dysphagia. This observation
suggests that such diameter is a very satisfactory end-point and, perhaps, it would not be
necessary to dilate the esophageal lumen beyond this limit, as observed in other
publications [30]. In postoperative stenoses patients, this diameter was significantly more
often reached than in patients with caustic or radiation injury, showing, once again, the
good response obtained in postsurgical patients.
All groups exhibited an excellent response to dilation, since in all of them there was
a significant improvement in the median dysphagia grade (from 4 to 1 in caustic and
postradiotherapy groups; from 3 to 0 in postsurgical and peptic groups). Such findings
undoubtly demonstrate the benefit of dilation therapy in esophageal strictures of different
33
natures and represent the importance of such technique to be included in the dayly practice
of most endoscopists.
The occurrence of esophageal perforation is the most dreaded complication of any
endoscopic procedure, and esophageal dilation is the one in which such complication can
occur more often. However, in our series the incidence of perforation was 0.21% per
dilation session, which, in fact, is comparable to another large series, which only evaluated
postsurgical strictures (0.4%), as the majority of our cases [31]. The guidelines of the
German Society of Gastrointestinal Endoscopy estimates an incidence of 0.5% [13], while
in the ASGE guidelines for esophageal dilation an incidence of 0.3% is expected in each
procedure [2]. Such incidence, of course, may vary according to the studied population
profile. For example, in one study including 251 patients, all of them with peptic strictures
or rings, being the majority of the cases considered as mild, no perforations were observed
[7]. On the other hand, in one study that included only patients with corrosive strictures, the
perforation rate was 3.5% [27]. It must be emphasyzed that more than 80% of the dilation
sittings performed in our study were done by gastroenterology fellows, usually with a few
months of practice in endoscopy. Thus, endoscopic dilation should be included in the
therapeutic armamentarium of small endoscopy units, even in community services.
We registered one case of cerebral abscess in a young woman with caustic injury,
which probably occurred in consequence of transient bacteremia secondary to endoscopic
dilation. After resolution of the brain infection this patient underwent other dilation
sessions under antibiotic prophylaxis. Endoscopic dilation is the endoscopic procedure with
the highest rate of bacteremia, however antibiotic prophylaxis is solely indicated in patients
with valvular heart diseases [32].
In summary, our results show that endoscopic dilation is an effective and safe way
to provide relief of dysphagia in patients with esophageal strictures of different etiologies,
even without the aid of fluoroscopy. Excellent results can be achieved in postsurgical
patients when they underwent an intensive treatment, the same happening to patients with
peptic lesions. Corrosive and radiation injuries, although showing significant responses to
therapy, remain the most difficult ones to be treated. A diameter of 45 F is associated with
98% of clinical response and should be considered the end-point of endoscopic dilation
34
therapy, i.e., to insert bougies wider than 45 F is not necessary in the vast majority of the
cases.
35
APPENDIX
Table 1. Number and proportion of patients according to stricture etiology
* Rings, webs, achalasia,scleroderma, unknown
36
Etiology of Esophageal
Stricture
Number and proportion of patients
N (%)
Postsurgical 204/64%
Peptic 60/19%
Postradiotherapy 13/4%
Caustic 13/4%
Other* 31/9%
Total 321/100%
37
Table 2.
Clinical response and absence of dysphagia according to stricture etiology
a: p<0.05 when comparing postsurgical and postradiotherapy groups vs overall response to therapy
b: p<0.05 when comparing postsurgical vs peptic and postradiotherapy groups
c: p<0.05 when comparing caustic and postradiotherapy groups vs overall absence of dysphagia after therapy
d: p<0.05 when comparing postsurgical vs caustic and postradiotherapy groups
e: p<0.05 when comparing peptic vs postradiotherapy group
f: p=0.065 when comparing peptic vs caustic group
Fisher test
38
Etiology of
Esophageal
Stricture
Esophageal Stricture Dilation
Clinical Response (%) Absence of Dysphagia (%)
(Grades 0-1) (Grade 0)
Postsurgical 92
a, b
68
d
Caustic 84 38
c, d, f
Peptic 81
b
67
e, f
Postradiotherapy 58
a, b
27
c, d, e
Overall 84
a
64
c
39
Table 3. Mean number of total dilation sessions, sessions in the first two months, and minimum and
maximum inserted bougie diameters according to esophageal stricture etiology
* Rings, webs, achalasia,scleroderma, unknown
a: p<0.05 when comparing postsurgical vs peptic group
b: p<0.05 when comparing caustic vs peptic group
c: p<0.05 when comparing postsurgical vs caustic and postradiotherapy groups
d: p<0.05 when comparing peptic vs postradiotherapy group
ANOVA test
40
Etiology
Mean number of
sessions
Mean number of
sessions in the first
two months
Mean minimum
bougie diameter
(French)
Mean maximum
bougie diameter
(French)
Postsurgical 8.48 3.53
a
30.2 45.3
c
Peptic 7.13 2.75
a, b
31.1 44.0
d
Caustic 13.23 4.23
b
25.3 41.6
c
Postradiotherapy 6.38 3.54 28.5 39.3
c, d
Other* 12.04 3.21 28.4 42.7
41
Table 4.
Pre and posttreatment grade of dysphagia according to stricture etiology
* p < 0.05 in all comparisons, Wilcoxon Signed Ranks Test
42
Etiology of
Esophageal
Stricture
N Pre Treatment
Grade of Dysphagia
(median)
Post Treatment
Grade of Dysphagia
(median)
Postsurgical 201 3* 0*
Peptic 60 3* 0*
Caustic 13 4* 1*
Postradiotherapy 12 4* 1*
43
Table 5.
Mean number of total dilation sessions, sessions in the first two months, minimum and maximum
inserted bougie diameters according to the pre-treatment grade of dysphagia
a: p<0.05 when comparing grade 4 vs grades 1, 2 and 3
b: p<0.05 in all comparisons, except between grade 1 vs 2
c: p<0.05 when comparing grade 1 vs 4
ANOVA test
44
Pre treatment grade
of dysphagia
Mean number of
sessions
Mean number of
sessions in the first
two months
Mean minimum
bougie diameter
(French)
Mean maximum
bougie diameter
(French)
1 3.5 2.3 38.1
b
46.7
c
2 5.3 2.4 35.3
b
45
3 7.9 3.1 31.3
b
44.9
4 11.2
a
4.0
a
25.9
b
43.4
c
45
Table 6.
Minimum and maximum inserted bougie diameters (mean) according to dysphagia grade after
endoscopic treatment
a: p<0.05 when comparing grade 0 vs grades 1, 2, 3 and 4
b: p<0.05 when comparing grade 1 vs grades 2, 3 and 4
46
Dysphagia grade after treatment Minimum bougie diameter
(French)
Maximum bougie
diameter (French)
0 31.0
a
46.9
a
1 28.8 42.7
b
2 28.1 37.2
3 26.0 36.6
4 28.6 36.6
47
REFERENCES
1
Spechler JS. American Gastroenterological Association Medical Position
Statement on Treatment of Patients With Dysphagia Caused by Benign
Disorders of the Distal Esophagus. Gastroenterology 1999; 117: 229-32
2 American Society for Gastrointestinal Endoscopy Guideline. Esophageal
dilation. Gastrointest Endosc 1998; 48: 702-4
3 Repici A, Conio M, De Angelis C, et al. Temporary placement of an expandable
polyester silicone-covered stent for treatment of refractory benign esophageal
strictures. Gastrointest Endosc 2004; 60: 513-19
4 Clouse RE. Complications of endoscopic gastrointestinal dilation techniques.
Gastrointest Endosc Clin N Am 1996; 6: 323-41
5 Pasricha PJ, Fleischer D, Kaloo AN. Endoscopic perforations of the upper
digestive tract: A review of their pathogenesis, prevention and management.
Gastroenterology 1994; 106: 787-802
6 Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilatation of
benign esophageal stricture? Dig Dis Sci 1994; 39: 776-81
7 Scolapio JS, Pasha TM, Christopher JG, et al. A randomized prospective study
comparing rigid to balloon dilators for benign esophageal strictures and rings.
Gastrointest Endosc 1999; 50: 13-7
8 Duseja A, Chawla YK, Singh RP, et al. Dilatation of benign oesophageal
strictures: 10 years’ experience with Celestin dilators. J Gastroenterol Hepatol
2000; 15: 26-9
9 Hine KR, Hawkey CJ, Atkinson M, et al. Comparison of the Eder-Puestow and
Celestin techniques for dilating benign oesophageal strictures. Gut 1984; 25:
1100-2
10 Ho SB, Class O, Katsman RJ, et al. Fluoroscopy is not necessary for Maloney
dilation of chronic esophageal strictures. Gastrointest Endosc 1995; 41: 11-4
11 Hernandez JL, Jacobson JW, Harris MS. Comparison among the perforation
rates of Maloney, balloon, and Savary dilation of esophageal strictures.
Gastrointest Endosc 2000; 4: 460-2
48
12
Boyce HW. Hiatus hernia and peptic diseases of the esophagus. In: Sivak MV
(ed). Gastroenterologic endoscopy (CD-ROM). 2
nd
edn. Philadelphia: WB
Saunders, 1999: Chapter 44
13 Scheurlen CH, Sauerbruch T. Ösophaguserkrankungen. In: Sauerbruch T,
Scheurlen CH (eds). Leitlinien der deutschen Gesellschaft für Verdauungs-und
Stoffwechselkrankheiten (DGVS), Demeter Verlag, Balingen, 1997: 17-25
14
Tulman AB, Boyce HW. Complications of esophageal dilatations and guidelines
for their prevention. Gastrointest Endosc 1981; 27: 229-34
15 Webb WA. Esophageal dilation: Personal experience with current instruments
and techniques. Am J Gastroenterol 1988; 83: 471-5
16 Kadakia SC, Cohan CF, Starnes EC. Esophageal dilation with polyvinyl bougies
using a guidewire with markings without the aid of fluoroscopy. Gastrointest
Endosc 1991; 37: 183-7
17 Marshall JB, Afridi AS, King PD, et al. Esophageal dilation with polyvinyl
(American) dilators over a marked guidewire: Practice and safety at one center
over a 5-year period. Am J Gastroenterol 1996; 91: 1503-6
18 Pereira-Lima JC, Ramires RP, Zamin Jr. I, et al. Endoscopic dilation of benign
esophageal strictures: Report on 1043 procedures. Am J Gastroenterol 1999; 94:
1497-501
19 Kadakia SC, Parker A, Carrougher JG, et al. Esophageal dilation with polyvinyl
bougies, using a marked guidewire without the aid of fluoroscopy: an update.
Am J Gastroenterol 1993; 88: 1381-6
20 Wang YG, Tio TL, Soehendra N. Endoscopic dilation of esophageal stricture
without fluoroscopy is safe and effective. World J Gastroenterol 2002; 8: 766-8
21 Vargas-Tank L, Ovalle L, Fernández C, et al. Use of a very flexible guidewire to
permit dilation of complex malignant strictures of the esophagus. Gastrointest
Endosc 1995; 41: 8-10
22 Fagundes RB, Barros SG, Putten AC. Occult dysplasia is disclosed by Lugol
Chromoendoscopy in alcoholics at high risk for squamous cell carcinoma of the
esophagus. Endoscopy 1999; 31: 281-5
49
23
Said A, Brust DJ, Gaumnitz EA, et al. Predictors of early recurrence of benign
esophageal strictures. Am J Gastroenterol 2003; 98; 1252-6
24
Smith PM, Kerr GD, Cockel P, et al. A comparison of omeprazole and ranitidine
in the prevention of recurrence of benign esophageal stricture. Gastroenterology
1994; 107: 1312-8
25 Andreollo NA, Lopes LR, Inogutti R, et al. Tratamento conservador das
estenoses benignas do esôfago através de dilatações. Análise de 500 casos. Rev
Ass Med Brasil 2001; 47: 236-43
26 Broor SL, Ragu GS, Bose PP, et al. Long term results of endoscopic dilation for
corrosive oesophageal strictures. Gut 1993; 34: 1498-501
27 Lahoti D, Broor SL, Basu PP, et al. Corrosive esophageal strictures: Predictors
of response to endoscopic dilation. Gastrointest Endosc 1995; 41: 196-200
28 Kochhar R, Ray JD, Sriram PVJ, et al. Intralesional steroids augment the effects
of endoscopic dilation in corrosive esophageal strictures. Gastrointest Endosc
1999; 49: 509-13
29 Camargo MA, Lopes LR, Grangeia TAG, et al. O uso de corticosteróides após
dilatação esofágica em pacientes portadores de estenose por substâncias
corrosivas – estudo prospectivo, randomizado e duplo cego. Rev Ass Med Brasil
2003; 49: 286-92
30 Saeed ZA, Graham DY. Treatment of benign esophageal strictures. Where do
we go from here? Dig Dis Sci 1994; 39: 2099-101
31 Honkoop P, Siersema PD, Tilanus HW, et al. Benign anastomotic strictures after
transhiatal esophagectomy and cervical esophagogastrostomy: Risk factors and
management. J Throrac Cardiovasc Surg 1996; 111: 1141-8
32 Maulaz EB, Mattos AA, Dietz J, Pereira-Lima JC. Bacteremia in cirrhotic
patients submitted to endoscopic band ligation of esophageal varices. Arq
Gastroenterol 2003; 40: 166-72
50
Livros Grátis
( http://www.livrosgratis.com.br )
Milhares de Livros para Download:
Baixar livros de Administração
Baixar livros de Agronomia
Baixar livros de Arquitetura
Baixar livros de Artes
Baixar livros de Astronomia
Baixar livros de Biologia Geral
Baixar livros de Ciência da Computação
Baixar livros de Ciência da Informação
Baixar livros de Ciência Política
Baixar livros de Ciências da Saúde
Baixar livros de Comunicação
Baixar livros do Conselho Nacional de Educação - CNE
Baixar livros de Defesa civil
Baixar livros de Direito
Baixar livros de Direitos humanos
Baixar livros de Economia
Baixar livros de Economia Doméstica
Baixar livros de Educação
Baixar livros de Educação - Trânsito
Baixar livros de Educação Física
Baixar livros de Engenharia Aeroespacial
Baixar livros de Farmácia
Baixar livros de Filosofia
Baixar livros de Física
Baixar livros de Geociências
Baixar livros de Geografia
Baixar livros de História
Baixar livros de Línguas
Baixar livros de Literatura
Baixar livros de Literatura de Cordel
Baixar livros de Literatura Infantil
Baixar livros de Matemática
Baixar livros de Medicina
Baixar livros de Medicina Veterinária
Baixar livros de Meio Ambiente
Baixar livros de Meteorologia
Baixar Monografias e TCC
Baixar livros Multidisciplinar
Baixar livros de Música
Baixar livros de Psicologia
Baixar livros de Química
Baixar livros de Saúde Coletiva
Baixar livros de Serviço Social
Baixar livros de Sociologia
Baixar livros de Teologia
Baixar livros de Trabalho
Baixar livros de Turismo