| 12. Upper Gastrointestinal Dilation and Tubal Prosthesis Insertion |
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| n = number of cases where information was provided |
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METHODS OF DILATION, COMPLICATIONS AND DEATH
| Key points |
X-ray control was used in 63% of procedures that included a tubal prosthesis insertion.
Oesophageal perforation during or within 48 hours occurred in 2.8% of cases.
Death within 48 hours occurred in 0.7% of cases. |
Methods of dilation
| Table 72. Methods of dilation of the oesophagus
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| Method of dilation |
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Graduated bougie |
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Forced pneumatic balloon |
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Through the endoscope balloon |
|
Two methods used |
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| None |
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Sub-total |
|
Not answered |
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| Table 73. X-ray screening for the types of procedure
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| Type of procedure |
Yes |
No |
Sub-total |
Not answered |
Total |
Flexible endoscopic dilation |
569 |
1,458 |
2,027 |
190 |
2,217 |
Flexible endoscopic dilation followed by tubal prosthesis |
34 |
19 |
53 |
11 |
64 |
Flexible endoscopic insertion of tubal prosthesis |
320 |
153 |
473 |
23 |
496 |
Rigid endoscopic dilation |
36 |
82 |
118 |
30 |
148 |
Rigid endoscopic dilation followed by tubal prosthesis |
5 |
4 |
9 |
0 |
9 |
Endoscopic insertion of tubal prosthesis other than oesophagus |
6 |
3 |
9 |
2 |
11 |
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1,719 |
2,686 |
256 |
2,945 |
As seen in Table 73, X-ray screening was used in 29% (603/2,080) of flexible endoscopic dilation procedures and in 63% (354/526) of procedures that included insertion of a tubal prosthesis. BSG guidelines recommend that radiographic screening is helpful when the stricture is tortuous or complex or associated with a large hiatus hernia or diverticulae, and when difficulty is encountered passing the guidewire1. NCEPOD advisors consider X-ray control mandatory for dilation using a guidewire if the endoscope cannot be passed into the stomach, i.e. the guidewire cannot be placed under direct vision. X-ray control was thought
to be highly desirable for placement of a tubal prosthesis, and that not to use it is unwise. They also believe that X-ray control is not required for routine endoscopic oesophageal dilation if flexible tipped dilators are used.
Complications (back to top)
During the procedure 1.5% (45/2,945) of patients had one or more of the complications listed on the questionnaire (Table 74).
| Table 74. Complications during the procedure (answers may be multiple)
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| Complication |
Total
n = 45 |
Perforated oesophagus followed by surgery |
12 |
Perforated oesophagus followed by medical treatment |
18 |
Oesophageal haemorrhage |
10 |
Cardio-respiratory arrest |
1 |
Pulmonary aspiration |
1 |
Chest infection |
5 |
Sepsis |
2 |
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In the 48 hour period after the procedure 2.5% (73/2,945) of patients had one or more of the complications listed on the questionnaire (Table 75).
| Table 75. Complications within 48 hours after the procedure (answers may be multiple)
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| Complication |
Total
n = 73 |
Perforated oesophagus followed by surgery |
35 |
Perforated oesophagus followed by medical treatment |
18 |
Oesophageal haemorrhage |
4 |
Cardio-respiratory arrest |
3 |
Respiratory arrest |
3 |
Pulmonary aspiration |
4 |
| Chest infection |
6 |
Sepsis |
3 |
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The perforation rate for patients with malignant disease was 4.3% (45/1,052) and for benign disease 2% (35/1,784).
Table 76. Dilation methods and oesophageal perforation during or within 48 hours
of procedure
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| Dilation method |
Total |
Perforation |
None |
369 |
15 |
Graduated bougie |
1,362 |
27 |
Forced pneumatic balloon |
191 |
8 |
Through the endoscope balloon |
861 |
21 |
Two methods used |
9 |
0 |
Sub-total |
2,792 |
71 |
| Not answered |
153 |
10 |
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2,945 |
81 |
In this study, a total of 2.8% (81/2,945) of patients suffered oesophageal perforation in association with upper GI dilation and/or insertion of oesophageal tubal prosthesis during
or within 48 hours of the procedure (Table 76). There was a trend for oesophageal tubal prostheses without dilation and oesophageal dilation using a forced pneumatic balloon to be associated with a greater incidence of oesophageal perforation than the graduated bougie or through the endoscope method. The findings suggest that a larger national audit of specific techniques and equipment may be indicated.
Death (back to top)
Where the outcome was known, 0.7% (20/2,828) of patients died within 48 hours of the procedure (Table 77).
| Table 77. Dilation method and death
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| Dilation method |
Died |
Survived |
Unknown |
Sub-total |
Not answered |
Total |
None |
4 |
328 |
21 |
353 |
16 |
369 |
Graduated bougie |
11 |
1,227 |
74 |
1,312 |
50 |
1,362 |
Forced pneumatic balloon |
2 |
165 |
11 |
178 |
13 |
191 |
Through the endoscopic balloon |
2 |
801 |
28 |
831 |
30 |
861 |
Two methods used |
0 |
7 |
1 |
8 |
1 |
9 |
| Sub-total |
19 |
2,528 |
135 |
2,682 |
110 |
2,792 |
Not answered |
1 |
137 |
8 |
146 |
7 |
153 |
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2,665 |
143 |
2,828 |
117 |
2,945 |
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