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UK Guidelines on Oesophageal Dilatation in Clinical Practice Guidelines UK guidelines on oesophageal dilatation in clinical practice Sarmed S Sami,1 Hasan, N Haboubi,2 Yeng Ang,3,4 Philip Boger,5 Pradeep Bhandari,6 John de Caestecker,7 Helen Griffiths,8 Rehan Haidry,9 Hans-Ulrich Laasch,10 Praful Patel,5 Stuart Paterson,11 Krish Ragunath,12 Peter Watson,13 Peter D Siersema,14 Stephen E Attwood15 ► Additional material is ABSTRACT 1.3 Obtain oesophageal biopsy specimens in published online only. To view These are updated guidelines which supersede the young patients with dysphagia or history please visit the journal online of food impaction to exclude eosinophilic (http:// dx. doi. org/ 10. 1136/ original version published in 2004. This work has gutjnl- 2017- 315414). been endorsed by the Clinical Services and Standards oesophagitis (GRADE of evidence: moder- Committee of the British Society of Gastroenterology ate; strength of recommendation: strong). For numbered affiliations see 1.4 Perform barium swallow in patients with end of article. (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone suspected complex strictures (such as Correspondence to extensive revision by the 16 members of the Guideline post-radiation therapy or history of Professor Stephen E Attwood, Development Group with representation from individuals caustic injury) in order to establish the Department of Surgery, Durham across all relevant disciplines, including the Heartburn location, length, diameter and number University, Durham DH13HP, UK; Cancer UK charity, a nursing representative and a of strictures (GRADE of evidence: low; seaattwood@ gmail. com patient representative. The methodological rigour and strength of recommendation: strong). Received 5 October 2017 transparency of the guideline development processes 2. Information and consent Revised 3 January 2018 were appraised using the revised Appraisal of Guidelines 2.1 Counsel all patients about the benefits and Accepted 14 January 2018 for Research and Evaluation (AGREE II) tool. risks of dilatation and the likely need for Dilatation of the oesophagus is a relatively high-risk multiple sessions before symptom resolu- intervention, and is required by an increasing range of tion can be achieved (GRADE of evidence: disease states. Moreover, there is scarcity of evidence in low; strength of recommendation: strong). the literature to guide clinicians on how to safely perform 2.2 Tailor information to the individual pa- this procedure. These guidelines deal specifically with the tient’s risk profile, based on the underly- dilatation procedure using balloon or bougie devices as a ing cause, location, length and diameter primary treatment strategy for non-malignant narrowing of the stricture and coexistent adverse of the oesophagus. The use of stents is outside the remit health problems (GRADE of evidence: of this paper; however, for cases of dilatation failure, low; strength of recommendation: strong). alternative techniques—including stents—will be listed. 2.3 Provide all patients with written informa- The guideline is divided into the following subheadings: tion on oesophageal dilatation before (1) patient preparation; (2) the dilatation procedure; the procedure and obtain written, signed (3) aftercare and (4) disease-specific considerations. consent. Inform patients about the perfo- A systematic literature search was performed. The ration risk and the potential need for en- Grading of Recommendations Assessment, Develop- doscopic or operative intervention should ment and Evaluation (GRADE) tool was used to evaluate a perforation occur (GRADE of evidence: the quality of evidence and decide on the strength of low; strength of recommendation: strong). recommendations made. 2.4 Inform patients— whenever appropriate— of any alternatives to dilatation, such as parenteral feeding or surgery in some cas- es (GRADE of evidence: low; strength of SUMMARY OF RECOMMENDATIONS recommendation: strong). Patient preparation 2.5 Do not perform oesophageal dilatation 1. Predilatation investigations in patients with active or incompletely 1.1 Obtain biopsy specimens from all strictures healed oesophageal perforation as it may for histological analysis to exclude ma- extend the oesophageal defect and pro- lignancy and eosinophilic oesophagitis mote mediastinal soiling (GRADE of ev- (GRADE of evidence: moderate; strength idence: low; strength of recommendation: of recommendation: strong). strong). 1.2 Repeat biopsy after cross-sectional imaging 2.6 Perform dilatation in patients with a re- (computed tomography (CT) or endo- cent, healed perforation; recent upper To cite: Sami SS, scopic ultrasound (EUS)) in cases where gastrointestinal surgery; pharyngeal or Haboubi H,N, Ang Y, et al. Gut Epub ahead of print: biopsies are negative, but clinical or endo- cervical deformity; or bleeding disorders [please include Day Month scopic features are atypical or suspicious after careful consideration of the benefits, Year]. doi:10.1136/ for malignancy (GRADE of evidence: low; risks and alternatives of the procedure gutjnl-2017-315414 strength of recommendation: strong). (GRADE of evidence: low; strength of rec- Sami SS, et al. Gut 2018;0:1–24. doi:10.1136/gutjnl-2017-315414 1 Guidelines ommendation: strong). 3.2 Consider using no more than three successively larger 3. Fasting diameter increments in a single session for both bou- 3.1 Advise patients to fast for at least 6 hours before the pro- gie and balloon dilators. The precise restriction of cedure in order to ensure emptying of the oesophagus 3×1 mm diameter increments is not evidence based and stomach. Patients with achalasia are likely to have (GRADE of evidence: low; strength of recommenda- oesophageal stasis and are therefore required to fast tion: low). for a longer time based on the clinician’s judgement 3.3 Use wire-guided (bougie or balloon) or endoscopically (GRADE of evidence: low; strength of recommenda- controlled (balloon) techniques for all patients to en- tion: strong). hance safety (GRADE of evidence: moderate; strength 4. Patient premedication of recommendation: strong). 4.1 Inform patients that dilatation is likely to be uncomfort- 3.4 Do not use weighted (Maloney) bougies with blind in- able, in particular, when push dilators are used rather sertion, because safer dilators are available (GRADE of than dilatation balloons (GRADE of evidence: low; evidence: high; strength of recommendation: strong). strength of recommendation: strong). 3.5 Perform dilatation without fluoroscopy for simple stric- 4.2 Offer patients intravenous sedation with a benzodiaze- tures as efficacy and safety have been shown in several pine and an opioid analgesic as a minimum. Propofol studies (GRADE of evidence: moderate; strength of rec- sedation (delivered by a suitably qualified person), or ommendation: strong). a general anaesthetic are valid alternatives based on 3.6 Use fluoroscopic guidance to enhance safety during the clinician’s and patient’s preference, procedure dilatation of strictures that are either high risk (such complexity as well as local availability and expertise as post-radiation and caustic); cannot be passed en- (GRADE of evidence: low; strength of recommenda- doscopically and are long; angulated; or multiple tion: strong). (GRADE of evidence: moderate; strength of recommen- dation: strong). 3.7 Perform repeat endoscopy or injection of contrast after The dilatation procedure dilatation in cases where perforation is suspected, to 1. Personnel, training and equipment consider immediate treatment with a fully covered 1.1 Oesophageal dilatation should be undertaken only by (or self-expanding metal stent (SEMS) (GRADE of evi- under direct supervision of) an experienced operator dence: low; strength of recommendation: strong). who performs sufficient numbers to maintain their 3.8 Use carbon dioxide insufflation instead of air during en- skills. The operator should be supported by at least doscopy whenever possible, in complex strictures to two assistants (one of whom must be a trained nurse) minimise luminal distension and postprocedural pain in the endoscopy/radiology room (GRADE of evi- (GRADE of evidence: high; strength of recommenda- dence: moderate; strength of recommendation: strong). tion: strong). 1.2 Ensure that trainees performing dilatation have adequate 3.9. Consider upper oesophageal sphincter dilatation in knowledge and understanding of the indications for, the treatment of dysphagia with disordered upper contraindications to, and complications of, this ther- oesophageal sphincter opening, post-cricoid web, apeutic procedure. An understanding of the steps cricopharyngeal bar with or without the presence of for recognition and management of complications is a Zenker’s diverticulum, or to permit passage of radi- required. Trainees should be familiar with different ofrequency ablation (RFA) catheters (GRADE of evi- dilatation techniques as well as alternative and com- dence: moderate; strength of recommendation: strong). plementary treatment options (GRADE of evidence: 4. Aftercare and follow-up moderate; strength of recommendation: strong). 4.1 Monitor patients for at least 2 hours in the recovery 1.3 Perform the procedure in a dedicated, fully equipped room and provide clear written instructions with ad- endoscopy room with access to X-ray screening and vice on fluids, diet and medications after the proce- surgical support, or a similarly equipped radiological dure (GRADE of evidence: moderate; strength of rec- suite (GRADE of evidence: moderate; strength of rec- ommendation:
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