Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Management of Esophageal Strictures. My name is Michael DeLutre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping notes. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI Fellow moderator, Laura Bach, from the Mayo Clinic. I will now hand over this presentation to her. Thank you for that introduction. I'm the Advanced Esophageal Diseases Fellow at the Mayo Clinic in Arizona, and I have the distinct honor and privilege of working with Dr. Alon Khan, who is our speaker tonight. Dr. Alon Khan is also the Program Director for the Gastrointestinal Fellowship here at Mayo Clinic Arizona, and he's also an outstanding teacher and mentor, who I'm sure we have a lot to learn from today. So with that, I'll hand over the webinar to Dr. Khan. So thanks again for the introduction. I'm sorry I missed it, but I'm sure it was fantastic. And I want to thank the ASGE, and I want to thank Michael for their help and for arranging this tonight. I want to especially thank Laura for being here to help moderate and answer questions. Grateful to have her as our esophageal fellow, and she's about to be bursting into the field of esophagology from here. So let me just get my slides started here. All right, well, I have been given the role of talking tonight about management of esophageal strictures, which is a topic that is very near and dear to my heart. And hopefully, we'll impart upon you some pearls and ideas about how to approach patients with strictures. I really want to keep this informal, and I want to try to get through my slides fairly quickly so we have a chance to get to the Q&A, which I think is really the most important part of any talk that you give. And so please feel free to share questions of any sort, and we'll try to answer them to the best of our ability here, okay? So this is my only disclosure, nothing relevant to this talk. So tonight, we're going to talk about stricture and patient characteristics that helped us to guide optimal dilation techniques. We're going to talk about what constitutes a refractory stricture, and then really formulating a personalized approach for your patient when it comes to stricture management. So just a case to start us off, imagine this is a 68-year-old man with dysphagia for solids, and he comes to you for an endoscopy, and you encounter this stricture. What are you going to do? Well, the first thing you're thinking when you encounter a stricture, and the mainstay of treatment in stricture management is dilation, right? So we're already probably thinking about dilation. So just to contemplate, I know we don't have an audience response system here, what should you do? So what is something that is true regarding management of esophageal strictures? Is it that initial diameter is most predictive of a refractory stricture, that bougie and balloon dilations are equally effective, that adherence to the rule of threes reduces risk of perforation, or that placement of a fully covered self-expanding stent is effective for refractory stricture? So think about what answer you might give for just a moment. Imagine it in your mind. And I would contend that B is the correct answer. And this is going to lead us into a discussion of dilation and some basic principles. So first of all, this is a very common discussion, right? Balloon or bougie, right? What should you use for your patient? So I would say that overall, the data are fairly convincing, multiple randomized control trials summarized in this meta-analysis, that there's really no significant difference in symptomatic relief, stricture recurrence, adverse effects. And the ultimate decision is that it really depends on the comfort and familiarity of the endoscopist, but in order to perform an adequate dilation, that's really, really an important concept here. And we're going to talk about what an adequate dilation is. So a quick word on this technique. If you're going to use a balloon, it's really important you do it the proper way. So I'm showing you two ways of doing this, and I've seen both done. And the technique on the left is incorrect, right? You need to be able to see through the balloon to judge adequacy of your dilation and to do it in a safe way. You should not be relying on your tech to be telling you the resistance or anything like that. That is not a validated measure for an adequate dilation. It really has no relationship to what you're doing to a stricture. And so it's your job as the endoscopist to actually visually judge the dilation and determine if it's effective. There is no haptic feedback with a balloon dilation. You don't get that information. So it's all dependent on visualization of the stricture. It's really important that you get this visualization through the balloon when you're dilating. This is particularly difficult when you're dilating with a smaller balloon. And on the picture on the right, you can see in a bigger balloon, you get a really beautiful view of the entire ring. This is how you judge how deep the tear is becoming and how adequate your dilation is. So to summarize, left bad, right good. So how should you approach strictures? I like to think about this in a concept that I've sort of thought of as the three S's of strictures. How do you approach them? So the first is stricture, which would be the most obvious, I suppose. Strictures come in all types of shapes and sizes. They're really not all the same. Some are very narrow. Some are very open, relatively. Some are very broad and long. Some are very short and fibrotic. They come in all shapes and sizes, and you need to approach them differently. So here are some characteristics of the stricture which should guide the way you approach them. The first is position. So if a stricture is more proximal, it really may be quite difficult for you to use a balloon dilation. You'd have to have your scope and your balloon essentially in the throat, and that's not an optimal position for dilation. So those are much better for bougie dilation. Second, consider the diameter of the stricture. So if the stricture is too narrow to pass an adult gastroscope, you have to have a plan in place of what you're going to do. You've got two options, really. You can either pass a balloon blindly through the stricture and dilate, or you can downsize to an ultra-thin scope and use a wire-guided dilation. If you use the former approach, you just have to be able to know what's on the other side. If you're dealing with a post-surgical anatomy or a situation where you don't know what's on the other side, then it's really important to be cautious or even consider a different method rather than just blindly passing a balloon through. If the stricture is too narrow even for the ultra-thin scope, then you're back to, you can either do a blind balloon passage or you may actually need fluoroscopy for proper safe wire placement. So think about these things, understand these things ahead of time. It's really important to have that sense. It also is helpful, as you can see, when you're assessing a stricture in clinic or what you think is a stricture, sometimes it's helpful to have an esophogram ahead of time to know these kinds of things and be prepared with the tools you might need at the time of the dilation itself. This is a trick that I like to use to measure diameter. We are notoriously bad at measuring diameter, especially in the antigrade view. All we know if a scope goes through the esophagus is that the esophageal diameter is greater than about a centimeter. It could be 1.1 centimeters, could be impeding food, could be making a patient quite symptomatic, and we would not detect that. We know from studies in EOE patients that, you know, upwards of 50% of strictures have been missed in those patients that were radiographically evident. So be aware of the limitations of your own visualization. When you turn the scope around in retroflexion and you bring it back towards the GE junction, you can use the scope itself as a reference point. So you know the scope is 9.9 millimeters. I would say this other portion here is about 4 or 5 millimeters. And Laura would tell you we do this all the time, and this really helps you to guide the selection of a dilator, be it a balloon or a bougie. If you're going to use a balloon, well, certainly don't reach for a 10 to 12 balloon. Maybe even a 12 to 15 balloon is a waste because you know you're going to get to at least 14, 15. So this patient, you probably pick a 15 to 18 or an 18 to 20. You don't want to waste that opportunity. What about the length of the stricture? Well, be aware that your balloon is 5.5 centimeters long. So if the stricture is longer than that, you're either going to have to overlap and try to dilate in multiple locations, or you're going to use a bougie, which that way you hit both locations at the same time. If a stricture is more complex or multifocal, I think bougie dilation is clearly preferred. And think about the adjacent anatomy. So if there's a really large hiatal hernia, you're going to want to protect yourself from causing trauma there. Consider using a guide wire. The balloons actually come with a guide wire built in. Consider advancing that to guide your balloon so that you don't cause an inadvertent puncture. If a patient has a Roux-en-Y anatomy, personally, I don't like to use a wire guided dilation there because the wire can be somewhat stiff in the jejunum, and that can cause trauma. When is a balloon preferred for me? Personally, I'm doing 95, 98% bougie dilation. These are situations. So I said, you know, a patient who needs a dilation distally in a Roux-en-Y, that's going to get a balloon. If you have a patient who's intubated, sometimes the endotracheal tube makes it really hard when you want to do a large caliber dilation, especially like a cricopharyngeal dilation. So you're not going to be able to do a cricopharyngeal dilation with a balloon, but if you know you're dilating a distal structure with a large caliber, you might choose a balloon because it's going to be very hard to judge resistance with that ET tube in place, especially once you get above about 16 millimeters. So just think about that when you're selecting. And if you have a mismatched diameter, so what do I mean by that? Well, let's say you have a high radiation stricture and then you have a low Schatzky ring. Well, you're not going to be able to dilate that Schatzky ring through the radiation stricture with a bougie. So you can dilate the radiation stricture, and if you're worried about food then getting stuck lower down, you can switch to a balloon and dilate that. So sometimes I have had to do multiple methods. But just to think about these things when you see a patient. The second S on my three S's is substrate. So what kind of a tissue are you dealing with when you're dilating these strictures? The first question to ask is, is it fibrotic or inflammatory? This is a very important distinction on the way you're approaching a stricture. So what do I mean by that? Well, here's a fibrotic stricture, okay? And so I don't know if you've had this experience before, but I've seen this many, many times. So you see a stricture, let's say you think it's a certain diameter, you dilate it up, the scope doesn't pass through. Let's say you've dilated to 12 millimeters here. You see clearly that you've gotten the balloon in place, you're dilating, and afterwards you take the balloon down. And even the balloon got to 12, 13 millimeters, you still can't pass the scope. So why would that be? Why would you not be able to pass the scope? What happened? Well, I think what happened is that when you dilated the balloon, the stricture was so fibrotic that it actually caused a waste to form in the middle of the balloon. The balloon actually doesn't reach the diameter that's advertised at that particular pressure. And so you're actually not dilating the stricture up to the diameter that you expect to. These are strictures where using a Bougie dilator is much more helpful because you know the diameter you're getting to. And so in this case, even after dilating with an 11 millimeter Bougie, I'm able to pass the scope because I know that I got to that size. So think about that when you're dealing with a fibrotic stricture. In contrast, inflammatory disorders are quite different. Here you may have to be very careful. This is a patient with lichen planus who I scoped, and these tears occurred with just insufflation of air. So you're talking about tissue that's very, very friable. If you're going to dilate in these patients, you've got to do so very carefully. And you may simply not feel the resistance that you would expect to feel. You may simply have tissue that splits much easier than you would expect. So really calibrate your dilation to the understanding of the substrate that you're dealing with. You can be a lot more aggressive with a fibrotic stricture than you can with an inflammatory one. Here's another example of an inflammatory stricture that was dilated. You can see how easily the tissue is splitting. The final S is symptoms. This is really important. When you're talking to a patient in the pre-procedure area, try to get a sense of what their symptoms are like, especially if it's an open access case and you don't know that patient well. I promise you when they're asleep and you're looking at the stricture, it's going to be helpful for you to understand how significant their symptoms are. If they have significant quality of life impairment, they're losing weight, they can barely eat anything, you might need to be a little bit more aggressive. If they're not, then you might not want to be very aggressive, right? So you really have to calibrate your approach to the way that the patient's doing, especially if you know they have a refractory stricture, you're trying to dilate them up to a larger size. Sometimes you really need to be a lot more aggressive. The final sort of fourth S, S plus, is sedation. If a patient has conscious sedation, it may be difficult for them to tolerate Bougie dilation and you may favor the balloon. I've done it before, certainly many times, but I would admit that they probably tolerate balloon dilation better since you're already in there with the scope. So less intubation causes less agitation for sure. What about this thing, the rule of three? So this gets used a lot in conversation and teaching, and I think it's often misused and it's misinterpreted. What is the actual rule of three? First of all, it's sort of something that's been passed around from lore. There's really no clear study that was done that brought this up. This is not based on any significant scientific data. The idea is that once you hit moderate resistance during Bougie dilation, you should not do more than three sizes above that. Again, Joel Richter wrote a nice editorial talking about how he thinks he got this from his mentor and he asked his mentor and he doesn't know where he got it from. So if you trace it back, it's unclear. But there have been multiple retrospective studies that have been done and they show that non-adherence does not increase the risk of perforation. Am I suggesting that you should go out and just dilate cavalierly and ignore everything? No, but just know that this is not some kind of a hard and fast rule and it's not based on any high quality research data. What is the goal of a dilation? We talked about this at the very beginning. So the goal is to safely achieve an adequate luminal diameter. How narrow a stricture is, is really not a risk factor for refractoriness. Sometimes you need to dilate patients many times to get them to a stable place and to get them away from dysphagia, but you can get there with many patients if you're patient. So ideally, you want to dilate them at intervals of one to two weeks initially, especially if they have a very narrow stricture, and you want to try to achieve about a diameter of 16 plus millimeters. It's really important to adequately photodocument. When you're going between endoscopies, you want to get a sense of like, did I accomplish anything? Patients will ask you, did you get to a higher size? Are we doing better? Are we making progress? If you've done X amount of cases between, you might not remember. So you really need to give yourself some adequate photodocumentation, and really be honest in your assessment of whether you're not making progress. If you're not making progress, you need to change what you're doing, and don't just keep dilating the same patient over and over again to the same size every week and hoping that something will change, because it won't. So let's talk a little about what an adequate dilation is. So here is a case of what I think is not an adequate dilation. So here's a stricture, and someone took a balloon and dilated it, and this is how it looks after. So what I want you to see is that, you know, all we've done here as an endoscopist is pulled the scope closer to the stricture. That also makes it look bigger on the screen. But as you can see, the ring of the stricture is really not disrupted. There's really not an adequate mucosal tear. You just sort of sloughed off the tissue without any real disruption. And this is just not an adequate dilation. What do we want to see in an adequate dilation? We want to see a rent like this. You want to see a depth of the dilation into even the submucosa. You want to see crossing submucosal fibers in this patient with EOE. This is the kind of effect you want to have. This should not frighten you. You do not have to clip this shut. You don't need to get an esophagram. You don't need to call the cardiothoracic surgeon. If you examine the bed of the tear and see that there's an intact tissue plane, this is not a perforation. This is just a good, solid dilation. And Laura would tell you that we see dilations like this. These are all cases I've done. This is very standard for us. So don't be afraid of these. You're not going to help the patient by just causing a little nick. If a patient has a significant stricture, they're going to need a significant disruption to get benefit. And you're doing them a good deed by doing that. So again, not adequate on the left, adequate on the right. You want to see that kind of effect. Just a word on empiric dilation. This comes up a lot. So what is an empiric dilation? You do an endoscopy and you don't see a stricture, but the patient's got dysphagia that seems like it's consistent with a stricture. I told you in the beginning that we're not good at judging diameter of the esophagus. So we could easily miss a sort of broad, narrow, sort of diffused stricture that isn't apparent on the endoscopy. So there was a meta-analysis that was done a couple of years ago, and it says it does not support the use of empiric dilation. But I really want to dig into that further for a second. So the first study included, or four studies included, this one was a randomized trial of 56 French versus 40 French dilation as the control. I don't think 40 French is an adequate control. That's bigger than the size of your scope. So to say that that's a control for a dilation is really not appropriate. And so this was a negative study, but I would contend that for that reason and the fact that they didn't rule out any kind of motility disorder was not an effective study. The second was just dilating the GE junction with a balloon, not dilating any of the rest of the esophagus versus sham. Again, that's not really testing what we're talking about. You need to dilate the whole esophagus effectively. So those were two negative studies. The other two studies that were included in that meta-analysis, one was retrospective, large caliber Bougie versus medical treatment. There was an improvement. It didn't reach statistical significance, but there was an improvement. And the last was a randomized trial of large caliber versus truly a control, a 26 French dilator. And that was statistically significantly improved. So I would argue that actually this was not conclusive against the use of empiric dilation. So when is empiric dilation helpful? So here's a case of a man that I saw who came to see me after going to a large academic center. He had had multiple endoscopies, video swallow, EUS, CAT scan, Botox, manometry, no better, not a little bit better even. All I did was pass a Bougie dilator. And I saw this tear in his proximal esophagus. And it basically completely resolved his symptoms. He was so happy. So does this happen every time? Absolutely not. But the risk of a dilation is low and the benefit could be tremendous. And you don't sort of have this patient chasing their tail trying to get to a solution that has been apparent to us all along. So I am a big advocate of doing this. And I think it really does move things forward for our patients. Let's talk a little bit about other dilation techniques other than just Bougies and balloons. There is such a thing as the Bougie cap. The idea is that balloons give you a view without haptic feedback. Bougies give you haptic feedback without a view. Well, here's the Bougie cap. You get both. You get a view and haptic feedback. It goes on the scope and it dilates the structure with visualization. There's very little data on the Bougie cap. There's one prospective study of 50 patients, just sort of a proof of concept. They dilated benign strictures. They had a very high success rate, but they did have some strictures where they weren't able to pass the cap due to high resistance. They did have to use about two caps per case and in several cases needed to use a guide wire. They did pass, sorry, they did lose a couple of the caps, which is a concern for sure. And they just kind of let them go and they passed in the stool. That's certainly something that raises concern about, whether the cap can stay on the scope. I suspect a lot of the time that was probably on withdrawal when it was sort of sleeved off the scope. So this is something that's out there. I've not personally used it, but is an option and certainly a reasonable thing to try. The other is something called the ESO flip balloon. This is the same as an endo flip balloon, except for it's a dilating balloon. So you get some measurement information while you're doing the dilation. The concept is on an even finer level, actually have lots of control over the pressure and the diameter of the balloon in real time. There's really no data. There's a single case report for dilating achalasia. And we're still waiting on information about how to use this device. So now let's switch gears and talk about refractory strictures, which is a large part of my practice and what a refractory stricture is. So there has been a lot of speculation about this. Everybody seems to reference this one editorial from 2005, which seems to have grown in favor to be the definition of a refractory stricture. So in this one instance, they said persistent dysphagia after at least five endoscopic dilations at one to two week intervals, or an inability to achieve or maintain at least 14 millimeter diameter. These are by definition benign. So I would not treat a malignant stricture the way I would treat a benign stricture. Very different in the way you approach those. The most common etiologies are the ones I've listed here. And we'll go through a little bit of how these differentiate themselves in their natural history. The prevalence is actually very difficult to ascertain. This is a European study of a large number of patients with strictures that were followed over time. Depending on the etiology, you can see by the time they got out to a year or two, there was sort of an asymptote for the line. It was leveling out. And what you can appreciate is that by a year or so, patients with caustic strictures had about a 20% rate of refractoriness, a little bit less for radiation and anastomotic. But for post-endotherapy, they did very well. Very few of them were refractory. And we see the same thing. So in terms of the number of sessions of endoscopic dilation, we see that patients with caustic, anastomotic, and radiation strictures by far have higher rates of endoscopic dilation. Those with post-endotherapy pectic strictures and Schatzky rings have far less. So I think that really does match our practice. Patients with the top three there are definitely our most difficult refractory stricture patients. And those are the ones where you have to know that going in and be willing to stay with them and think about some other possibilities. So how do we manage refractory strictures? One thing that's been used over the years is intralesional steroids. This is an adjunct to dilation. Typically, we're talking about injecting triamcinolone, either 40 or 80 milligrams and half milliliter aliquots. The technique is quite variable. If you read the literature and actually read the studies, the primary studies, they're very variable. Some of them just say we injected it. They don't say where. Some of them say we injected it before, some after. It's very unclear. I really try to create kind of a submucosal bleb, almost like you were doing a polyplift, proximal to and around the site of the stricture to allow that triamcinolone to infiltrate the tissue. It's very important to try to aim tangentially, not perpendicularly to the tissue. You don't want to inject triamcinolone into the underlying muscle. It can thin the muscle out and cause complications. And so that is the basic principle. There are some rare complications, but generally very well tolerated. The question of whether it works or not, these are some selected studies. There's a lot of information here, but to say that there have been a couple of randomized trials. The one in anastomotic strictures was negative. The one in peptic strictures and an observational study in a mixed population did show an effect. There has been a meta-analysis of multiple trials. And overall, it showed that in the pooled, what's called the periodic dysphagia index, there was a reduction, but they did not see a significant reduction in the number of dilations or the dysphagia score for patients. So overall, when you pool all the patients, it does not seem like a panacea. It does not seem like a great benefit. I think it does have a role in certain strictures and it's a very low risk thing to do. And we'll talk a little bit more about where we position that. What about esophageal stent? So the idea is you place a self-expanding, fully covered stent across the stricture. There's this prolonged radial force and that will lead the stricture to remodel and it will stay in place. That's the idea at least, right? The risks, of course, are that it can migrate. Of course, you're trading, as I tell patients, you're trading one symptom for another. So you're trading dysphagia for a foreign body sensation because there's a foreign body in your esophagus. So that makes sense. And of course, there is a risk for fistula formation. For stent fixation to prevent migration, there are a couple of products that are available. This is one. This is another. So you can you can clip or you can suture the stent in. So how does stent do for refractory strictures? I think this might be one of the most important slides and the important studies in this talk. So I think we, as a field, don't acknowledge this. But in this study, they took 70 patients defined in the typical way as refractory and they treated them with either dilation or dilation and stenting. And the outcome measure here was six months free of dilation. And in the stent group, achieved that outcome in only twelve and a half percent of the time. So that is a very poor outcome. And what we see here on the left is this is dysphagia free period. So in this light blue, you can see that in the initial two, three months, the patients with stents had a fantastic response. And as soon as they removed the stent, that response went away. And that absolutely matches our clinical practice. Stents, generally speaking, have a low rate of durable response. They're very effective while they're in refractory strictures in terms of patency. But as soon as you remove them, it often recurs. And so you have to have a realistic discussion with patients about that before you're considering stent placement. You're stenting as a bridge to what? What is the next plan? Because it's very likely that when you remove the stent, that will recur. What about endoscopic incisional therapy? It's also been called radial incision and cutting. This is the use of an electrosurgical device, usually a needle knife, to cut the stricture and distribute the physical force of dilation across the stricture, generally speaking. So the idea is that when you dilate a stricture, there's a physical weak point in the stricture. Like from a physics perspective, as it takes on that load, there's an area that's prone to tearing. And as you increase the diameter of the balloon, you're just going to tear deeper into that site and increase your risk of perforation. So if you were to cut radially around the stricture and then dilate, you distribute that force more equally. And you can take that patient up from a very small stricture to a very large size balloon in one session, which is very helpful. Sometimes this technique has involved incising and just removing that extra tissue around the circumference of the stricture without dilation, sometimes with dilation. There have been variable reports in the literature. It's especially good for short fibrotic strictures. As you'd imagine, it's very difficult to incise a long, angulated, inflammatory stricture. It'd be very dangerous and prone to complications. So how does this actually play out? Here's a case that I had of a patient with an anastomotic stricture. So here's his stricture when he approaches me. We do a dilation. This is the post-dilation effect. And then he comes back later, and it basically looks exactly the same. And this is what we've all experienced, right? These patients have very difficult strictures. So the patient comes back, and we try this technique. So we actually incise the stricture in several locations. In one session, I'm able to dilate him up to 20 millimeters, and I can see through the balloon that this is safe. And here's the end result when he comes back several months later. And you can see that actually we were pretty successful in maintaining patency. I remember he was able to eat sandwiches. He was very happy. So this is a good result for him. How does this actually work? Dr. Fukami shared this video with me. I'm not going to go through the whole thing. It's quite long. But basically here he's using a hook knife to incise into the stricture. He's going to keep creating additional cuts. As you can see from the presence of a staple, this is an anastomotic stricture. I'm hoping this video will work. So he's going to create multiple cuts around the circumference of the stricture, and he keeps cutting very carefully, of course, around the circumference of the stricture. And as you can see, the stricture kind of starts to open up. Oh, now we're in the stomach. I missed it. So the stricture really starts to open up, and he's able to pass the scope through and continue cutting. So you can see you can take a patient from a very narrow stricture up to a pretty good size in one session. This is a lot of information, multiple studies that have been done on this technique. There was a randomized trial that did not show a statistically significant effect of Bougie versus endoscopic incisional therapy. However, these were all patients who had never had a prior dilation. So probably anything you would have done would have been effective. Now in this retrospective study, these patients had had at least three prior dilations, and this was balloon versus endoscopic incision, and they did much, much better with the incisional therapy. So I think it really does depend on the population you're looking at. If they're truly refractory, things like this might be very useful. But that same patient I showed you, well, guess what? He's back again. So what do we do now? So now I've repeated intervention. I'm doing another cutting procedure, dilating him up again. He's feeling good for another several months. Six months later, it's back again. Okay, so now this patient has had dilation after dilation. He's had a strict uroplasty. He's had a second strict uroplasty. We know that stents in this situation are only a temporary effect. So what are we going to do for this patient? So this is where I think esophageal self-dilation plays an important role. So this is the use of a Bougie type Maloney dilator. It's non-wire guided to maintain stricture patency. It's kind of a misnomer. We actually don't want patients to dilate themselves. We want to dilate them ourselves and then have them use the Maloney to keep things open. It reduces their need for and dependence on endoscopic therapy. This can be important for patients who live far away, who are under undue financial burden from coming. It's important to consider all the factors that come with a patient having to repeat endoscopies over and over and over again. So how do we select patients for this? Well, it depends on the stricture. So why do they have a stricture? Of course, if it's malignant, we're not going to do this. What's the angulation, the length, the behavior of the stricture? If a patient is doing fine getting dilated every three or four months, this probably is not for them because they're going to trade that for daily dilation. So that's really not an appropriate thing to do. But if they're getting dilated every week, that's a patient who might really benefit from this. What's their motivation? How far do they live? How much financial burden are they under? And making sure they have an adequate understanding of what they're about to take on. It is very safe. Obviously, these patients are the sickest of the sick. And so when we've reported on this, outcomes of this in the past, a reasonable number of them do go on to develop complications of their underlying disease and even die, especially the cancer patients who have radiation strictures and things like that. So they're a sick population, but generally speaking, it is very safe. So what are the outcomes of self-dilation? So this on the y-axis is proportion alive and endoscopy free. No endoscopy. As opposed to the other graph I showed you earlier, now we're looking at basically a year, two years out, we're looking at something like 80-90% alive and endoscopy free. So you're probably wondering, how do you do it? And boy, I'm glad you asked. I wrote a paper on this a few years back, and this is the citation and you're free to go look it up. And there's a very specific instruction about how exactly we set up our self-dilation program. I encourage you to reach out to me directly by email, by whatever method. I'm happy to talk anyone through how to do this. And I've helped colleagues around the country and always happy to see your patients who need it. So I will end by just proposing an algorithm for the management of refractory strictures. I would say you want to start by dilating them at a frequent interval. I oftentimes will even dilate a patient multiple times in a week or every other, you know, every five, seven days. There's nothing wrong with doing that. I've found it to be very safe. Then if it's not working, okay, you need to have an honest assessment of that and an honest conversation with the patient. What am I going to do next? So if it's a short fibrotic and asthmatic type stricture, consider incisional therapy, offer that to the patient, explain the risks and benefits. If you have a colleague who can do that, that would be beneficial. If it's not, or if you don't want to try incisional therapy, that's a reasonable time to try incorporating steroids. I would typically do a triamcinolone injection during one or two dilations. And as I bring them back, try to realistically assess if I'm getting benefit. A lot of that comes from the patient. Hey, did you notice this was better this time? Did you go longer? Was it easier to swallow? If that's not working, you need to move on to the next step, discuss risks and benefits and consider your other options. Tell them about what a stent can do for them. Consider the limitations of that. Is it worth trying knowing you have a 12% likelihood of six months free of dilation? If it is for them, then it's worth trying. And I think that's perfectly fine. If they go in with eyes wide open, they might not tolerate it. They might tolerate it just fine. If you take out the stent and it recurs, you need to have some other option. If you don't have it recur, that's wonderful. Or maybe they don't want a stent. And then you talk to them about self-dilation. That's, I think, where it's well positioned. Oftentimes, this is where the word surgery gets put into this algorithm. And I would argue that surgery is truly the last resort for most of these patients, especially patients who have more proximal strictures where there's really no good way to deal with that surgically without a pretty morbid operation. So we really try very hard to prevent the need for surgery. And we've had, I mean, I've taught probably hundreds at this point of patients how to do this with good effect and to avoid surgery. So it doesn't mean surgery is never needed. We really try to avoid that wherever we can. So I really appreciate you being here and listening to me and really want to move into the Q&A and make sure all of your questions are answered. So with that, I will stop sharing my screen and we can move back to the webinar for any questions. We didn't have any questions just yet. And so I thought that maybe I might lead with one because I find that, you know, this is somewhat of an important point, but maybe for the group, when you see a new patient who has an inflammatory stricture, this is your first time seeing them for an upper endoscopy and you choose to do a bougie dilation. Do you follow any personal guidelines for when to recheck after your dilation to check the rent because the field may not necessarily be what you might expect for a tear when you go look? Do you follow any particular rules or guidelines? I think that's a great question. I think that there's a lot of weird kind of bravado about the whole second look thing. And I think there's nothing wrong with looking after dilation. And as you and I have experienced many times together, it does give you a lot of information. I don't think it's a risky thing to keep putting the scope in and looking. So I would say that if a patient is new to you, especially if you suspect that they have a more inflammatory phenotype, that it would be good to do your first dilation, whatever it is, and then go back in and judge and see if what you're feeling is matching what is happening inside. And if you see that there's a mismatch, you can recalibrate your dilation aggressiveness accordingly. I think the same thing really goes even for other types of strictures, where you really want to, like that first time you dilate, you want more feedback. And I think it really helps you to know and calibrate. The next time they come back, hopefully their inflammatory condition's treated and things are better. And now you have an opportunity to incorporate that and treat more aggressively. But even if it's not that type of stricture, now you have that information, you know them, you know what you're comfortable with, and you can use that information moving forward. So I think just being a little bit more cautious about looking and incorporating that information is really valuable on the first time you're dilating someone particularly. What do you think? Is that your impression? Yeah, I think there's no harm in taking another look, but there is if you are uncertain of the results, it's always better to be on the safe side and see what you've done after a dilation or two, especially if it's your first patient. Excellent. What other questions do we have? There's a question regarding whether or not you have a protocol specifically for EOE strictures. No, I mean, I think it dovetails nicely with that discussion, which is that, you know, EOE, when you first encounter it, it's an inflammatory condition. And so you want to make sure to be appropriately careful about the way you're dilating it. But I think patients with EOE tolerate dilation very well. I think there's now good literature to show that initial concerns about the safety of EOE dilation were unwarranted. Certainly the mucosal rents will be bigger than you would see in non-EOE, but that doesn't mean that they're more likely to have a perforation. And so I will dilate EOE even when they come in the ER with a food impaction and I remove it, I will dilate them, I will dilate them before treatment, but I will dilate less aggressively before they're treated. And I think that really has more to do with the fact that it's just not going to be very effective. Like if they come with a food impaction, I dilate them to reduce their likelihood of having a subsequent food impaction, which I think is well-supported. But if they're coming in and they're generally just having sort of subacute symptoms, if their inflammation is not controlled, I don't think that dilation is going to be very effective, honestly. And I think you're much better off dilating after they have control, both from a safety and effectiveness standpoint. So I don't have a particular protocol. I'm a big fan of getting esophagrams as a baseline for EOE patients to understand the nature of their stricturing, because it can be very, very subtle. And that's good to know when you're going in to do dilation or doing endoscopy for them. Any additional thoughts on that, Laura? I agree with you. And actually, I'm glad that that question was asked too for the same reason, because that's actually board's question that you'll be asked, is like the safety of dilation of eosinophilic esophagitis strictures. And so it's a really good question to go over. Let's see if we have any additional questions. Looks like that's the one that we have so far. But I have a question about- A couple that came up here. Let me just see. I just opened this up. So let me try to read through some of these. So how to reduce the chance of perforation with incisional therapy? It's a great question. First of all, you need to have adequate training. It's not something that you just want to take on like sort of on your own. You want to have someone who teaches you. I was fortunate to have mentors who were willing to teach me how to do that. I think the most important thing is knowing your knife. They're very different. So some of the knives have an angled filament at the insulated tip that cuts at a 45 degree angle and it cuts much deeper than you would expect as opposed to one that's parallel to the axis of the stricture. You really generally want to move sort of sideways with the scope, not into the tissue. And when you're cutting, just cut carefully. Look, cut again. Look, you can always cut more. But I think those are the most important things. Just know your knife because they're all very, very different. Get a knife that you're comfortable with and use that for all your cases because otherwise if you're switching, I think that's where things really get dangerous. Let's see. There was a, let's see, tips on very proximal refractory radiation stricture just below the UES. Yeah, so, I mean, I would say those are probably conservatively maybe 70% of my self-dilation cases. The ENT doctors, the post-laryngectomy radiation stricture patients, like they will often just send those patients directly to me for self-dilation because they've learned the futility of ongoing dilation in those cases. Some of those are really, really difficult. They don't even really dilate very well. You won't even really see much of a mucosal defect or tear even despite significant resistance. And oftentimes they will actually need like a surgical rigid endoscopic laser incisional therapy to get that stricture, that fibrous band cut open just to even get a benefit. I have seen where dilations, even bougie dilations just fail to cause any effect on that thick fibrous band. So if you see one of those thick fibrous bands, just know that you may not have much effect dilating. Don't be afraid to engage with your surgical colleague about that. But I find that those are probably the most successful self-dilation, the most gratifying self-dilation patients because otherwise they just recur. It gets so bad. They even get complete obstructions requiring rendezvous procedures. I mean, the stakes are very high. So I think those are great for that. But generally speaking, yeah, it's just aggressive bougie dilation, working with your surgeon, seeing if you can get things under control. Let's see, next one says there's a question in the chat. So the first one I see is really more of a comment about using a jag wire sometimes, which I agree with. Let's see, using a biliary balloon in pediatric strictures seems very reasonable. So I agree with that. Do you have any additional tips or approaches for post-ESD strictures? Yeah, so post-ESD strictures definitely constitute a significant number of refractory strictures. And so they are challenging. We have definitely, I think, evolved in our understanding of preventing post-ESD strictures. I think a lot of ESD practitioners and endoscopists are now using more steroid therapy protocols. Some of them are doing prophylactic stenting at the time of the procedure. I think that prevention is really helpful as much as you can do it in preventing a stricture from forming. Once they've formed, they can be very recalcitrant. And sometimes, you just have to hang in there and dilate them and even do short-term stenting, bring them back, dilate them again, and they'll eventually settle down. I have not had great success using injected steroids for those, especially for the longer ones. I just don't think you get enough coverage. And the tissue's so fibrotic, you probably don't get good tissue penetration. But I still have tried it in the past. I've found it to be much more helpful prophylactically. So when I do circumferential resection and I've used steroids prophylactically, I have found that those patients have done much better than when I haven't in the past. For treatment, I would say one thing I know is like ESD in the esophagus, where I tend to work, we have noticed, at least anecdotally, that if you need to treat residual disease like Barrett's in an area of ESD, probably better off using cryotherapy in terms of stricture risk, because RFA, for whatever reason, tends to promote pretty exuberant stricturing. So just some tips about ESD. Let's see. What else, Laura? What else do we have? I think you're able to see some of the questions better than I can, because I don't see any open questions on the question and answer board. And then you saw the one in the chat. I don't see an additional one after that. So this one says, what kind of stricture is a peptic stricture, and do you prefer Bougie or dilation? What are your thoughts on that? A peptic stricture? Well, I would want to know first if there's active esophagitis there too, because then there's definitely an inflammatory component to that. Yeah, and I think, you know, we consider a peptic stricture one that's related to GERD, typically, you know, with erosive esophagitis, but not always. I think it's different from a Schatzky ring in that it's not just a pure ring, but it has sort of a depth to it. But they're fairly similar, and obviously in their location, and their response to dilation. You can really dilate a peptic stricture. I mean, you can tolerate a fair amount of resistance, and they do very well. I think peptic strictures in general are very rarely refractory. So if they're refractory, you probably just need to dilate a little bit more aggressively, and you could consider the use of a triamcinolone, but those tend to do very well. Let's see. We talked about radiation stricture below the UES. Thoughts about cricopharyngeal narrowing due to cervical vertebrae impression on esophagram and Roland dysphagia. Do you dilate with Savory? What do you think about that, Laura? We've talked about this multiple times, and we do, the idea behind that is that maybe you can try to break up some of that muscular tissue somewhat, but typically, I don't think that they necessarily have like a large response to that because it's coming into, it's extrinsic compression from that muscle. Yeah, I totally agree. I think that if it's, so I would differentiate cricopharyngeal hypertrophy from cervical vertebral compression. If they have cervical vertebral compression, I don't, I mean, I don't have a problem dilating. I'll dilate anyone, but I don't think it's gonna help. I really don't. If they have cricopharyngeal hypertrophy, we know that some of those patients improve quite a bit. You know, in a small study that was done at the Mayo Clinic, median about 13 months of symptomatic improvement, and might, may be a nice way of stratifying whether a permanent myotomy would be helpful. So a reasonable thing to do, and we do it very often. But as Laura says, a lot of those patients don't get much symptomatic relief. Then you're left either with a different etiology, which is important to chase down, or just they need a different type of therapy for their cricopharyngeal hypertrophy. But if they have vertebral compression from an osteophyte, I don't think there's much role for dilation there, because you're not gonna affect a bone in any way with a dilator, you know? I'll take this one here. Any thoughts of cryotherapy for refractory stricture? So I didn't mention it in my talk because it's so sort of fringe, but there is this idea of doing what's called a cryodilation. This has been described in a series of, a very small series of I think six cases that was presented as an abstract, but not yet published. This is the use of liquid nitrogen spray cryotherapy to freeze a stricture and then dilate it. In the protocol that they reported, I think they were doing between 30 and 60 seconds of freezing prior to like balloon dilation. I think that's fine. I like that people are innovating and trying to come up with better ways to do this. I have not, you know, we have done a couple of cases, not noticed much of a difference. I'm not sure that this is a game changer yet, but very open to it if there's research done and comes out and shows benefit. I think it's, technically speaking, it's very doable, but I don't have any thoughts on that beyond that. Next question. Speaking of Schatzky rings, do you incorporate biopsy forceps to disrupt the ring? And if so, before or after your other dilation modality? Great question. Laura, what do you think about that? Do you incorporate forceps biopsy to disrupt the ring? I think if it's pretty open and you're not necessarily going to get it with a large dilator, like a balloon or a bougie, and the patient is reporting symptoms that are consistent with it, it's an option that you have. Yeah, I totally agree. I mean, there actually is some literature supporting the use of it that is better than nothing. I don't think it's better than dilation or even equivalent to dilation. So I think it's great as an adjunct. If I have a fairly large, like if I have a patient comes in and is describing intermittent dysphagia for solids localized to the chest, just sounds like it's the Schatzky ring, right? But then it's like fairly open and I dilate it, you know, up to 20 millimeters, balloon, bougie, what have you. And I'm not getting a very good tearing or a very minor tear. I almost always go and just take a biopsy and disrupt the ring because why not? Like you're there, you want to get as much benefit as you can from that procedure. The risk is so low. I do it after I dilate. I always, I don't know if it's superstition or what, but I always biopsy after I dilate in all cases. I just don't like having a leading point for a tear that could go deeper. I don't know how it's going to affect my sense of resistance. So I can't say that you need to do that, but that's always what I do. I just always dilate first, biopsy after. So that's a great question and very, very reasonable thing to do. Well, I think that is all the questions I'm seeing for now. I'm happy to answer any others, but we're approaching the top of the hour. So if there's nothing else, we'll give it a couple more seconds here. Then we're happy to step out and just thank you again for being here, all of those who attended. I know there's going to be a recording of this available on GI Leap to the SGE and look forward to answering any questions any of you have afterwards if you do. So thanks again to the SGE and to all of you and to Laura for being here. And I hope you have a wonderful night. Thank you. Thank you, Dr. Kahn, great talk. Thanks. Thank you to our GI moderator and to our content expert for tonight's presentation. Before we close out, I want to let the audience know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of the 2024 ASGE events. The next Endo Hangout session, Approaching Your First Job, will take place on Thursday, May 9th from 7 to 8.30 p.m. Central Daylight Savings Time. Registration is open. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, ASGE training membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to sign up today. In closing, thank you again to our presenters for this excellent webinar and thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Please have a wonderful night.

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esophageal strictures

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cricopharyngeal narrowing

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intralesional steroids

endoscopic incisional therapy