And now it's time for us to invite our course chair, Prateek Sharma, from University of Kansas School of Medicine, and he's going to talk about complex esophageal strictures. Prateek. Okay. Thank you, Prakash and Srivanti, and good afternoon, everyone. So there will be some slides also on eosinophilic esophagitis and dilation, but I just thought I'd go over what are some of the tricks that you could be using for patients who have some difficult strictures, you know, to treat. Here are my conflicts of interest. So if you look at benign esophageal strictures, and before you start the dilation, it's always good to know what the etiology is, and I think that's something that we tell our fellows all the time is that figure out what's the etiology and you can base your treatment based on that. So it could be from peptic injury, caustic injury, iterogenic, and those are listed here. In fact, the ones which are on the extreme right are the ones which are sometimes the most difficult to treat, and those are the complex strictures that you may need additional therapy rather than just a simple savory dilation. So it's important to recognize what the etiology is. So here are the steps is how do you achieve success, how do you approach a refractory stricture, and then how can you avoid complications when you're treating or dilating these strictures. So let's just look at this one step at a time. So to assess the stricture, I mean, this is important, especially in the long tortuous strictures is we talked about the etiology, how long has the patient had it? I think that's extremely important. Where's the location? What's the diameter and the length? And then, of course, the complexity, which is usually defined by a stricture which is multifocal as well as the one which is angulated. So make sure you assess that stricture appropriately. And again, just as we've heard earlier for other diseases of the esophagus is endoscopy or just one tool may not be sufficient. So do you need a barium study prior to your endoscopy or prior to dilation? Fluoroscopy, I mean, many of our units now because of advanced procedures, we have fluoroscopy available or a scope alongside the balloon or things like that. So is that required or not? And then having the availability of small caliber endoscopes, I think, has really changed this in which you can even sometimes use a cholangioscope, which our ERCP colleagues use. But because of the small diameter, you can traverse the stricture and therefore look and see what's beyond it. So I think look at all of these different tools and use them to your disposal. The question always comes up, should I use a Bougie or should I use a balloon dilator? And is one better than the other or not? So let's look at the Bougie dilators. These are the ones that are listed here. The ones that we typically used are the reusable ones, which are the savory dilators. And then, of course, we have the balloon dilators as well. In summary, there is very insufficient evidence to suggest that one's better than the other. And in fact, most of the RCTs which have been conducted show that they are non-inferior. So they're quite similar. So go with the one that you feel most comfortable with and the one that you think is appropriate for the patient. So for example, in a patient with a very focal stricture, you can use a balloon because it's a focal stricture. It's there. In a patient with eosinophilic esophagitis, you probably want to use a savory dilator because there may be multiple focal strictures which you may not see endoscopically as Iko told you about. And so you want to dilate the entire length of the esophagus rather than just one short area. So you have to do it. So at the end, it's a personal preference. But again, the etiology of the stricture, why you are doing this may also make an impact. And so it's important to look at it. Here's the focal stricture that you see. This is a patient with Barrett's esophagus. And this actually is a pill-induced stricture that we figured out in this patient. And here you can use a balloon dilator. And so the key is always is pull up the balloon towards the tip of your endoscope so that you can see across it. And then you're able to traverse the stricture after you've done that simple dilation. Now, here's more of a pinhole stricture, right? This is occurring after anastomosis, which was created. In this situation, again, this is being done under fluoroscopy. So you have the balloon, but you pass the guide wire through it and you are looking at it under fluoroscopic guidance because you want to make sure that this is going into the stomach and not into the mediastinum, and that's not what you're dilating. So here's a situation where you would want fluoroscopy and use it to your benefit. If you're unable to traverse the stricture, you can see how tight this is. So even using a very thin caliber endoscope may not be possible. So you do it under fluoro. You pass the guide wire of the balloon across it, and then you do graded dilations for it. Even with the balloon, you want to go slow, and you want to make sure that in one dilation you're not overtly aggressive in reaching a diameter in this situation of 14 millimeter at the first setting. That's not your goal to do because the stricture itself was probably close to a couple of millimeters at most. So this is the end product that you get after dilation has been achieved. So this is a tough stricture, but you can do this if you have the right tools and the right setting to do it. The other question is how much should you dilate, and how aggressive should you be at one setting, and what's your goal here to do? This comes from Worth Boyce that many of you may not have heard of him, but he came up with this rule of three, which I think still holds true, although it's never been very scientifically validated, but from a very practical perspective, this is actually very important for all of you to recognize. And that's the rule of three, that once moderate resistance is encountered, don't go more than three consecutive dilators, which are more than a millimeter. So that's the rule of three. So always remember that. So if you're at 12 millimeters, you're getting moderate resistance, 15 is probably the max or 14 is the max that you want to go to. Don't try to get to a 17 in that setting because that's when you will run into complications. With the balloon, it's very difficult to know how much can you do. If you're doing it under fluoro, there's been some suggestion that when you see obliteration of the waste, that's probably the max that you can do. But besides that, it's very difficult to know because unlike the savory, you don't get that tactile sensation with the balloon, and therefore in many of the situations, I tend to prefer the savory dilator over the balloon just because I feel that I can encounter that resistance. I know what mild, moderate, severe resistance to me is. It may be different for different people. With the balloon, you don't get that. And here are the targets. So you necessarily don't need, for a tight stricture like that, a target of 20 millimeters. There's really not going to be any difference in the dysphagia score or the symptom of the patient of achieving an 18 millimeter versus a 20 millimeter. So know what your target is that you're going to achieve. Go by the patient's symptoms as well as by the diameter that you have achieved in that. So if you're starting with a 2 millimeter stricture, at 15 millimeter, the patient will really be good and will be able to maintain weight and will be able to gain weight. So in that situation, really, you're pushing it if you want to achieve a diameter of 20 millimeters. So make sure you have those targets in mind rather than just blindly calling the patient every month or every two months to come for an endoscopy to do it. How about the stricture with these simple techniques do not work? So you've tried a savory, it didn't work. You switch to a balloon, it didn't work, right? So that's a little bit of refractory. So what's the definition? How will you define these strictures? Here are some of the reasons why you get refractory strictures. So it's important. It goes back to the etiology. So some of your caustic strictures, strictures from radiation, strictures post-anastomosis, these will be your refractory strictures that you will be seeing. Here's one definition, inability to achieve a diameter of 14 over five sessions at two week intervals. And again, there's really no science behind it, but this is just from a practical standpoint of how will you define that it's refractory so that now you try something else. And which makes sense because if five times you've tried a balloon dilation and the patient keeps coming back with that same pinpoint stricture, you need to do something different because it is now a refractory stricture. Here's another definition of looking at a refractory stricture. Nonetheless, it tells you that if you've tried a therapy, it's not working, then what are your next steps which are there? So the first thing that should be coming to your mind is steroids. Should I be injecting steroids in this situation or not? So if you decide to do it, here's how you should be doing it. So use triamcinolone. You dilute it with saline. And then you inject it with a scleroneedle in aliquots of about one cc in every quadrant of it. And so you inject it in all four quadrants circumferentially into the stricture. There's really no good consensus on whether you should inject first and then dilate or dilate first and then inject. Some experts think that perhaps if you dilate first, get that disruption of the mucosa and then inject into it, it's much better. But that's just a preference. I mean, there are no data to suggest that one's better than the other. So as long as you're doing it this way, you're good to go and you should be able to do that. What's the evidence that this works? Well, there are data from randomized control trials looking at use of triamcinolone after balloon dilation. And you can see that small number of patients and what they were able to show is that repeat dilation happens significantly less in the triamcinolone group as compared to the sham group and also that the period in between dilations could be extended if you were using steroids. So this is a good start after regular dilations don't work is to go to triamcinolone or steroid injection in your patients. The next is stents. What are the different types of stents which are available and when should you be using it? So we have fully covered metal stents. And now remember, we're talking about benign strictures. This is not talking about malignant strictures. That would be a different discussion altogether. This is a self-expanding plastic stent. And hopefully none of us are using this anymore. And then, of course, we have biodegradable stents. A lot of hype around it, but really they haven't panned out. So we are unfortunately left with the one on the left, which is using a fully covered metal stent and remembering that they are not FDA approved for this specific indication, but yet we use them. So what's the efficacy of this and looking and seeing that they actually help? So this was looking all across. SEMS is the self-expanding metal stent followed by the self-expanding plastic stent and then the biodegradable stent. So you can see that even the literature is limited to a few hundred patients rather than a large cohort that you have. So if you compare the three and you look at the success rate, which was defined that ability to put it and having the patient have some relief of symptoms. This is the major issue with the stents, is migration. And you can see that a third of these stents will migrate. And again, this was done in the era prior to suturing. So that's one of the reasons you will find that now if you put in a self-expanding metal stent, you probably do want to anchor it because a third of them will otherwise migrate in this situation. And also adverse events are reported after stent placement. So be aware of this information, discuss it with your patient before you go in and go this route of placing stents for your benign strictures. If you look at outcomes again, this is a more recent study looking at fully covered self-expanding metal stents and biodegradable stents and comparing it head to head. You can see the clinical success rate remains better with the metal stents. Migration rate, of course, is much higher with the metal stents. Even it can happen with the biodegradable stents because they don't biodegrade right away. So they can also migrate. And so that is there. It's less. Overall, adverse events are similar between the two stents. Of course, major side effects were noted more with the biodegradable stents as compared to the metal stents. And therefore, as I said, the biodegradable stents really, with the initial hype, they really haven't panned out. And at least we don't use them in our unit at all. How long should you place them for if you decide to place a self-expanding metal stent in your patient? Well, you leave it until the inflammation is resolved. If the strictures are long or ischemic etiology, they require a little bit longer, so up to about eight weeks. The shorter stricture and other non-ischemic etiologies, you should be pulling those out roughly at about six weeks after you've placed the stent in. Of course, in biodegradable stents, unless there's a migration, you don't need to remove that at all. How do you do it? Well, most of them come with a thread, so you use a rat tooth forceps, and then you just pull it out. As you pull the string, the stent would collapse, and then as you come back, the stent comes out along with that. Of course, this is the easiest stent removal. With the migration, you know it from the stomach, it can sometimes be challenging, specifically if the thread is facing the antrum, you can use a snare, try to collapse it, and get it out in different ways if there is a stent migration. These are the complications you should be worried about if you place a stent in for your patient. Pain, bleeding, perforation, these are the ones which happen relatively soon. Of course, then we've talked about migration for sure, but also remember that there can be ingrowth as well as overgrowth with these stents, and that's important. Sometimes you may need to treat that if it's put in. Of course, fistulas can happen if there is a lot of radial pressure exerted by the stent. These are complications you should be aware about for that. What do the guidelines say about this? These are the ESG guidelines, and then again, you can see that it gives it a weak recommendation, but unfortunately, sometimes you do have to go this route because we don't have much to offer to our patients, saying consider temporary stent placement for refractory or difficult-to-treat benign strictures. Do not use this as the first-line therapy, so again, that's, I think, an important message to remember. The ESG guidelines are very similar, but they also warn us that have a discussion with your patient because these are not approved for benign strictures, and so this is an off-label use. Again, we can't use it because we practice off-label use all the time in medicine, but again, just because there are serious complications associated with it to do it. Now just a few words about some specific instances of what you can do. Some of them are the anastomotic strictures and the very proximal strictures, like the post-laryngectomy strictures, very difficult to treat. In this situation, you want to be aggressive. You want to repeat dilation every one to two weeks and bring that patient back very soon because otherwise that pinhole stricture at 28 centimeters or 25 centimeters is going to come back if you give the patient a month to come back again. These are very tight strictures. You have to be aggressive in order to do that, and these strictures, you may have to reach a diameter of at least 18 millimeters before the patient starts experiencing relief or complete absence of symptoms. So do this and bring the patient back frequently. So that's an important take-home message for this. Short fibrotic strictures, you can also use a needle knife if your regular dilation is not helping, and this is how you do that. So here's a very short fibrotic stricture, which is post-anastomotic, and what you want to do is just in a four-quadrant fashion is just cut the muscle or the fibrosis because your balloon, your savory, as soon as you look back in, the strictures come back again because of the fibrosis. So just take your needle knife and cut it in four different directions, and after you've achieved this, you can dilate this with a balloon dilator as well. You may need to retroflex if you're not getting a good view at this, but again, this is a very simple technique, again, something different that you may have to try in your patient if the regular dilations with or without, you know, Triamcinolone are not helping. So after you've actually cut through this and you've opened it, you can go in with your balloon dilator and stretch it further open because now that result will last much longer because you've disrupted the fibrosis there, which is what was making that stricture coming back all the time. So again, another thing that you can do, these are for specific, very focal strictures. If you have a long stricture, please don't use this technique, okay? So this is very focal. EOE strictures, we heard from Iko about this, and you can see these deep tears, and again, you know, these tears happen, this is normal. If you see it, you know, don't, you know, get too concerned about them. This is not a perforation. This is what you would see after a stricture from EOE has been dilated. So what are some of the tips of this? For this, you don't want to be overtly aggressive, like I said, about a fibrotic stricture. These are not really those fibrotic strictures, so you shouldn't go in very aggressive. 58% of them will require a second dilation, and majority within a year. Through the scope, as I said, is for very short strictures, but I try to avoid that, and I try to use a savory for the majority of these strictures. And the key here is to start low and go slow. You don't want to achieve, again, a very large diameter in a single setting in order to do that. And so, finally, how do you avoid complications in these patients? Make sure that you discuss the risk of perforation with these patients. Stop the anticoagulation if it's required, and antibiotics are not required routinely for all our patients. As I said, these are some of the deep tears that you will get. This is after a very similar to what Iko showed you. And again, these deep tears do happen, but again, don't require any further treatment in this situation. And in the majority of the situation, it's been shown that these strictures, if done the right way, there's no increased risk of complications or perforation as compared to the other strictures that we are treating. So finally, I'll just leave you this algorithm from Peter Siersma about step one, which is listed here. We've talked about that, regular dilation. Then go to steroids if that's required, and then you can go to stent placement. Finally, we haven't talked about self-dilation, but Malonies may be required, and self-dilation, which is very difficult to motivate your patients, and finally, surgery, hopefully you won't reach that stage. Thank you very much for your attention.

esophageal strictures

etiology

dilation

tools and techniques

bougie dilators

balloon dilators