Dilation. Julius Špičák, Jan Martínek. Institute for Clinical and Experimental Medicine, Prague

Transcription

1 Dilation Julius Špičák, Jan Martínek Institute for Clinical and Experimental Medicine, Prague

2 Complications - terminology Immediate complications Technical failure Ineffectiveness Costs Extended hospitalization Patient dissatisfaction Complications Adverse effects Unplanned effects

3 Dilation - indications All kinds of GI and BP strictures which can be visualised endoscopically Benign strictures Malignancies - temporary relief only, stenting and debulking techniques should be preferred

4 Stenoses of GIT Schatzki ring M.Crohn peptic stenosis

5 Dilation - techniques Balloons: Through-the-scope (TTS) Over-the-wire (OTW) Controlled-radial-expansion (CRE) Bougies, olives Temporary stenting Electrocautery Combined techniques

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7 Dilation of esophageal strictures without fluoroscopy Savary-Gilliard dilators, rule of three, 2-3 sessions within 10 days Malignant 30, benign 25 strictures N patients 55 N sessions 177 Immediate success 100% Stent 5 Complications 0 Conclusions: Safe and effective in various conditions. Wang YG et al., World J Gastroenterol 2002;8:

8 Esophageal dilation comparison of balloon and bougienage TTS vs. Savary bougies, end point dilation: 45F / 15mm Balloon Bougie N Sessions/patient 1.1± ±0.2 Saed ZA et al. Gastrointest Endosc 1995;41:

9 Esophageal balloon dilation - review Injury Study Year Noncaustic Caustic Perforation % Failure % Allmendiger Babu Goldthorn Hoffer Jayakhrisnan Johnsen Kukkady Lang Lisy Said Sandgren Sato Shah Yeming Lan

10 Predictors of early recurrence of esophageal strictures Heartburn Hiatal hernia Nonpeptic strictures Narrow stricture diameter Said A et al. Am J Gastroenterol 2003;98:

11 Esophageal dilatation in children Balloon dilatation, postesophagial atresia repair 63, reflux7, caustic 3 N, patients 77 N, sessions 260 (3.4) Perforations 4 (1.5%) Surgery 1 Success 75 (97%) Conclusions: safe and effective. Lan BLCL et al. J Pediatric Surg 2003;38:

12 Esophageal dilatation in children 4 Complications 2 Learning curve 2 Larger size balloon catheter than recomended Therapy: chest drainage, fasting, antibiotics collectionon CT surgery 1 Lan BLCL et al. J Pediatric Surg 2003;38:

13 Endoscopic dilation in epidermolysis bullosa TTS dilation, 75% single (1-6) strictures, median 20 cm from incisors, Dilation 2-4x, appropriate pressure maintained 30 sec N patients 53 N procedures 182 Success 49 Complications 0 Conclusions: safe and effective. Anderson SHC et al. Gastrointest Endosc 2004;59:28-32

14 Dilation of cervical web of esophagus Savary-Gilliard N 16 Success 100 % Recurrence 0 Minimal (self limited) hematemesis 3 (18%) Conclusions: simple, safe, effective. Sreenivas DV et al. Hepato-Gastroenterol 2002;49:

15 Factors influencing application of endoscopic balloon dilatation for benign esophageal strictures TTS, CRE, minutes, 3mm 15mm (rule of three) Effective treatment solid or semisolid diet was sustained for more thatn 12 months Groups Success Relapse Failure N Stricture length 2.6± ±3.4 8< Mild complications:(oozing (self limited) bleeding, chest pain only Conclusions: Diameter and length of the stricture are predictive factors. Chiu YC et al. Endoscopy 2004;36:

16 Temporary placement of an expandable polyester silicone-covered stent for treatment of benign esophageal strictures Polyflex stent, polyvinyl dilation prior stenting, etiology caustic 5, radiotherapy 4, surgery 3 N 15 Mean N of dilations 9.5 Success 100% Complications 0 Conclusions: enormously safe and effective. Repici A et al. Gastrointest Endosc 2004;60:

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18 Endoscopic treatment of benign esophageal stenosis with electrocautery Esophagojejunostomy due gastric carcinoma, sphincterotomy, six radial incisions N/succeess 6/6 Complications 0 Brandimare G et al. Endoscopy 2002;34:

19 Dysphagia without evident disease: dilate? TTS, min Dilation Sham N months improvement 84% 73% Complications 0% 0% Conclusions: Results do not support empiric dilation without evident cause of dysphagia. Scolapio JS et al. Am J Gastroenterol 2001;96:

20 Evaluation of three interventional procedures in achalasia Fluoro control Stent Dilation Un/covered Partially/temporary N Dysphagia relaps, 12 m 60% 50% 9.2% Dysphagia relaps, 36 m 90% 66.7% 14.5% Pain 50% 62.5% 40% Reflux 26.7% 62.5% 20% Bleeding 10% 37.5% 12.3% Conclusions: Temporary partially covered metal stent was the best method. Complications were not characterized. Cheng Y-S et al. World J Gastroenterol 2003;9:

21 Botulinum toxin vs. balloon dilation for treatment of achalasia Witzel dilation Dilation Botulotoxin N Remission, 1 y 89% 38% Additional dilation 9 Perforation 2 Conclusions: Both methods had excellent immediate relief, but much better long-term outcome after dilation. Bansal R et al. J Clin Gastroenterol 2003;36: Botox Czech experience: N 49, long-term response 41 % Martínek J Špičák J. Diseases of Esophagus 2003;16:

22 Balloon dilation in achalasia Author Year N Success Complications West % perforations 2 surgery 7 Sabharwal % 0 Cheng % pain 50% reflux 26% bleeding 10% Dobrucali % perforation 1 reflux 4 Karamanolis % perforation 1 tears 9 (4.2%) surgery 13% Boztas % immediate 0 reflux 12 surgery 5 Gockel % NR IKEM 2006 > 100 perforations 3 surgery 2 clipps 1 esophagitis easy to control

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26 Balloon dilation in achalasia 12 hours fasting Sedation, air ways protection Fluoro/endo control 30-mm balloon, 1-2 minutes Further sessions: on demand, according to manometry? Contrast, endoscopy, to exclude perforation Perforation treatment: ATB, fasting, surgery, clipps?

27 Pyloroduodenal peptic stenosis TTS N 19 Symptoms improvement Stenosis resolution Scintigraphy confirmed improved gastric emptying Artifon EL et al. Surgical Endosc 2006;20:

28 Dilation of gastric outlet obstruction with/without Hp infection TTS,, CRE, 3 minutes, mm N 33, immediate dilation success 76%, recurrence 36% within 2 years 2 perforations after 16-mm balloon perforation Conclusions: Results better in Hp eradicated patients, in Hp negative and recurrent patients the surgery should be the first choice. Lam YH et al, Gastrointest Endosc 2004;60:

29 Strictures following laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity Pneumatic balloons, Savary-Gilliard bougies LRYGB 369 Anastomotic stricture 19 (5.1%) Stricture resolution 90% Microperforation 1 Conclusions: symptoms free at a mean follow-up 21 months. Goiten D et al. Surg Endosc 2005;19:

30 Colonoscopic balloon dilation of Crohn s strictures Baloon dilation: 3 minutes, 18 mm N 22 Success 16 > 2 sessions 15 Surgery (unsuccess) 6 Complications 0 Dear KLE et al. J Clin Gastroenterol 2001;33:

31 Colonoscopic balloon dilation of Crohn s strictures TTS dilation N patients/procedures 38/53 Recurrence/surgery 43% Complications 5 (9.4%) Perforation surgery 1 Fever 2 Hematochezia 1 Pain 1 Conclusions: Safe, dilation can avoid or postpone surgery. Sabaté JM et al. Aliment Pharmacol Ther 2003

32 Ileal pouch strictures Through-scope-balloons N patients 19 Inlet/outlet strictures 14/14 Mean sesseions p/p 1.74 Complications 0 Conclusions: safe and effective Shen B et al. Am J Gastroenterol 2004;99:

33 Stenosis after stapled colorectal anastomosis N 179 Stenosis 8 Endoscopic dilation 5/8 Relaps 1 Conclusions: early stenosis is often asymptomatic and disappears spontaneously. Dilation is a method of choice. Bannura GC et al. World J Surg 2004;28:

34 Colorectal stricture after low anterior resection Prospective controlled trial, two balloon types, TTS, OWB, 24-months follow-up TTS OWB N Mean N of sessions Response, mean, days Conclusions: Better results with OWB. Di Giorgio P et al. Gastrointest Endosc 2004;60:

35 Stenosis after stapled colorectal anastomosis Incidence depends on the criteria Clinically relevant in < 5% Stenosis is often asymptomatic and can disappear Dilation excellent choice

36 Colorectal cancer - stenting-dilation-perforation Summary metaanalysis perforation rate 3% Early / delayed 71 / 19% Stenting and dilation With Without N Perforation 14% 2.6%

37 EST - consequences Bacterial colonization of bile ducts Increased rate of primary choledocholithiasis Increase risk of bile duct tumor Clinical relevancy?

38 Histological analysis of the papilla after endoscopic dilation N patients balloon dilation 467 Histology 10 Muscle disruption 1 Architectural distortion 1 Inflammation 9 Fibrosis 9 Kawabe T et al. Hepato-Gastroenterology 2003;50:

39 Influence of papillary dilation and sphincterotomy on sphincter Oddi function Pure bile collection: Before, 1 week, 1 year after the procedure No difference in pancreatic enzymes before and after procedures Both dilation and sphincterotomy preserve sphincter Oddi function Takezawa M et al. Endoscopy 2004;36:

40 Balloon dilation of the sphincter of Oddi - increased risk of pancreatitis? EBD EST N Stones removal 88% 93% Mechanical lithotripsy 31% 13%* Early complications 17% 22% Pancreatitis 8% 8% Hyperamylasemia 23% 8% Conclusions: No difference in pancreatitis, hyperamylasemia in EBD may indicate more irritation. Bergman JJGHM et al. Endoscopy 2001;33:

41 Balloon dilation for common bile duct stones A metaanalysis: Velavinous, Fujita, Arnold, Minami, Bergman, Ochi, Natsui, Yasuda EBD EST Stones removal Complications, total Bleeding - 2.0%* Pancreatitis 7.4% 4.3%* Severe 5 2 Death 1 1 Lithotripsy need 20.9% 14.8% Conclusions: EBD should be preferred in coagulopathy only. Baron TH et al. Am J Gastroenterol 2004;99:

42 Balloon dilation of the sphincter of Oddi EBD EST N Success 97.4% 92.5% Complications, total 17.9% 3.3% Severe 6.8% 0 Pancreatitis 15.4% 0.8% Deaths 2 Conclusions: dilation is unsafe. DiSario JA et al. Gastroenterology 2004;127:

43 Stent placement in the pancreatic duct prevents pancreatitis after dilation Stent removed 3 days later (38/40) Stent Controls N Pancreatitis (mild) 0 6 Conclusions: pancreatitis and hyperamylasemia was prevented by pancreatic stent insertion. Aizawa T et al. Gastrointest Endosc 2001;54:

44 Papillary balloon dilation from percutaneous approach Fragments after lithotomy removal N 16 Stones removal (one session) 12 Complications 0 Conclusions: simple and effective Moon Jong Ho et al. Gastrointest Endosc 2001;54:

45 Endoscopic balloon dilation for specific indications only Coagulopathy Anatomy B II

46 Endoscopic treatment of patients with PSC Author Year Stent Dilation Johnson Craig Gaing Lee Van Milligen Wagner Petersen Baluyut Stiehl

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48 Enteroscopic balloon dilatation of hepaticojejunostomy after liver transplantation 7-year-old boy, 6 years after OLT Double-balloon-enteroscopy Successful dilation (2-years follow-up) Haruta H et al. Liver transplantation 2005;11:

49 Dilation - risk factors Stricture Long Irregular Hard Bowel/esophageal wall involved, scaring Etiology Caustic Achalasia Malignancy Radiation

50 Conclusions - complications - how to prevent Patients selection (vs. other techniques) Equipment cannot be significantly improved To avoid unadequate overpressure Most of complications are not reported, they are caused by incorrect approach Declared guidelines will not be principally changed, the goal is to respect them