Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture

BackgroundIndeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures.MethodsThe international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement.ResultsNine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties.ConclusionEvidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.     

PERORAL CHOLANGIOSCOPY: AN IMPROVED PROCEDURE

Cholangioscopy provides direct visual assessment of the bile ducts, tissue sampling, and therapeutic interventions. Delineation of intraductal lesions equivocal with direct cholangiography, differentiation between malignant and benign biliary strictures, and assessment of longitudinal extent of cholangiocarcinoma are major indicators for diagnostic cholangioscopy. Peroral cholangioscopy is readily performed at an initial endoscopic retrograde cholangiopancreatography. Owing to substantial refinement in terms of image quality and technical feasibility achieved with the development of a new video cholangioscope, peroral cholangioscopy has become a powerful tool. However, compared with percutaneous cholangioscopy, there remain several disadvantages in peroral cholangioscopy: less favorable maneuverability, small instrumental channel, and limited therapeutic instrumentations. With further advances in endoscopic functions and increasing availability of suitable instruments, peroral cholangioscopy, because of its less invasiveness, will become mandatory for diagnostic and therapeutic biliary endoscopy.     

Endoscopic retrograde cholangiopancreatography: Current practice and future research

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.     

经口胆道镜的临床诊疗进展

自20世纪70年代以来,经口胆道镜的问世实现了对胆道内病变的直视观察,解决了在对胆道不明原因狭窄的诊断以及胆道困难结石的治疗等临床难题,成为了继ERCP之后胰胆管疾病诊治的重要手段。经口胆道镜系统已由最开始的相对笨拙的双人操作胆道子母镜系统,发展为单人操作的胆道镜系统,以上消化道超细内镜和SpyGlass系统为代表,它们在在高质量的图像及胆道内活检及碎石等操作中更具优势。临床使用时应根据不同胆道镜系统的特点来选取合适的机型。     

Biliary interventions using single‐operator cholangioscopy

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single‐operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single‐operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single‐operator cholangioscopy techniques in the diagnosis and management of biliary disorders.     

Prospective evaluation of the short access cholangioscopy for stone clearance and evaluation of indeterminate strictures

BACKGROUND:Peroral cholangioscopy facilitates diagnosis and therapy of biliary disorders.This study prospectively evaluated a new short access cholangioscopy.METHODS:Consecutive patients were included as follows:difficult stones (group 1) underwent cholangioscopy with electrohydraulic lithotripsy and indeterminate biliary strictures (group 2) were evaluated with macroscopic assessment and cholangioscopy guided biopsy sampling.We evaluated the complete stone clearance rate (group 1) and diagnostic accuracy (group 2).Follow-up was performed over a median of 13 and 16 months,respectively.RESULTS:Group 1 (n=21):complete stone clearance defined as lack of stones in cholangiography and stone removal during cholangioscopy was achieved in 15 (71.4％) patients.Clinical stone clearance defined as lack of symptoms,laboratory abnormalities and hospital visits during follow-up,irrespective of stone clearance was evident in 17 (81.0％) patients.One serious adverse event occurred (bile duct perforation).Group 2 (n=28):malignancy was confirmed in 15 patients.Sensitivity,specificity and diagnostic accuracy of cholangioscopy were 85.7％,75.0％ and 80.7％,respectively.Sensitivity,specificity and diagnostic accuracy of biopsies were 54.5％,100.0％ and 72.2％,respectively.No serious adverse events occurred,and one patient was lost to follow-up.CONCLUSIONS:The novel system enabled complex stone treatment and biliary stricture diagnosis.Cholangioscopy outperformed direct biopsy regarding characterization of indeterminate strictures.     

Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology.

BACKGROUND & AIMS: We report the usefulness of cholangioscopy in patients with indeterminate pancreaticobiliary pathology. METHODS: A prospective collection of 62 consecutive patients during a period of 2.5 years who were referred to our tertiary referral center for cholangioscopy for indeterminate strictures suspicious for malignancy were included. Tissue sampling followed cholangioscopic visualization. Biopsies were obtained under direct visualization (cholangioscopy-directed) or through the duodenoscope (cholangioscopy-assisted). RESULTS: Sixty-two patients had 72 examinations. Forty patients had nondiagnostic sampling before cholangioscopy. Indications were stricture (n = 67: 16 primary sclerosing cholangitis, 51 non-primary sclerosing cholangitis), ductal dilation, or intraductal mass (n = 5). Biopsies were not performed in 19 because cholangioscopy did not identify suspicious lesions. Of the remaining 53 procedures, 29 underwent either cholangioscopy-directed or cholangioscopy-assisted biopsy, and 24 had both. Cholangioscopy findings consisted of primary sclerosing cholangitis only (n = 18), benign stricture or inflammatory changes (n = 18), bile duct cancer (n = 14), normal (n = 10), pancreatic cancer (n = 5), and other (n = 7). Fifty-eight patients (94%) had follow-up for a mean of 12.4 months (95% confidence interval, 10.1-14.7). Sixteen of 18 (89%) patients with a final diagnosis of malignancy were detected with cholangioscopy. The 2 missed cancers were intrahepatic cholangiocarcinomas. Overall, sensitivity to detect malignancy by cholangioscopy with and without biopsy was 89%, specificity 96%, positive predictive value 89%, and negative predictive value 96%. CONCLUSIONS: Cholangioscopy with and without biopsy is highly accurate in diagnosing and excluding pancreaticobiliary malignancy in patients with indeterminate strictures.     

Prospective study of biliary strictures to determine the predictors of malignancy.

BACKGROUND: There have been few prospective studies regarding the investigation of biliary strictures, principally because of rapid technological change. The present study was designed to determine the sensitivity of various imaging studies for the detection of biliary strictures. Serum biochemistry and imaging studies were evaluated for their role in distinguishing benign from malignant strictures. METHODS: Thirty-one patients with suspected noncalculus biliary obstruction were enrolled consecutively in the study. A complete biochemical profile, ultrasound, Disida scan and cholangiogram (endoscopic retrograde cholangiopancreatography [ERCP] or percutaneous cholangiogram) were obtained at study entry. Stricture etiology was determined based on cytology, biopsy and/or clinical follow-up at one year. RESULTS: Twenty-nine of 31 patients had biliary strictures, of which 15 were malignant. The mean age of the malignant cohort was 73.9 years versus 53.9 years in the benign cohort (P<0.001). Statistically significant differences between the malignant and benign groups, respectively, were as follows: alanine transaminase 235.2 versus 66.9 U/L (P=0.004), aspartate transaminase 189.8 versus 84.5 U/L (P=0.011), alkaline phosphatase 840.2 versus 361.1 U/L (P=0.002), bilirubin 317.8 versus 22.1 micromol/L (P<0. 001) and bile acids 242.5 versus 73.2 micromol/L (P=0.001). Threshold analysis using receiver operative characteristic (ROC) curves demonstrated that a bilirubin level of 75 micromol/L was most predictive of malignant strictures. Intrahepatic duct dilation was present in 93% of malignant strictures versus 36% of benign strictures (P=0.002). Common hepatic duct dilation was less discriminatory (malignant 13.5 versus benign 9.6 mm; P=0.11). Ultrasound was highly sensitive (93%) in the detection of the primary tumour in the bile duct or pancreas, or in the visualization of nodal or liver metastases. In benign disease, ultrasound failed to detect evidence of intrahepatic or extrahepatic biliary dilation in most cases. Disida scans were not able to distinguish between malignant or benign strictures and could not accurately localize the level of obstruction. The sensitivity of Disida scan for the diagnosis of obstruction was 50%. Cholangiographic characterization of strictures revealed an equal distribution of smooth (eight of 13) and irregular (five of 13) strictures in the malignant group. Ten of 13 benign strictures were characterized as smooth. Malignant strictures were significantly longer than benign ones - 30.3 versus 9.2 mm (P=0.001). Threshold analysis using ROC curves showed that strictures greater than or equal to 14 mm were predictive of malignancy (sensitivity 78%, specificity 75%, log odds ratio 11.23). CONCLUSIONS: A serum bilirubin level of 75 micromol/L or higher, or a stricture length of greater than 14 mm was highly predictive of malignancy in patients with a biliary stricture. Ultrasound was useful in predicting malignant strictures by detecting either intrahepatic duct dilation or by visualizing the tumour (primary or metastases). Strictures with a 'benign' cholangiographic appearance are frequently malignant. Disida scan did not add additional information. ERCP is necessary to diagnose benign strictures, which tend to be less extensive at presentation.     

Adenocarcinoma arising from a strictureplasty site in Crohn's disease

The occurrence of small-bowel cancer in Crohn's disease (CD) is a rare event. The risk seems to be greatest in patients with long-standing disease. Strictureplasty has proved to be a valuable alternative in the management of Crohn's strictures of the small-bowel. Critics and proponents of strictureplasty for selected patients with smallbowel Crohn's disease have voiced their concerns about cancer risk in the strictured or strictureplasty site. To date, there has been no clear or detailed report of such an occurrence. The authors report the first case of small-bowel adenocarcinoma arising at the site of a previous strictureplasty. In this patient, biopsies of the strictures at the original operation confirmed CD and excluded both cancer and dysplasia. Malignancy occurred seven years later at a strictureplasty site. The main clinical sign associated with the adenocarcinoma was severe, persistent anemia. The authors conclude that the risk of adenocarcinoma developing at the site of a previous strictureplasty for CD, although small, is real.     

Balloon or bougie for dilatation of benign oesophageal stricture? An interim report of a randomised controlled trial.

Seventy one patients with benign oesophageal strictures were randomised to receive balloon or bougie dilatation. Sixty five patients were eligible for analysis. At the end of five months the balloon group had significantly more dysphagia and the calibre of the strictures in the balloon group had narrowed by a greater degree. The methods were equally safe and acceptable to patients. While the choice of the method of dilatation depends on the individual patient's needs and operator experience, bougie dilatation is more effective in reducing dysphagia and maintaining stricture patency.     

Endoscopic therapy of benign biliary strictures

Benign biliary strictures result from many etiologies, including postoperative injuries, anastomotic strictures, and chronic pancreatitis. Therapy is generally required to relieve symptoms of cholestasis or cholangitis and prevent secondary cirrhosis. Surgery has been the traditional method for treatment of benign biliary strictures but is associated with significant morbidity and variable long-term outcomes. More research is needed to define the best methods and materials for various patient populations. Endoscopic management, including stricture dilation and stent placement, is more appealing because it is less invasive and better tolerated, but repeated treatments are required. Outcomes of endoscopic management depend on both the etiology and the location of the stricture. Accumulating data suggest that long-term success is substantially greater when multiple rather than single plastic stents are placed. Uncovered metallic stents are problematic and generally not recommended. Emerging alternatives to plastic stents include the placement of removable covered metallic stents.     

Endoscopic management of Crohn's strictures

Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease(CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation(EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.     

Management of Acid- and Alkali-Induced Esophageal Strictures in 79 Adults by Endoscopic Dilation: 8-Years’ Experience in New Delhi

Experience with endoscopic dilation of acid- and alkali-induced strictures of the esophagus using Savary-Gilliard (SG) and balloon dilators is limited, especially in adults. The aim of this study was to determine the safety and efficacy of endoscopic dilation in the management of corrosive esophageal strictures and to compare results with regard to acid- vs. alkali-induced strictures. The records of 230 patients who were treated by endoscopic dilation between 1997 and 2005 at our center were reviewed. This study included all the patients who had corrosive-induced esophageal strictures. SG dilators were used in most of our patients [67/79 (85%)], while only a few patients [12/79 (15%)] were treated with balloon dilators. Dilation was found to be successful after an initial course of dilation (not requiring further dilations) in 28/37 (75.67%) cases in the SG dilator group and in 9/12 (75%) in the balloon group. Strictures caused by acids required a greater mean number of dilations for initial relief of dysphagia compared with that for alkalis. Some of these patients responded to a second course of dilation, leading to final combined SG dilator and balloon dilator success rates of 24/28 (86%) in the acid group and 17/21 (81%) in the alkali group. A total of 359 sessions of dilations were performed with a complication rate of 2/359 (0.56%). Endoscopic dilation using Savary-Gilliard and balloon dilators is safe and effective in managing corrosive esophageal strictures, but it is operator-dependent and the final outcome depends largely on the technical expertise and appropriate selection of patients.     

Reduced Sensitivity to Intra-Oesophageal Acid in Patients with Reflux-Induced Strictures

Patients presenting with benign reflux-induced oesophageal strictures often have no antecedent symptoms of reflux, which might be a consequence of decreased oesophageal sensitivity. This has been investigated in 36 patients with strictures and 30 patients with uncomplicated oesophagitis by means of a visual analogue scale (0 to 10) to assess preceding symptoms and acid perfusion tests to assess oesophageal sensitivity. Patients with strictures had lower symptom scores (median, 2.7) than those with uncomplicated oesophagitis (median, 4.85) and were more likely to have a negative acid perfusion test (18 of 28 compared with 6 of 23, respectively; p <0.05). Furthermore, the volumes of acid perfused at the onset of symptoms in the stricture group (median, 80 ml) were greater than in the oesophagitis group (median, 40; p < 0.05). These results support the hypothesis that patients who develop reflux-induced strictures have decreased sensitivity to intra-oesophageal acid. This may be a factor in the pathogenesis of reflux-induced strictures.     

Endoscopic management of biliary strictures after liver transplantation

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation （OLT）. Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Nonanastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. Thisreview focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.     

Endoscopic management of biliary strictures after liver transplantation

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Nonanastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.     

Endoscopic balloon dilation for management of stricturing Crohn's disease in children

BACKGROUND Crohn's disease(CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation(EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODS In a single-center retrospective study, we looked at pediatric patients(ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients' strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.RESULTS Of the 139 patients with CD, 25(18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients(48%) and EBD in 13 patients(52%). However, 4(33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients(68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients(50%) had a fistula present near the stricture site and 4(50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two(88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.     

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.     

Esophageal Dilation: Personal Experience with Current Instruments and Techniques

The popularity and widespread use of flexible panendoscopy has produced a dramatic change in the management of benign strictures of the esophagus. Most are now managed medically. Two new esophageal dilators, the balloon and Savary, have made a major impact on the endoscopist's armamentarium. The Maloney dilator is still used 56% of the time, in the author's experience with strictures that are symmetrical and greater than 1.2-1.4 cm in diameter. Hydrostatic balloon dilators are used 24% of the time with strictures that are asymmetrical and 1.2 cm or more in diameter. The Savary thermoplastic dilators have replaced Eder-Puestow dilators and are used 20% of the time in strictures 1.2 cm or less in diameter. Morbidity and mortality rates should be under 1% with all dilators and are 0.1% and 0.05%, respectively, in the author's last 2000 dilations.     

NSAIDs, aspirin, and esophageal strictures: are over-the-counter medications harmful to the esophagus?

There are several studies that suggest that aspirin (acetylsalicylic acid [ASA]) and nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with esophagitis or esophageal stricture formation. There are limited data on the potential of low-dose ASA and over-the-counter (OTC) NSAIDs to cause esophageal injury. The goal of this study was to determine whether there is an association between esophageal strictures and ASA/NSAID use, including low-dose ASA and OTC NSAIDs. A total of 79 consecutive patients (mean age, 52.8 years; 38 men, 41 women) referred for endoscopy from 4/1/96 to 11/15/96 for chronic gastroesophageal reflux disease symptoms were evaluated. Data collected include gender, race, and age, NSAID or ASA use, as well as an assessment of dysphagia, heartburn duration, and heartburn frequency. Patients taking NSAIDs or ASA at least twice a week were considered ASA/NSAID users. There were 46 patients without strictures and 33 patients with peptic strictures. Patients with strictures were older than patients without strictures (mean age, 58.7 versus 48.6 years; p < 0.01), had longer duration of heartburn symptoms (8.6 versus 6.4 years, p < 0.05), and were more likely to have mucosal injury (50% versus 26.1%). Stricture patients were more likely to use ASA/NSAIDs (63.6% versus 26.1%; p < 0.01). In particular, stricture patients were more likely to use low-dose ASA than patients without strictures (30.3% versus 2.2%; p < 0.01). Otherwise, there were no significant differences with regard to gender, race, or heartburn duration or frequency. Linear regression analysis showed that ASA/NSAID use had a greater influence on the incidence of peptic strictures than age. There is an association between esophageal stricture and ASA/NSAID use, which includes OTC NSAIDs and low-dose ASA.