We will be using this video as a teaching tool to show you the technique of esophageal self-dilation. Esophageal self-dilation is a treatment option for patients with resistant benign esophageal strictures. In this teaching guide, we will provide a background on the topic of resistant esophageal strictures and describe our teaching program for esophageal self-dilation. Specifically, we will discuss the equipment needed, the choice of dilators, and the procedure of self-dilation. We will also show you discussions with patients about their experiences with self-dilation, as well as instructions regarding their routine at home. As early as 1674, Thomas Willis reported the use of a sponge button mounted on a whale bone as a dilator, and the first bougainvillea was reported in the 1800s. In rare instances, despite repeated physician-performed endoscopic treatment and medical therapy, relief from dysphagia is only short-lived. These resistant strictures are most apt to be caused by radiation injury, caustic congestion, and post-surgical anastomotic scarring. Best patients for management include repeated physician-performed dilation, intralesional steroid injections, incisional therapy, stem placement, and self-dilation. The best patients for self-dilation are those who are motivated and compliant. The teaching of self-dilation consists of three parts. The first part involves patients watching an educational video on self-dilation. In the second part, patients meet with another patient experienced with self-dilation to discuss any issues or concerns they might have. The third part consists of one physician-performed dilation, followed by a minimum of two to three self-dilation teaching sessions. The physician-performed dilation is used to determine the exact location of the stricture and to determine what diameter dilator the patient will use for self-dilation. The teaching sessions cover the actual technique of self-dilation. Individual self-dilation is initiated with a Maloney dilator a few sizes smaller than that used during the previous endoscopic dilation. All of these sessions are completed under close supervision of a doctor and a registered nurse. The first teaching session is usually the day after the physician-performed endoscopic dilation. In general, the sedated endoscopic dilation is performed on Monday, and self-dilation sessions follow on Tuesday, Wednesday, and Thursday. Following the self-dilation teaching sessions, patients go home with a Maloney dilator of the same size that was successfully passed during the last teaching session. Once they go home, daily self-dilation is performed. Furthermore, the patients get instructions on the subject of the Maloney dilator care and cleaning. Periodic physician follow-up visits are scheduled. During those office visits, patients bring their Maloney dilator for technique and compliance observation. As you know, this is a Maloney dilator. It's a tungsten-weighted bougie, which is used for stricture dilation. We initially use a dilator a few sizes smaller than that used last, when the dilator passed through the stricture during the endoscopy, which is done to make measurements for the self-dilation. For example, if we used a 48 French dilator last in the endoscopy suite, we'll start with a 44 French, which is, as you know, 14.5 millimeters. The size of the dilator is increased based on the patient's tolerance and on their symptoms of dysphagia. Each Maloney dilator that a patient takes home has a tape mark that points out the distance from the incisors to which the dilator needs to be advanced in order to achieve successful dilation. The required depth of insertion is commonly 5 to 10 centimeters distal to the stricture location. As you can see, the required material for self-dilation is very simple. It only requires a Maloney dilator, lubricant gel, and a topical anesthetic. Patients are instructed to follow specific steps when performing self-dilation. These steps include numbing of the throat, lubricating the dilator, comfortably position the head and hands. Some patients find mental preparation often helps. Introduce the dilator to the throat, insertion of the dilator, and finally, withdrawal. We're going to mix together viscoxilacane, 50 milliliters, with 50 milliliters of water in this med cup so that he can gargle that and numb his throat. Typically, we use either a lubricant jelly or water on the dilator, and Mr. prefers to use the water, so that's what he's going to do today. So if you don't mind gargling with this, and then you could just spit it out into this basin. Just tell us, Todd, what you would be doing. I take my dilator and I put the tip of it into the water, and then I take my dilator up higher. What a pro. Good job. What a pro. There you go. Good. Then I clean off my dilator, and I put it up until the next day. Boy, I tell you. And just how long would it normally take you in the morning? It takes less than a minute. Really? You just get up, you go in the bathroom, do that, and then you're kind of off about your business. Yeah. I'm left-handed. And so everybody who showed me was right-handed, of course, and so when you're left-handed, you watch, and then you do it your way. So I learned that you go in very slowly at the beginning, and then tilt your head back and go the rest of the way, like this. That's a professional at work. Thank you very much. Bravo. Bravo. And you bring it out immediately. And tell us a couple of things. You don't use any lubricant, you don't use any water, you don't use any numbing medicine. I did at the beginning. Absolutely. I used them all. But after you've done it day after day after day, you find that you don't need the numbing medicine, and then you find you don't need the lubricant. Well, I take it out of my case, and I take the lubricating jelly, and I put it all around, about an inch, inch-and-a-half down on all sides, about like that, and then I dip mine into water, and then I just ... Sometimes I leave it in, and I try to swallow why it's down. Yeah. And I usually just run the dilator under the sink, just get some water on it to get it lubricated. And I know you don't have to go down all the way, but I usually do. This is just a demonstration of someone who's really an expert at doing this. Tell me a little bit about when you started. What were your concerns? Did you say, this would be scary, or you thought, this is something I can handle? How did it all start at the beginning? Yeah. When I first saw the dilator, I was a little intimidated, but really, it's not scary. After the first or second time, it just goes down easily, and it's completely natural. I mean, they say to me that the reflex, the gag reflex, is strictly in your head. Well, nobody believes that. Nobody who hasn't tried it believes it, but in fact, it's true. I do the panting because it seems like when I inhale the air, it keeps the Mahoney easier for it to go down, and keep it in the right spot so it doesn't go down into my lungs. What was it that allowed you to get the strength to do it? Well, it was to have a more normal life without a feeding tube, because if you don't get this done, you always have to have a feeding tube. So why do that when this is easier in the long run? After the instructional sessions are complete, and the patients feel absolutely comfortable with the procedure, and have demonstrated the competency performing it alone, we send them home with their own dilator. Self-dilation is generally carried out in the morning before breakfast. Many patients choose to stand up in front of a mirror. When the patient is comfortable with the procedure, self-dilation takes literally less than a minute. At home, patients are instructed to wash the dilator after each use with soap and water, and lay it down on a flat surface. The patient will use a carrying case to protect the dilator, particularly its tip. During each outpatient visit, the patients are advised to bring the Maloney dilator with them. Initially, the patient returns to the office in one week to demonstrate the technique and competency, and to ask questions or express concerns. The patient is always reassured that the staff is available if they have questions or concerns, and that the staff can be called seven days a week. Most patients are asymptomatic at 44 French, and they can eat whatever they like. As time passes, based on individual symptoms, we may start increasing the size of the dilator. A typical increase is from a 44 French to a 46 French dilator, to a 48 French dilator. Over time, the frequency of self-dilation can be decreased. A typical decrement may be from daily, to every other day, to once a week. In some instances, we can stop self-dilation completely after a period of time. Esophageal self-dilation is an effective method for treatment of recurrent benign esophageal strictures. The procedure is generally well-tolerated, is associated with significant patient satisfaction, and has a low incidence of complications. In this program, we have illustrated several step-by-step techniques of esophageal self-dilation. Education and careful patient follow-up, reinforcing the appropriate technique of esophageal self-dilation, are essential for successful treatment. Physicians responsible for patients who require frequent physician-performed dilations should consider self-dilation as a viable treatment option.

esophageal self-dilation

benign esophageal strictures

procedure

patient experiences

home self-dilation