**3. Treatment method for diseases with dysphagia**

A general approach to the treatment of adult patients with dysphagia caused by benign disorders of the distal esophagus is outlined in the "Medical Position Statement on Treatment of Patients with Dysphagia Caused by Benign Disorders of the Distal Esophagus" from the American Gastroenterological Association (AGA) [3]. The review describes the management of dysphagia, peptic stricture, lower esophageal mucosal rings, and achalasia. More recently, the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) updated its previous guideline. In sections covering the role of endoscopy in evalua‐ tion and management, the uses of endoscopy evaluating dysphagia and dilation techniques for various dysphagic diseases are discribed [1.3]. The endoscopic management of esophageal dysphagia is summarized in Table 1.

#### **3.1. Preparation and dilation technique**

Patients who have esophageal stasis because of underlying achalasia, diverticula, or tight strictures may require a prolonged nasogastric tube placement to minimize the risk of aspiration and are instructed to refrain from intake of solids for 6 hours and clear liquids for 2 hours before the procedure in the outpatient setting. The esophageal dilation procedure carries a high risk of adverse bleeding events. In patients considered low risk for thromboem‐ bolic events, oral anticoagulation with warfarin should be withheld for 5–7 days before the procedure. Bridging therapy with heparin before restarting warfarin is often recommended for patients at high risk for thromboembolic events. Thienopyridines (e.g., clopidogrel) are usually withheld for 7–10 days before the procedure.

Bougie dilators exert both radial and axial forces along the entire length of the stricture. In the technique of wire-guided bougie dilation, a guidewire is passed through the esophagus and its tip is positioned in the antrum.

Balloon dilators exert only a radial force along the length of the stricture. This circumferential pressure, called hoop stress, is a product of the diameter and pressure within the balloon.

#### **3.2. GERD: Peptic strictures**

Various methods for endoscopic management of peptic stricture were reported [25]. The AGA recommend progressive dilatation to 40–60 F using polyvinyl bougies or balloons for both simple (diameter<10 mm, not tortuous) and complicated (diameter >10 mm, tortuous) strictures, and mercury bougies for only simple strictures [3]. The ASGE reported that patients with peptic strictures may be treated with Maloney, push-type dilators and balloon dilators with similar efficacy. The degree of dilation in a session should be based on the severity of the stricture [1]. The first dilator that causes resistance to passage is counted as 1. The "rule of three" states that only two additional dilators of sequential size should be passed (three dilators in total). The "rule of three" for bougie dilation has been accepted but not formally studied for safety. The initial dilator is selected based on the stricture diameter. This is estimated to be about the same size as the lumen of the stricture, or not more than 1–2 mm larger than the lumen. Sequential dilation is then performed.

The AGA described the endoscopic therapy for GERD and concluded that radiofrequency ablation is generally effective for the treatment of GERD [26].

Endoscopic fundoplication is also successfully performed in many institutes [27]. Transoral incisionless fundoplication (TIF) with the EsophyX TM device is effective for creating a continent gastroesophageal valve and obtaining good functional results, as measured by pH impedance in patients with gastroesophageal reflux disease (GERD). TIF significantly im‐ proved both atypical and typical symptoms in patients: the corresponding GERD healthrelated quality of life (HRQL) and reflux symptom index (RSI) score was reduced by 50% or more compared to baseline on proton pump inhibitors (PPIs).

Several reports confirmed the beneficial effect of intralesionally administered corticosteroids or triamcinolone in benign esophageal strictures of different etiologies [6].

#### **3.3. Lower esophageal mucosal ring**

for various dysphagic diseases are discribed [1.3]. The endoscopic management of esophageal

Patients who have esophageal stasis because of underlying achalasia, diverticula, or tight strictures may require a prolonged nasogastric tube placement to minimize the risk of aspiration and are instructed to refrain from intake of solids for 6 hours and clear liquids for 2 hours before the procedure in the outpatient setting. The esophageal dilation procedure carries a high risk of adverse bleeding events. In patients considered low risk for thromboem‐ bolic events, oral anticoagulation with warfarin should be withheld for 5–7 days before the procedure. Bridging therapy with heparin before restarting warfarin is often recommended for patients at high risk for thromboembolic events. Thienopyridines (e.g., clopidogrel) are

Bougie dilators exert both radial and axial forces along the entire length of the stricture. In the technique of wire-guided bougie dilation, a guidewire is passed through the esophagus and

Balloon dilators exert only a radial force along the length of the stricture. This circumferential pressure, called hoop stress, is a product of the diameter and pressure within the balloon.

Various methods for endoscopic management of peptic stricture were reported [25]. The AGA recommend progressive dilatation to 40–60 F using polyvinyl bougies or balloons for both simple (diameter<10 mm, not tortuous) and complicated (diameter >10 mm, tortuous) strictures, and mercury bougies for only simple strictures [3]. The ASGE reported that patients with peptic strictures may be treated with Maloney, push-type dilators and balloon dilators with similar efficacy. The degree of dilation in a session should be based on the severity of the stricture [1]. The first dilator that causes resistance to passage is counted as 1. The "rule of three" states that only two additional dilators of sequential size should be passed (three dilators in total). The "rule of three" for bougie dilation has been accepted but not formally studied for safety. The initial dilator is selected based on the stricture diameter. This is estimated to be about the same size as the lumen of the stricture, or not more than 1–2 mm larger than the

The AGA described the endoscopic therapy for GERD and concluded that radiofrequency

Endoscopic fundoplication is also successfully performed in many institutes [27]. Transoral incisionless fundoplication (TIF) with the EsophyX TM device is effective for creating a continent gastroesophageal valve and obtaining good functional results, as measured by pH impedance in patients with gastroesophageal reflux disease (GERD). TIF significantly im‐ proved both atypical and typical symptoms in patients: the corresponding GERD healthrelated quality of life (HRQL) and reflux symptom index (RSI) score was reduced by 50% or

dysphagia is summarized in Table 1.

98 Seminars in Dysphagia

its tip is positioned in the antrum.

lumen. Sequential dilation is then performed.

ablation is generally effective for the treatment of GERD [26].

more compared to baseline on proton pump inhibitors (PPIs).

**3.2. GERD: Peptic strictures**

**3.1. Preparation and dilation technique**

usually withheld for 7–10 days before the procedure.

Large-bore endoscopic dilation or bougienage (15 mm/45 Fr or larger) is the mainstay therapy for both upper and lower esophageal lesions. The AGA recommends progressive dilatation to 45–60 F using mercury or polyvinyl bougies or balloons [3]. This procedure is frequently performed with either Savary or Maloney dilators, though balloon dilation has also been reported. The ASGE pointed out that dilation with a single large (16–20 mm) dilator leads to rupture of the Schatzki ring and symptomatic relief in almost all patients. Electrocautery incision with a needle-knife papillotome and four-quadrant biopsies of the ring has been performed together with dilation as adjunctive methods.

#### **3.4. Head and neck and esophageal tumors: extrinsic compression**

Bougie dilation and balloon dilation are both unavailable for malignant tumors of the esoph‐ agus and head and neck, as dilation is considered a high-risk procedure for adverse bleeding and perforation events. Endoscopic dilation is performed temporarily for nutritional support in patients who are to undergo tumor resections. Figure 3A,B showed the typical esophageal advanced cancer and endoscopic balloon dilation for its stricture.

(a) Esophageal advanced cancer (b) Pneumatic balloon dilation

**Figure 3.** Endoscopic balloon dilation for esophageal cancer

Self-expanding metal stents (SEMS) are a well-established palliation modality for dysphagia in patients with tumors of the esophagus and head and neck [28]. Stenting is also temporarily effective for extrinsic compression. Health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic or palliative intervention.

#### **3.5. Eosinophilic esophagitis and infection**

Pharmacological, endoscopic, and dietary interventions are used as treatment modalities for patients with eosinophilic esophagitis (EE), either singly or in combination.

For endoscopic dilatation, the balloon is positioned across the gastro-esophageal junction and inflated to the smallest diameter. The endoscopist grasps the catheter to assess the tension during pull through and then slowly withdraws the endoscope to the proximal esophagus. The procedure is repeated using a sequentially larger diameter balloon until adequate dilation is achieved [3,14].

#### **3.6. Postradiation stricture**

Several sessions of bougie dilation may be necessary for adequate treatment for radiationinduced strictures because most strictures are complex. The ASGE report summarizes a combined antegrade–retrograde rendezvous approach described in case reports and case series for the management of severe radiation-induced strictures with complete occlusion of the proximal esophagus. After dilation, the endoscopist performing this technique passes a standard endoscope or small-caliber endoscope through the stomach into the esophagus via an existing gastrostromy tract.

### **3.7. Achalasia**

Esophageal dilation for achalasia involves forceful disruption of the lower esophageal sphincter. This is usually accomplished with 30- to 40-mm-diameter pneumatic balloon dilators. Dilation is generally performed over a wire under fluoroscopic guidance, although nonfluoroscopically guided dilation using endoscopic visualization alone has been reported.

POEM is a new endoscopic procedure used for the treatment of achalasia [29]. This novel endoscopic esophagomyotomy method was first reported by Pasricha et al. in porcine models and then by Inoue et al. in humans. POEM is performed by dissection and division of the inner circular muscle layer of the esophagus through a submucosal tunnel created endoscopically by a small proximal opening of the esophageal mucosa. A study evaluating the role of POEM reported a significant improvement in dysphagia scores.

A further option is endoscopic botulinum toxin injection into the lower esophageal sphincter. This technique offers good short-term results.

Ham et al. identified the currently available biodegradable stents for benign esophageal strictures [30]. This technique will also be available for the treatment of achalasia.

#### **3.8. Postesophagectomy anastomotic strictures**

Anastomotic strictures have been reported in 9–48% of patients after esophagectomy for esophageal cancer. The strictures are diagnosed in patients with dysphagia in whom a standard flexible esophagoscope cannot be passed across the anastomosis. Both bougie and balloon dilation have been used for the treatment of anastomotic strictures with success rates of up to 93%. In Figure 4A,B showed the typical anastomotic stricture and endoscopic balloon dilation for it. There is a high recurrence rate, however, and patients often require frequent sessions.

(a) Anastomotic stricture (b) Pneumatic balloon dilation

**Figure 4.** Endoscopic balloon dilation for Anastomotic stricture
