Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

Abstract

Background & Aims: Little is known about esophageal dilation as a long-term treatment eosinophilic esophagitis (EoE). We examined the impact of a “dilate and wait” strategy on symptoms and safety of patients with EoE. Methods: This retrospective cohort study included two groups of EoE patients: those who underwent a dilation-predominant approach, defined as >3 dilations as EoE sole therapy or for histologically refractory disease (>15 eos/hpf); and those who had routine care, defined as <3 dilations or histologic response. Characteristics of the groups were compared and outcomes for the dilation-only group assessed. Results: Of 205 patients, 53 (26%) received the dilation-predominant strategy (n=408 dilations total), most commonly because of histologic treatment non-response (75%). These patients were younger (33 vs 41 yrs, p=0.003), had a narrower baseline esophageal diameter (9.8 vs 11.5mm, p=0.005), underwent more dilations (7.7 vs 3.4, p <0.001), but achieved a smaller final diameter (15.7 vs 16.7mm, p=0.01) compared to routine care. With this strategy, 30 patients (57%) had ongoing symptom improvement, with esophageal caliber change independently associated with symptom response (aOR 1.79; 95%CI 1.17-2.78); 26 (49%) used the strategy as a bridge to clinical trials. Over a median follow-up of 1001 days (IQR 581-1710), there were no deaths or dilation-related perforations, but there were 9 ER visits, including 1 for post-dilation bleeding and 4 for food impaction. Conclusions: A dilation-predominant long-term treatment strategy allows for symptom control or bridge to clinical trials for patients with difficult to treat EoE. Close follow-up and monitoring for complications is required.

Underrecognized Fibrostenotic Luminal Narrowing May Explain Dissociation Between Symptoms and Histology in Eosinophilic Esophagitis

“…Further supportive evidence for the role of strictures, rather than inflammatory activity, in generating symptoms includes the positive initial symptomatic response from dilation in patients where eosinophilic inflammation is left unchecked. 5,6 The findings of Safroneeva et al 1 are therefore supportive of the postulate that fibrostenotic luminal narrowing resultant from untreated eosinophilic inflammation, rather than the inflammation itself, is the predominant driver of symptoms in a proportion of patients with eosinophilic esophagitis. Although this is yet to be conclusively established, further research into the relationship between fibrostenosis (both endoscopically apparent and inapparent), dilation, and symptom burden in eosinophilic esophagitis will be invaluable, and has potential to change the treatment paradigm by expanding the role of dilation in these patients.…”

Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference

“…A dilationpredominant long-term treatment strategy can be considered for symptom control in patients with a persistently symptomatic refractory stricture or as a temporizing measure at the initial or continued implementation of medical therapy. [95][96][97][98] 11. The immediate endpoint of endoscopic dilation is the appearance of a mucosal disruption or reaching the target diameter.…”

“…However, multiple studies have addressed technique, target diameter, and overall outcome. [95][96][97][98] Potential factors that contribute to dilation success in EoE include predilation stricture diameter, location and extent of the fibrostenotic disease, presence of inflammation or fragility of the tissue, when moderate resistance is encountered during dilation, presence of blood on a dilator, and/ or visualization of mucosal disruption. The bougie method allows for tactile feedback so the endoscopist may gauge when initial and moderate resistance is encountered as an endpoint.…”

“…Data suggest that perforation risk in EoE patients is low. [95][96][97][98] Dougherty et al 96 found in a systematic review and meta-analysis of 2034 dilations in 977 EoE patients that the estimated perforation rate was .033% (range, 0%-.226%) per procedure (9 perforations in 2034 procedures). None resulted in surgical intervention or mortality.…”

Refractory eosinophilic esophagitis: what to do when the patient has not responded to proton pump inhibitors, steroids and diet

“…A systematic review and meta-analysis found 95% clinical improvement with dilation and low rates (<1%) of major complications [8]. Dilation is an option for managing fibrostenotic disease and can provide symptomatic relief for 15–17 months regardless of medical therapy [9,40 ▪ ,41]. Work from the Northwestern group in a group of patients with severe strictures (oesophageal lumen <10 mm) managed with serial dilations found that 89.4% of patients experienced improvement in oesophageal diameter to at least 13 mm and 65.2% to at least 15 mm.…”