Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy

Multimedia article. Sphincterotome stricturoplasty for long ampullary stenoses and benign biliary strictures (with video)

BACKGROUND

Long ampullary stenoses and fibrotic distal biliary strictures are not infrequently encountered during endoscopic retrograde cholangiopancreatography (ERCP). Instead of balloon dilation and stenting, we propose that these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP.

OBJECTIVE

To report our clinical experience with SS for benign distal biliary strictures.

DESIGN

Review on prospectively collected data.

PATIENTS

All (consecutive) patients who underwent ERCP and SS performed by the authors in a 12-month period. Long ampullary stenosis and/or distal biliary stricture is defined as significant narrowing of CBD from the level of duodenal wall into the common bile duct (CBD) after initial sphincterotomy. The upstream CBD is dilated. Despite adequate ES, contrast drainage is poor due to the downstream stricture. SS was performed using the same sphincterotome in slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire was placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS the majority of the cutting wire was inside the biliary opening. This differs from ES, where about one-third to one-half of the length of cutting wire is outside the ampulla.

MEASUREMENTS

Clinical data, hospital course, procedure-related complication rates, and outcomes were prospectively collected in a database.

RESULTS

During the study period, 308 ERCPs were performed. Benign and short (≤15 mm in length) distal biliary strictures were observed in 25 patients. Mean ± SD stricture length was 7.4 ± 3.0 mm. The presumed etiologies for these strictures were choledocholithiasis (n = 22) and postsphincterotomy stenosis (n = 3). There was no perforation, post-ERCP pancreatitis, postsphincterotomy bleeding, or cholangitis. To date, none of these patients who had SS have needed follow-up ERCP.

LIMITATIONS

Single-operator experience, limited follow-up period.

CONCLUSIONS

Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP.

Endoscopic dilation of benign colorectal anastomotic stricture after low anterior resection: A prospective comparison study of two balloon types

BACKGROUND

Benign strictures arise in 5.8% to 20% of colorectal anastomoses. For such strictures, endoscopic dilation has proven to be a valid and safe treatment. A variety of endoscopic techniques have been proposed, but controlled prospective trials are lacking. This study compared dilation of this colorectal anastomotic stricture with an over-the-wire balloon designed for treatment of achalasia and with a through-the-scope balloon.

METHODS

Thirty patients with symptoms caused by benign colorectal anastomotic stricture were randomly allocated to two treatment groups: 15 underwent dilation with a through-the-scope balloon and 15 had dilation with an over-the-wire balloon. Success was defined as an anastomotic lumen wide enough to allow passage of a standard 13-mm-diameter colonoscope, with resolution of symptoms. The success of dilation, the number of sessions required, the complications, and the duration of the dilation were recorded. Patients were followed for 24 months.

RESULTS

Dilation was successful in all patients, with no procedure-related complication. The mean number of sessions required was 2.6 (0.98) in the through-the-scope group and 1.6 (0.77) in the over-the-wire group ( p = 0.009). The duration of response in days was greater in the over-the-wire group vs. the through-the-scope group, 560.8 (248.5) days vs. 294.2 (149.3) days, respectively, p = 0.016.

CONCLUSIONS

Through-the-scope and over-the-wire dilation techniques are both effective and safe for treatment of benign colorectal anastomotic strictures. Using a greater diameter over-the-wire pneumatic balloon reduces the number of dilation sessions required and provides a longer-lasting response to dilation.

Combined use of electrosurgical incisions and balloon dilatation for the treatment of refractory postoperative pyloric stenosis

BACKGROUND

Drug therapy plus balloon dilatation without gastroscopic incision does not always relieve postoperative pyloric stenosis.

METHODS

Five patients with postoperative pyloric stenosis whose symptoms did not improve with drug therapy and balloon dilatation underwent a combination of gastroscopic incision and balloon dilatation. Two or 3 small radial incisions were made in the stenotic muscle of the pylorus electrosurgically at gastroscopy. Then the stenotic muscle layer was loosened and split bluntly along the incisions with balloon dilatation for 15 to 20 minutes. One week later, the combination procedure or balloon dilatation alone was repeated to prevent restenosis.

RESULTS

In the 5 patients, the stenosis was improved with the combination therapy. No complications were observed.

CONCLUSIONS

Combined use of gastroscopic incision and balloon dilatation may be considered for patients with refractory pyloric stenosis caused by surgical truncal vagotomy.