Andrew W White, MD, Carl Westcott, MD. Wake Forest Baptist Medical Center
INTRODUCTION: Endoscopic balloon dilation of the gastroesophageal junction (GEJ) is generally limited to 20mm in diameter. In many stenotic or spastic disorders of the GEJ 20mm is just not big enough. Larger balloon sizes are available (30 and 40mm), although these are deployed under fluoroscopy without endoscopy. Thus, these larger dilations are often not feasible at the time of the diagnostic endoscopy because different facilities and/or equipment are needed. Also, fluoroscopic 30mm balloon dilations are associated with a 5 percent perforation rate. To address these shortcomings we present an experience with a retroflexed “against the scope” balloon dilation of the GEJ. In detail, the GEJ is visualized while retroflexed and a balloon is then placed through the scope. The GEJ is cannulated next to the scope and deployed. Please see the attached image for example.
METHODS AND PROCEDURES: A retrospective chart review was performed for a single surgeon during the past five years. We identified those who had retrograde dilations and evaluated the indications, repeat dilations, complications and symptomatic response.
RESULTS: A total of 24 retrograde dilations were performed on 15 patients with GEJ related dysphagia. The average age was 54.2 years. 17 of 24 dilations were with a 20mm balloon while other dilations used as small as a 14mm balloon. 19 dilations were performed for persistent dysphagia after cardiomyotomy between 57 and 5971 days after surgery. Other indications for dilation were dysphagia after fundoplication (3/24), dysphagia after paraesophageal hernia repair (1/24) and achalasia during pregnancy (1/24). 5 patients required a total of 9 repeat retrograde dilations at an average time of 488 days after previous dilation. There were 2 instances reported where the dilation did not improve symptoms. There was mucosal breakdown noted in 7 instances although there were no perforations. Bleeding was noted in 5 instances although this was always minimal and self-resolving.
CONCLUSIONS: Retrograde endoscopic dilation is safe and effective in this small series. The 20mm balloon against a 10mm scope gives a 30mm diameter, but a different shape and a decreased total circumference. There is a possible added safety advantage given that the balloon is inflated under visualization. It can be inflated in steps or stopped if it appears too aggressive. In addition these larger dilations were provided at the time of the initial diagnostic EGD without extra equipment. More studies are needed to compare retrograde endoscopic dilation to other methods of management of GEJ stenosis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86742
Program Number: P367
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster