Safe and Proper Management of Esophageal Stricture Using Endoscopic Esophageal Dilation

Treatment of esophageal stricture is important because esophageal stricture reduces the quality of life of patients by increasing their risks of dysphagia, weight loss, nutritional imbalance, and pneumonia due to aspiration. Esophageal stricture is mainly classified as benign or malignant esophageal stricture, and may occur as fibrous production and collagen deposition due to chronic ulceration or chronic inflammation or as complications after chemotherapy, radiotherapy, and surgery such as esophagectomy, or endoscopic procedures such as endoscopic mucosal resection and endoscopic submucosal dissection for the treatment of esophageal cancer. Esophageal stricture caused by active peptic ulcer or gastroesophageal reflux can be treated with drugs such as proton pump inhibitors, which inhibit gastric acid secretion. However, esophageal dilation has been used as the first-choice treatment modality for esophageal stricture without acute inflammatory response. Esophageal dilation generally involves esophageal bougination, balloon dilation, and stent insertion. Among these, endoscopic balloon dilation using a through-the-scope balloon is widely used as an important treatment approach for esophageal stricture owing to its lower complication rates than other methods. Endoscopic balloon dilation can be operated under direct endoscopy, and the risk of perforation is lower than that with esophageal bougination because the force is not applied to the longitudinal axis of the stricture zone and the radial pressure is applied completely. Moreover, the possibility of pressure or damage to the pharynx and larynx is also relatively low. However, in the case of malignant esophageal stricture, esophageal bougination or balloon dilation can provide a short-term symptom improvement and is usually used as an auxiliary procedure prior to stenting or photodynamic therapy. In this issue of Clinical Endoscopy, Goyal et al. retrospectively analyzed the health-care utilization of endoscopic dilation for the treatment of esophageal strictures in the inpatient setting, and defined the rate of complications and outcomes of this procedure by using data from the National Inpatient Sample (NIS) database. They analyzed 591,187 hospitalizations involving esophageal stricture that occurred between 2007 and 2013, and endoscopic dilation was performed in 29% of esophageal stricture cases. Compared with the benign stricture group, the malignant stricture group had more frequent utilization, longer hospital stays, higher in-hospital mortality rate, and higher incidence of esophageal perforation. Although they already mentioned some limitations in the Discussion section, they presented evidence-based conclusions by analyzing data from the NIS database. In a previous large-scale study, the major complications reReceived: June 20, 2017 Revised: July 18, 2017 Accepted: July 18, 2017 Correspondence: Jae Jin Hwang Department of Internal Medicine, Digestive Disease Center and Research Institute, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea Tel: +82-32-621-5212, Fax: +82-32-621-5080, E-mail: [email protected]