Self dilation of esophageal strictures

Over 22 years, 26 patients were taught to dilate their esophageal strictures. Fifteen had peptic strictures, four malignant neoplasms, three achalasia, three dysphagia following fundoplication and one esophageal lichen planus. The patients with peptic strictures (mean age 58 years) did particularly well, repeatedly dilating themselves over an average of six years (range two months to 18 years). There were no serious complications. Self dilation is a safe, convenient and inexpensive way to manage patients who require repeated, frequent dilations for esophageal strictures.

A SMALL SUBGROUP OF PATIENTS with esophageal strictures will require repeated and frequent dilations (1-5).If they are not surgical candidates the authors' approach has been to teach such patients, if th ey are able and willing, to dilate themselves.The authors report a 22 year experience with this effective, inexpensive, convenient and safe form of treatment for selected patients with esophageal strictures.

PATIENTS AND METHODS
Between December 1968 and January 1990, 26 patients (17 male, nine female) ranging in age from 12 to 76 years were taught by SNS or W CW to dilate their own esophageal strictures.In April 1990, their c harts were reviewed and the patients followed up by questionnaire, either add ressed to themselves or to their next of kin.Twenty-two patients used blunted end mercury-weighted Hurst bougies ranging in size from 30 to 44 French { 15 used 40 to 44 French).Four used tapered Maloney bougies 36 to 52 French.T he frequency of dilation ranged from twice daily to once monthly, with most patients passing their bougie daily or weekly.Seven patients found the bougies difficu lt to use, and four were known to require the assistance of a family member.While learning, several had trouble with the technique, usually tipping the head too fa r back or not passing the bougie fully through the stricture.Two patients were intermittently noncompliant and redeveloped tight strictures requiring semirigid dilation over a guidewi re.One patient developed a monilial esophagitis.There were no serious complications.
Fifteen patients aged 22 to 78 years {mean 58) had peptic strictures.Eight have since died.T hey dilated themselves for one to 10 years.Of the seven still alive, one was a noncompliant alcoholic and the procedure was aba ndoned after fou r weeks; one dilated himself for two months until he had a Nissen fundoplication and intraoperative dilation; and another dilated herself for fou r years until age 73 when she had an esophagectomy because of deve lopment of carcinoma.One patient was lost to follow-up.
The other four patients, now aged 39, 71, 76 and78years,havebeendilating themselves for eight, two, five and five years, respectively.None have difficu lty passing the bougie or require• help.All a re satisfied with their swa llowing.
Three pati ents had c hronic dysphagia fo llowing Nissen fundopl ica ti o ns.In two, the dysphagia resolved complete ly after six weeks or ~ix mo nths o f sdf dilatio n.The other patient also has a peptic stric ture and has heen dilating himse lf every second d ay for two years.
Three patients aged 12, 70 a nd 76 yea rs haJ achalasia.The c hilJ di lated himself for several months a nd then had a myotomy.The 70-year-old, a man, was first seen in l 971.Because of concomitant illnesses he was unsuitahlc for su rgery or pneumatic dilation with a Brown-Md-lardy bag.He di lated himself daily with a 42 French Hurst bougie for three and one-half years.He eventually required a feeding cube.The other patient dilated herself once weekly fo r one year and was lost to fo l low-up in 1975.
O ne patient had a lo n g stric ture due co e ophageal liche n planus.S h e has heen dilating herself weekly for three and one-half years.S he maintains her nutrition but is very dissatisfied with the dilations because o f the d iscomfort involved.
Finally, four patients had malignant invas io n of the esophagus ( two gastric, REFERENCES

DISCUSSION
Most esophageal strictures are due to reflu x esophagitis.The majo rity can be managed by medical o r surgical antireflux measures and a short course of esophagea l d ilation.H owever, IO to 20% will require repeated and frequent dilations (l -5 ).The technique of self Jilarinn is easy to learn and has been well dcscrihed in a recent report from the Mayo C linic (6).S urprisi ngly, only two papers ( 6, 7) and one lette r to the editor ( 8) have dealt specifically with this topic , although it is men tioned briefly in a numberofo ther reports (2,9-12 ).The published experience comprises only 40 patients and is very like the present authors' experience.The maj ority o f patients have peptic strictures, arc in the ir 60s, and do no t want or a re no t suitable for surgery.Merc urywe ighted bo ugies, usually size 40 to 44 Frenc h a rc usecl.The frequency of di latio n rtmges fro m da ily to every month or two.Good to excellent relief of dysesophageal snicwre managed by bougienage.Dig Dis Sci l 982;27:884-8.phagia is obLai nccl by most pat icnts.The procedure is safe.T here are on ly two reports of pe rforntinn, one of which occurred after 30 years of uneventfu l self dilation with the more rigid EJer-Pucscow Jilaror~ ( 11, l 2).
In the early 1970s two of t he authors' patients with achalas ia and two with malignant st rictures were treated by self dilation.T hat 1~ not the authors' approach now.The fo rmer wou Id undergo pneumatic dilation with a Rigiflex achalasia di lator, and the latter would have laser ablat ion of rhc rumou r or placement of a Cclesrin tube.
While self dilation may not be the most pleasa n t prccedure, it is q uick, con venient, cost effective :mJ safe.lt takes only a few m inutes to perform; the patient docs not have to attend the hospita l; and the cost is o nly that of the bo ugie, which cu rrentl y is CDN$ 150 for a 4 2 French Hurst.If the patiem is properly instructed and observed and physician back up or adv ice is available by telephone o r in the clinic, self dilation should be re lati vely risk free.For these reasons the autho rs recommend that more patients be taugh t to dilate their own esophageal stric tures if they are not surgical candidates and requi re frequent d ila tion by a physician.