All right, so turning to esophageal strictures and management. So in terms of deciding how you're going to manage an esophageal stricture, you really need to characterize the stricture, and there's a number of different ways to do this. So this is what I propose as the way that you would consider strictures. The location is very important. It's going to inform what type of dilator you're going to use, how you're going to perform the dilation. And proximal strictures, you should always be careful, as Pratik said, about intubating the esophagus, but you want to be particularly careful if you know there's a proximal esophageal stricture in terms of intubation. And generally, it can be fairly difficult to dilate a proximal esophageal stricture with a balloon. Patients, unless they're very deeply sedated, are not going to tolerate that particularly well. And then just visualization in general is going to be difficult if you have part of your balloon hanging into your oropharynx. You want to ascertain the presence of inflammation, because it's not always safe to dilate an inflammatory stricture, whether it's a peptic stricture, an EOE stricture, lymphocytic esophagitis stricture. So you want to assess that at the time of the endoscopy and make a decision at that time whether to dilate. There's absolutely no harm in pursuing medical treatment for a period of time and then bringing that patient back to perform the dilation, and that in many instances can be the safest way to approach it. You also want to know if there's a single or multiple strictures, because it's going to be informative in terms of which dilator that you choose, because obviously a wire guided or polyvinyl dilator is going to be better for multiple strictures versus a single stricture. You could use either a balloon or the polyvinyl dilators, although if you have multiple strictures but only one of them really appears to be clinically significant, you can choose to only dilate the single stricture, but it really just depends on the situation. And then you want to know if it's simple versus complex, because you're going to have to choose your approach to dilation and whether or not you're also administering medical therapy concurrently if you have a simple versus a complex stricture. So there's different criteria to categorize simple versus complex procedures, but these are the ones that I'll propose. So a simple procedure is going to be smooth surface such as a ring. It's generally going to be short. It's going to be straight so that you can see the stomach below it fairly easily. Generally it's going to be concentric and it's going to allow passage of an endoscope. The standard gastroscope is, I believe, 9.8 millimeters outer diameter. So if you can pass the endoscope easily, you know that the diameter of the stricture is at least 10 millimeters and that's going to help inform what type of dilator you use and what size of dilator you use. Complex strictures are those that are longer. They may be angulated, which is very important in terms of performing a safe dilation where visualization is really important. They may have an irregular surface. They may be associated with ulcerations such as my patient with the radiation esophagitis and stricture. A severely narrowed stricture is generally considered to be complex, although I would argue that some strictures that may be much smaller than that, or that may be smaller, I'm sorry, can be simple in terms of how you treat those. And then you have to be really aware of associated findings such as a large hiatal hernia, esophageal diverticulum, or a tracheoesophageal fistula. So in terms of management of strictures, obviously some strictures such as EOE and peptic strictures require acid suppression in addition to endoscopic therapy. So you need to understand the appropriate situation in which to use those. So if you know or see that the patient has acid reflux disease, you certainly want to have them on good acid suppression. And what I found is that a lot of patients and a lot of primary care providers that put patients on PPIs don't really know the best way to take them. So I think important patient education point is to make sure they know to take the PPI on an empty stomach and then to eat something 30 to 60 minutes later so they get the best effect of their PPI. And also to make sure they understand it's a medication that they need to take every day. They don't just pop a PPI if they're having acid reflux after a big dinner. They really need to commit to the fact that this is a chronic condition and needs to be treated like a chronic condition. So the mainstay of management esophageal strictures is generally dilation. And so there are savory or polyvinyl guided dilators, which are wire guided, and then there are balloon dilators. And I chose not to talk about stents for refractory stricture just based on a short amount of time of this talk, but that is an option for refractory strictures and those associated with, for example, a TE fistula. And then I often, my patients, particularly those with refractory strictures or those that have had a food impaction, I do talk to them about diet. And I don't know about you all, but every time, almost every time that I've come into the ER for a food impaction, it's been meat. And so I generally advise them strongly if I'm dealing with a complex stricture and I know that refractory stricture, I know that there's going to be cereal dilation. I caution them about their diet in particular about eating meat until we get them dilated up to a size such that they should be able to eat meat safely. And I think that's an important discussion to have, particularly in the presence of their family member. So I mentioned there's really two main types of dilators. There's the guidewire or polyvinyl dilators, which generally tend to be best for multiple strictures or proximal strictures. And then there are balloon dilators, which are best for single strictures, good for middle or distal esophageal strictures. They're not great for proximal strictures for the reasons that I've already mentioned. One real advantage, as you know, is it allows for multiple size dilations in a single session, single placement of a catheter. You just have to put one balloon through your endoscope channel in order to get free sizes of dilation that are generally a millimeter and a half apart. And then allows for endoscopic visualization of the stricture in the balloon. Sometimes we take biopsies at the same time as dilation. I think that's fine to do. My personal preference is to do the dilation first. And the reason is that the bleeding that I see, I want to know what bleeding is from the dilation. So I want to do the dilation and inspect the mucosal tear first. Then I'll know how significant it is or if it's significant enough. And then I'll do biopsies, particularly if I'm suspicious of EOE. So that's my approach. So something that I wanted to point out, and I hope these pictures turn out okay, we have American dilators. That's just a brand. But on one side of the dilators in blue are marking centimeter markings and the word American. And on the other side of the dilators in red are a set of markings in centimeters and the words European. And I wanted to make sure that everyone knew that the markings were different, depending on whether you're looking at the blue American markers or the red European markers or whatever brand that you have, there's often going to be two different kinds. And the difference is with the American markings, they're measuring the centimeters from the very tip of the dilator, so the tapered portion. So the measurement includes the tapered portion. So, and I can't even see this, but yeah, I think it says 20 centimeters. So it's measuring 20 centimeters from the tapered portion. And to me, this measurement is irrelevant. And I'll be honest, I'm not quite even sure why it's there. With the European markings, this is where, let's just say this is a 48 French dilator. So the European markings start measuring when the dilator becomes 48 French across. And to me, this is the relevant marking because if you have a stricture, it really is not helpful to get the tapered portion of the dilator across the stricture. What you want to do is get the 48 French, you know, for example, portion of the dilator through the stricture. So my practice, and I would strongly encourage you, is to pay more attention to these measurements because this really allows you to do an effective dilation. It's also important to accurately measure the site of your stricture based on centimeters from the bite block, because you want to make sure that you get, you know, a good portion of the dilator that's the size you want to achieve through the stricture. I know we all use a lot of balloon dilators and I find them to be particularly handy because they're available in multiple sizes. And as you know, you can put one balloon down and inflate it to three different sizes. And you can have some direct visualization. You can't really see your stricture typically when you're doing the dilation, but you can visualize your balloon in the esophagus and know that you're keeping it in place. So it's very important, again, to identify the site of the stricture based on centimeters from the bite block because typically these balloons from the, again, let's just say this is a 15 millimeter balloon. So the segment of the balloon that, 15 through 18, that's what I meant to say. So the segment of the balloon that blows up to 15 millimeters is generally, depending on your brand, but it's going to be on your package, is generally going to be about eight centimeters long. So you want to make sure that you position this accurately because you don't want to have the tapered tip or the tapered part through your stricture because you're not going to get an effective dilation. So you, I generally identify the site of the stricture and then I want to make sure I at least have four centimeters of the balloon through the stricture so that hopefully the waist of the balloon is going to be right where the stricture is. So it's very important to get proper positioning. So this is an old study but it directly compared savory to balloon dilators in terms of number, no recurrence of stricture over time and it appears to be a difference but that wasn't statistically significant. So just to point out that it really depends on your comfort level with each dilator in terms of what you use and the features of the stricture that you're going to dilate to really inform which dilator that you're going to choose. So in many situations either one is fine. I wanted to mention this rule of three and then I got really curious like where did this come from? And as best as I can tell, I think we all learned the rule of three in training which is that you don't do more than three incremental sizes of dilation in one single setting. And as it turns out this is not an evidence-based recommendation. I sort of followed a trail back to 1977 and then I kind of stopped looking but Worth Boyce who's a well-known gastroenterologist in his time said the policy of limiting any one treatment session to a maximum of three dilators has proved reasonable. And I would tend to agree with that statement. The UK guidelines on esophageal dilation say that the precise restriction of three dilations is not evidence-based and that's true. And then GIE has published something that said the rule of three has been accepted and applied to bougie dilation of esophageal strictures. So I would say that I generally follow the rule of three but not because it's a rule. When I'm doing a balloon dilation I really try to accurately judge what size dilator I need based on my estimate of the size of the lumen size of the stricture. And also I'm kind of frugal and I don't like to open two balloon dilators. I think I should be accurate enough that I can get a good dilation by judging the size and just opening one balloon package. But I don't necessarily even do three. If I do a dilation, and I do this commonly, if I do a dilation for an obvious stricture I very commonly will do the first dilation. Let's say I'm using a 15 through 18 balloon and then I'll have the assistant deflate the balloon and then I'll go take a look. And if I have a mucosal tear after the first dilation and I feel like I've disrupted a ring for example, I don't think it's necessary or maybe not even safe to do further dilation and then I'm done. But if I look and there's been no mucosal tear I'm going to go to the next size and so on. But I generally adhere to the rule of three but not necessarily because it's a rule, but I think it does make a fair amount of sense. Less is safer. So this slide is sort of the cue to myself to talk about refractory strictures. So depending on where you look, the definition of a refractory stricture is where you can't achieve 14 millimeter dilation after about five sessions spaced two to four weeks apart. And this is my cue because I always use steroid injection in patients with refractory stricture. So this is a study, it's fairly old and there's been several studies looking at steroid injections but I chose this one because it was a randomized trial. And they randomized patients to have a balloon dilation and then to also get a steroid injection or not get a steroid injection. And as you can see, it's significantly longer time to needing a repeat dilation in the patients that received a steroid injection compared to those that didn't. So this is a study that I did so I generally do this in refractory strictures. I'll do my dilation first and then assuming I achieve a mucosal tear or more than one mucosal tear, I use Triamcinolone 40 milligrams per ml diluted to five mls. And then I kind of just judge where I want most of the steroid to go. I don't necessarily do it four quadrants. If I don't get mucosal tears in four quadrants, focus my injection on where the mucosal tear occurred because that's obviously the most narrow part of the stricture. So I tend to see patients back every two to four weeks if they have a refractory stricture and try to increase the size of their dilation by at least a millimeter or more each time. Sometimes the strictures regress in that period of time. So you may have to start let's say you started at 10 millimeters and went to 12 and then when they come back you can't you can barely get the scope through so you may have to start at 10 millimeters again. So I just sort of judge that based on the appearance of it in the follow-up but almost always use steroid injection for refractory strictures. So just to circle back to this patient I showed earlier, this is the 80 year old with the solid food dysphagia and the severe esophagitis. So I placed her on high-dose PPI therapy, brought her back in a couple of weeks and her esophagitis was much improved. It wasn't completely gone but at that point I did do a dilation and have dilated her I think four times now and have gotten her to the point where she can generally tolerate most anything she wants to eat. So in terms of take-home points I think characterization of strictures is very important before choosing the best method of treatment. Dilation is almost always required in addition to medical therapy. It does sometimes if I see a patient with severe esophagitis I treat them with high-dose acid suppression and say you know if your if your dysphagia goes away completely we don't need to do a dilation. I need to follow you up to make sure you're healed but we don't have to do a dilation and that does sometimes occur that medication therapy alone is effective but in almost all other situations dilation is required. Wire-guided polyvinyl dilators do have an advantage in that they achieve both radial and longitudinal dilation but they can't be visualized so that is somewhat of a disadvantage balloon dilators allow for three increments in size in dilation and do provide visualization so tend to be my go-to dilator for most strictures and then steroid injection into the structure should be strongly considered for refractory strictures. All right thanks very much.

esophageal strictures

management

characterizing strictures

dilation technique

medical therapy