2006年美国胃肠道内镜协会食管扩张内镜诊治指南
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TECHNIQUES
The degree of dilation within a session should be based on the severity of the stricture. A conservative approach to dilation may reduce the risk of perforation. The "rule of 3" has been accepted and applied to bougie dilation of esophageal strictures.Specifically, the initial dilator chosen should be based on the known or estimated stricture diameter. Serial increases in diameter are then performed. After moderate resistance is encountered with the bougietype dilator, no greater than 3 consecutive dilators in increments of 1 mm should be passed in a single session. Although this rule does not apply to balloon dilators, a recent study suggested that inflation of a single large-diameter dilator (O15 mm) or incremental dilation of greater than 3 mm may be safe in simple esophageal strictures. There are no data on the optimal duration the balloon should remain inflated. Dilation therapy for symptomatic Schatzki's ring is directed toward achieving rupture of the ring; therefore, larger caliber dilators (16-20 mm) may be needed.33If a lower esophageal ring cannot be distinguished from a short peptic stricture, graded stepwise dilation is recommended.
During esophageal dilation the endoscopist should be supported by assistants who are familiar with the endoscopic and dilating devices considered for use and are capable of monitoring patient comfort and safety throughout the examination. Patients should be closely observed after esophageal dilation, with pulse, blood pressure, and temperature measured regularly detect complications.
Steroid injection into benign strictures immediately before or after dilation has been advocated to improve outcomes by decreasing the need for repeat dilation in strictures that have not responded to initial dilation. Most of the published studies to date have been small, nonrandomized, and uncontrolled.Additionally, not all causes of stricture respond similarly to steroid injection. A recent randomized trial of intralesional steroid injection with PPI therapy versus sham injection with PPI therapy in patients with recalcitrant peptic esophageal strictures showed that the need for repeat dilation was significantly diminished in the steroid group.
RESULTS
Regardless of the specific method of dilation, early improvement in the ability to swallow is achieved in virtually all patients; however, longer-term outcomes are influenced by the underlying pathologic condition. If a luminal diameter of at least 13 to 15 mm can be achieved, nearly all patients will be relieved of dysphagia. In patients with benign peptic strictures, a graded stepwise dilating approach between 13 and 20 mm yields relief in 85% to 93%.Bougie-type dilators exert not only radial forces as they are passed but also longitudinal forces as the result of a shearing effect.Longitudinal forces are not transmitted with balloon dilators because the entire dilating force is delivered radially and simultaneously over the entire length of the stenosis rather than progressively from its proximal to distal extent.37Despite these differences, no clear advantage has been demonstrated between the two dilator types.Factors associated with a poor response to balloon dilation of benign strictures are a length of O8 cm and a small predilation luminal diameter.41In patients with benign peptic strictures, the long-term benefits of dilation appear greatest when a luminal diameter of greater than 12 mm is achieved.
Several clinical features are associated with outcome. For peptic strictures, smaller lumen diameter, presence of a hiatal hernia O5 cm, persistence of heartburn after dilation, and number of dilations needed for initial dysphagia relief were significant predictors of early symptomatic recurrence.A multivariate analysis revealed that a nonpeptic etiology of strictures was a significant predictor of early symptomatic recurrence within 1 year of initial dilation.One study suggested that patients with peptic strictures but without heartburn or patients with weight loss may be more likely to require frequent dilations.
Patients with peptic strictures should be treated with PPI therapy. Compared with histamine receptor antagonist therapy, PPI use decreases stricture recurrence and the need for repeat stricture dilation. Recent studies suggest that acid suppression may prevent recurrence of Schatzki's rings after dilation.
ACHALASIA
Esophageal dilation for achalasia involves the forceful disruption of the lower esophageal sphincter (LES). This is usually accomplished with 30- to 40-mm diameter pneumatic balloon dilators. Several balloon types are available. Although short-term relief of dysphagia is good, recurrence occurs in approximately one third51and, in some series, long-term resolution of symptoms after initial response may be as low as 40% to 50%. The risk of perforation with balloon dilation in achalasia is in the range of 3% to 4% with a mortality rate of !1%. Dilation is generally performed over a wire under fluoroscopic guidance initially using a 30-mm balloon,although nonfluoroscopically guided dilation using endoscopic visualization alone has been reported.
An alternative to dilation is the endoscopic injection of botulinum toxin. Botulinum toxin acts by inhibiting the calcium-dependent release of acetylcholine from nerve terminals. The proposed mechanism of action is relaxation of the LES, but the effect on manometrically determined LES pressure is variable.59Botulinum toxin is injected at 4 to 5 sites at the endoscopically identified LES. The usual total dose is 100 units diluted in 5 to 10 mL. Injection of botulinum toxin into the LES is effective in relieving symptoms in about 85% of patients. This response, however, is short lived, with symptom recurrence in greater than 50% by 6 months.In randomized studies, pneumatic balloon dilation is more effective than botulinum toxin injection with significantly higher cumulative remission rates (70%-89% compared with 32%-38%). Surgical treatment of chalasia has yielded greater therapeutic efficacy than either pneumatic dilation or botulinum toxin injection. Myotomy offers good to excellent symptom improvement in 83% of patients. Laparoscopic cardiomyotomy has shown similar results; however, longer term follow-up is continuing.61Cardiomyotomy may be more difficult and less effective in patients treated previously with botulinum toxin due to submucosal scarring. A randomized controlled trial comparing laparoscopic myotomy and botulinum toxin injection showed similar safety, but with better outcomes achieved with surgery.
Before endoscopic treatment, patients with achalasia should be informed of the various therapeutic options available. Symptomatic patients with achalasia who are good surgical candidates should be given the option of either graded pneumatic dilation or cardiomyotomy. Open surgical repair with myotomy of early recognized endoscopic perforation offers an outcome similar to that of elective open myotomy.63However, if endoscopic perforation occurs after pneumatic dilation, laparoscopic myotomy is usually not technically feasible.63In patients with failed myotomy, pneumatic dilation can be safely performed.64,65 The subset of patients in whom this approach has failed may require esophagectomy. In patients who are poor candidates for surgery, initial therapy with botulinum toxin may be the preferred approach. In prohibitive operative candidates, pneumatic dilation is not recommended.
Cost analysis models indicate that, for otherwise healthy patients with achalasia, initial pneumatic dilation was the least costly strategy compared with botulinum toxin injection66or laparoscopic Heller myotomy.
CONTRAINDICATIONS AND COMPLICATIONS
The principal complications of esophageal dilation are perforation, bleeding, and aspiration. The most serious complication of esophageal dilation is perforation. The perforation rate for esophageal strictures after dilation has been reported to be 0.1% to 0.4%.The risk of perforation is lower in simple strictures and higher in more complex strictures.Perforation may be more common and severe with radiation-induced strictures.The perforation rate may be influenced by endoscopist experience level; one study indicated that the perforation rate was 4 times greater when the operator had performed fewer than 500 previous diagnostic upper endoscopic examinations.Perforation after esophageal dilation usually occurs at the site of the stricture, either intraabdominally or intrathoracically. This complication should be suspected if severe or persistent pain, dyspnea, tachycardia, or fever develops. The physical examination may reveal subcutaneous crepitus of the chest or cervical region. Although a chest radiograph may indicate a perforation, a normal study result does not exclude this diagnosis and a water-soluble contrast esophagram or contrast chest computed tomogram may be necessary to delineate a perforation.The use of large-diameter covered metal stents and the use of expandable, removable plastic stents have been shown to be effective in the management of perforations after dilation of benign and malignant esophageal strictures, although the routine use of these devices in benign disease is not recommended.
Esophageal dilation should be performed with caution in patients who have had a recent, healed perforation or upper gastrointestinal surgery. Continuing esophageal perforation is an absolute contraindication to esophageal dilation.
SUMMARY
For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion. Dilation is indicated in patients with symptomatic esophageal strictures (B).
The degree of dilation within a session should be based on the severity of the stricture. A conservative approach to dilation may reduce the risk of perforation. The "rule of 3" has been accepted and applied to bougie dilation of esophageal strictures.Specifically, the initial dilator chosen should be based on the known or estimated stricture diameter. Serial increases in diameter are then performed. After moderate resistance is encountered with the bougietype dilator, no greater than 3 consecutive dilators in increments of 1 mm should be passed in a single session. Although this rule does not apply to balloon dilators, a recent study suggested that inflation of a single large-diameter dilator (O15 mm) or incremental dilation of greater than 3 mm may be safe in simple esophageal strictures. There are no data on the optimal duration the balloon should remain inflated. Dilation therapy for symptomatic Schatzki's ring is directed toward achieving rupture of the ring; therefore, larger caliber dilators (16-20 mm) may be needed.33If a lower esophageal ring cannot be distinguished from a short peptic stricture, graded stepwise dilation is recommended.
During esophageal dilation the endoscopist should be supported by assistants who are familiar with the endoscopic and dilating devices considered for use and are capable of monitoring patient comfort and safety throughout the examination. Patients should be closely observed after esophageal dilation, with pulse, blood pressure, and temperature measured regularly detect complications.
Steroid injection into benign strictures immediately before or after dilation has been advocated to improve outcomes by decreasing the need for repeat dilation in strictures that have not responded to initial dilation. Most of the published studies to date have been small, nonrandomized, and uncontrolled.Additionally, not all causes of stricture respond similarly to steroid injection. A recent randomized trial of intralesional steroid injection with PPI therapy versus sham injection with PPI therapy in patients with recalcitrant peptic esophageal strictures showed that the need for repeat dilation was significantly diminished in the steroid group.
RESULTS
Regardless of the specific method of dilation, early improvement in the ability to swallow is achieved in virtually all patients; however, longer-term outcomes are influenced by the underlying pathologic condition. If a luminal diameter of at least 13 to 15 mm can be achieved, nearly all patients will be relieved of dysphagia. In patients with benign peptic strictures, a graded stepwise dilating approach between 13 and 20 mm yields relief in 85% to 93%.Bougie-type dilators exert not only radial forces as they are passed but also longitudinal forces as the result of a shearing effect.Longitudinal forces are not transmitted with balloon dilators because the entire dilating force is delivered radially and simultaneously over the entire length of the stenosis rather than progressively from its proximal to distal extent.37Despite these differences, no clear advantage has been demonstrated between the two dilator types.Factors associated with a poor response to balloon dilation of benign strictures are a length of O8 cm and a small predilation luminal diameter.41In patients with benign peptic strictures, the long-term benefits of dilation appear greatest when a luminal diameter of greater than 12 mm is achieved.
Several clinical features are associated with outcome. For peptic strictures, smaller lumen diameter, presence of a hiatal hernia O5 cm, persistence of heartburn after dilation, and number of dilations needed for initial dysphagia relief were significant predictors of early symptomatic recurrence.A multivariate analysis revealed that a nonpeptic etiology of strictures was a significant predictor of early symptomatic recurrence within 1 year of initial dilation.One study suggested that patients with peptic strictures but without heartburn or patients with weight loss may be more likely to require frequent dilations.
Patients with peptic strictures should be treated with PPI therapy. Compared with histamine receptor antagonist therapy, PPI use decreases stricture recurrence and the need for repeat stricture dilation. Recent studies suggest that acid suppression may prevent recurrence of Schatzki's rings after dilation.
ACHALASIA
Esophageal dilation for achalasia involves the forceful disruption of the lower esophageal sphincter (LES). This is usually accomplished with 30- to 40-mm diameter pneumatic balloon dilators. Several balloon types are available. Although short-term relief of dysphagia is good, recurrence occurs in approximately one third51and, in some series, long-term resolution of symptoms after initial response may be as low as 40% to 50%. The risk of perforation with balloon dilation in achalasia is in the range of 3% to 4% with a mortality rate of !1%. Dilation is generally performed over a wire under fluoroscopic guidance initially using a 30-mm balloon,although nonfluoroscopically guided dilation using endoscopic visualization alone has been reported.
An alternative to dilation is the endoscopic injection of botulinum toxin. Botulinum toxin acts by inhibiting the calcium-dependent release of acetylcholine from nerve terminals. The proposed mechanism of action is relaxation of the LES, but the effect on manometrically determined LES pressure is variable.59Botulinum toxin is injected at 4 to 5 sites at the endoscopically identified LES. The usual total dose is 100 units diluted in 5 to 10 mL. Injection of botulinum toxin into the LES is effective in relieving symptoms in about 85% of patients. This response, however, is short lived, with symptom recurrence in greater than 50% by 6 months.In randomized studies, pneumatic balloon dilation is more effective than botulinum toxin injection with significantly higher cumulative remission rates (70%-89% compared with 32%-38%). Surgical treatment of chalasia has yielded greater therapeutic efficacy than either pneumatic dilation or botulinum toxin injection. Myotomy offers good to excellent symptom improvement in 83% of patients. Laparoscopic cardiomyotomy has shown similar results; however, longer term follow-up is continuing.61Cardiomyotomy may be more difficult and less effective in patients treated previously with botulinum toxin due to submucosal scarring. A randomized controlled trial comparing laparoscopic myotomy and botulinum toxin injection showed similar safety, but with better outcomes achieved with surgery.
Before endoscopic treatment, patients with achalasia should be informed of the various therapeutic options available. Symptomatic patients with achalasia who are good surgical candidates should be given the option of either graded pneumatic dilation or cardiomyotomy. Open surgical repair with myotomy of early recognized endoscopic perforation offers an outcome similar to that of elective open myotomy.63However, if endoscopic perforation occurs after pneumatic dilation, laparoscopic myotomy is usually not technically feasible.63In patients with failed myotomy, pneumatic dilation can be safely performed.64,65 The subset of patients in whom this approach has failed may require esophagectomy. In patients who are poor candidates for surgery, initial therapy with botulinum toxin may be the preferred approach. In prohibitive operative candidates, pneumatic dilation is not recommended.
Cost analysis models indicate that, for otherwise healthy patients with achalasia, initial pneumatic dilation was the least costly strategy compared with botulinum toxin injection66or laparoscopic Heller myotomy.
CONTRAINDICATIONS AND COMPLICATIONS
The principal complications of esophageal dilation are perforation, bleeding, and aspiration. The most serious complication of esophageal dilation is perforation. The perforation rate for esophageal strictures after dilation has been reported to be 0.1% to 0.4%.The risk of perforation is lower in simple strictures and higher in more complex strictures.Perforation may be more common and severe with radiation-induced strictures.The perforation rate may be influenced by endoscopist experience level; one study indicated that the perforation rate was 4 times greater when the operator had performed fewer than 500 previous diagnostic upper endoscopic examinations.Perforation after esophageal dilation usually occurs at the site of the stricture, either intraabdominally or intrathoracically. This complication should be suspected if severe or persistent pain, dyspnea, tachycardia, or fever develops. The physical examination may reveal subcutaneous crepitus of the chest or cervical region. Although a chest radiograph may indicate a perforation, a normal study result does not exclude this diagnosis and a water-soluble contrast esophagram or contrast chest computed tomogram may be necessary to delineate a perforation.The use of large-diameter covered metal stents and the use of expandable, removable plastic stents have been shown to be effective in the management of perforations after dilation of benign and malignant esophageal strictures, although the routine use of these devices in benign disease is not recommended.
Esophageal dilation should be performed with caution in patients who have had a recent, healed perforation or upper gastrointestinal surgery. Continuing esophageal perforation is an absolute contraindication to esophageal dilation.
SUMMARY
For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion. Dilation is indicated in patients with symptomatic esophageal strictures (B).
Fluoroscopy is recommended when using non-wireguided dilators during dilation of complex esophageal strictures or in patients with a tortuous esophagus (B).
Bougie and balloon dilators are equally effective in relief of dysphagia in patients with esophageal strictures (A).
The rule of 3 should be followed when dilation of esophageal strictures is performed with bougie dilators (B).
Injection of corticosteroids into recurrent or refractory benign esophageal strictures may improve the outcome after esophageal dilation (B).
Pneumatic dilation with large-diameter balloons is effective for the treatment of achalasia (A).
Botulinum toxin therapy is the preferred endoscopic treatment for achalasia in poor operative and nonoperative patients (B).
Administration of PPIs is effective in preventing recurrence of esophageal strictures and the need for repeat esophageal dilation (A).
REFERENCES(Ellipsis)
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作者: American Society for Gastrointestinal Endoscopy
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