Esophageal dilation GUIDELINE INTRODUCTION EOSINOPHILIC ESOPHAGITIS INDICATIONS FOR DILATION

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1 GUIDELINE Esophageal ilation This is one of a series of statements iscussing the use of gastrointestinal enoscopy in common clinical situations. The Stanars of Practice Committee of the American Society for Gastrointestinal Enoscopy prepare this text. In preparing this guieline, a MEDLINE literature search was performe, an aitional references were obtaine from the bibliographies of the ientifie articles an from recommenations of expert consultants. When little or no ata exist from well-esigne prospective trials, emphasis is given to results from large series an reports from recognize experts. Guielines for appropriate use of enoscopy are base on a critical review of the available ata an expert consensus. Further controlle clinical stuies are neee to clarify aspects of this statement, an revision may be necessary as new ata appear. Clinical consieration may justify a course of action at variance to these recommenations. INTRODUCTION The purpose of this upate guieline is to provie practical recommenations regaring the inications an techniques for the use of esophageal ilation. Esophageal ilation (EGD) is performe for treatment of ocumente anatomic, an sometimes functional, narrowing of the esophagus cause by a variety of benign an malignant conitions. 1 The formation of benign strictures of the esophagus is believe to be cause by the prouction of fibrous tissue an eposition of collagen stimulate by eep esophageal ulceration or chronic inflammation. 1 The most common form of an esophageal stricture, a peptic stricture, is a sequela of reflux esophagitis. In the recent past, nearly 80% of strictures were ue to gastroesophageal reflux, 2 although this may be ecreasing with the wiesprea use of proton pump inhibitors (PPIs). Other common benign causes inclue Schatzki s ring, raiation therapy, congenital strictures, caustic ingestion, an anastomotic strictures. Less common causes of benign esophageal strictures inclue those following enoscopic therapy of varices, photoynamic therapy (PDT), 1 reaction to a foreign boy or pill, infectious esophagitis, an Copyright ª 2006 by the American Society for Gastrointestinal Enoscopy /$32.00 oi: /j.gie eosinophilic esophagitis (Table 1). Narrowing of the esophagus from malignancy may result either from intrinsic luminal tumor growth or from extrinsic esophageal compression. During the enoscopic evaluation of an esophageal stricture, biopsy specimens shoul be taken to exclue malignancy when this iagnosis is suspecte on the basis of clinical presentation or enoscopic appearance. In young patients with ysphagia with or without enoscopic abnormalities, especially with a history of foo impaction, miesophageal biopsy specimens shoul be obtaine to exclue eosinophilic esophagitis. 3 Enoscopic esophageal biopsy samples can be safely obtaine before esophageal ilation. 4 Patients with an esophageal stricture characteristically have ysphagia to solis an generally have no ifficulty swallowing liquis, in contrast to those with an esophageal motility isorer in which liqui an soli ysphagia occurs. 1 Symptoms in the latter group of patients are generally not improve with esophageal ilation, with achalasia being the most notable exception. EOSINOPHILIC ESOPHAGITIS Eosinophilic esophagitis eserves special mention because it is becoming increasingly common, 5 there is available therapy in aition to ilation, 6 there are recognizable enoscopic 7-9 an histologic features, 10 an there appears to be an increase risk for mucosal tearing uring enoscopy. 11 The latter may translate into an increase risk perforation uring ilation. 12 Eosinophilic esophagitis is common in young patients with otherwise unexplaine ysphagia. A clinical presentation of foo impaction is not uncommon. 13 INDICATIONS FOR DILATION The primary inication for esophageal ilation is to relieve ysphagia. Cost analysis evaluations have suggeste that initial EGD with therapeutic intent is less costly than a barium swallow in patients with a history suggesting esophageal obstruction. 14 Aitionally, early enoscopy shoul be the initial iagnostic test performe in patients with ysphagia who are R40 years ol an those with concomitant heartburn, oynophagia, or weight loss because of the high yiel of fining significant pathology in these patients Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 755

2 Esophageal ilation TABLE 1. Common causes of esophageal strictures/ obstruction Gastroesophageal reflux isease (peptic) Schatzki s ring Esophageal cancer Raiation therapy Esophageal surgery Eosinophilic esophagitis Sclerotherapy Caustic injury PDT Esophageal strictures can be structurally categorize into two groups: simple an complex. 16 Simple strictures are symmetric or concentric with a iameter of R12 mm or easily allow passage of a iagnostic upper enoscope. Complex strictures have one or more of the following features: asymmetry, iameter %12 mm or inability to pass an enoscope. Regarless of the cause, ysphagia is an inication for ilation of benign strictures. 1 Although some enoscopists suggest that large-bore ilators be passe empirically if the enoscopy has normal results, 3 results from two of three stuies have shown that empiric ilation oes not improve ysphagia scores. Thus, because of the potential risk of perforation with use of large-bore ilators, particularly in patients with unrecognize eosinophilic esophagitis, 12 empiric ilation cannot be routinely recommene if no structural abnormalities are seen at enoscopy. Most ata regaring management of esophageal strictures have been gathere in the ault population. The safety an efficacy of esophageal ilation in chilren has also been confirme. 20,21 Enoscopic ilation of malignant strictures can be one to assist the completion of enoscopic proceures such as enoscopic ultrasonographic tumor staging 22,23 or to ai the placement of an esophageal stent to achieve temporary palliation. 24 Most malignant strictures respon to ilation, but relief of ysphagia is transient an more efinitive treatment is usually neee. The ysphagia cause by malignant extrinsic compression of the esophagus respons poorly to esophageal ilation. DILATOR TYPES Three general types of ilators are currently in use. These are (1) mercury or tungsten-fille bougies (Maloney or Hurst), (2) wire-guie polyvinyl ilators (Savary- Gilliar or American), an (3) TTS ( through-the-scope ) balloon ilators. The Maloney type bougies have a tapere tip an can be passe either blinly 25 or uner fluoroscopic control. Fluoroscopy may lea to better functional results an fewer averse events. 26 This type of ilator is use for simple strictures with a iameter of 12 to 14 mm. The risk of esophageal perforation may be higher with blin passage of Maloney ilators than with Savary or TTS balloons, particularly in patients with a large hiatal hernia, a tortuous esophagus, or those with complex strictures. 16 Savary an American ilators are passe over a guiewire that has been positione with the tip in the gastric antrum, with or without fluoroscopic guiance. 27 There are a variety of available TTS balloon ilators available in either single or multiple iameters that may be passe with or without wire guiance. A new enoscopically guie bougie has recently become available (InScope) but clinical experience with it is limite. PREPARATION Anticoagulants shoul be iscontinue. 28 Routine antibiotic coverage is not recommene; enocaritis prophylaxis guielines shoul be followe. 29 During the informe consent process, patients shoul be informe about the risk of perforation an the possible nee for surgery shoul it occur. Esophageal ilation is routinely performe in an outpatient setting. Patients shoul fast for 4 to 6 hours before the proceure. Patients with achalasia are susceptible to esophageal stasis an a prolonge fast or esophageal lavage may be require to empty the esophagus. Although some patients may tolerate ilation with use of only topical anesthesia, conscious seation is generally use. 30 When bougie ilators are use, neck extension may facilitate passage of the ilator. TECHNIQUES The egree of ilation within a session shoul be base on the severity of the stricture. A conservative approach to ilation may reuce the risk of perforation. The rule of 3 has been accepte an applie to bougie ilation of esophageal strictures. 31 Specifically, the initial ilator chosen shoul be base on the known or estimate stricture iameter. Serial increases in iameter are then performe. After moerate resistance is encountere with the bougietype ilator, no greater than 3 consecutive ilators in increments of 1 mm shoul be passe in a single session. Although this rule oes not apply to balloon ilators, a recent stuy suggeste that inflation of a single largeiameter ilator (O15 mm) or incremental ilation of greater than 3 mm may be safe in simple esophageal strictures. 32 There are no ata on the optimal uration the balloon shoul remain inflate. Dilation therapy for symptomatic Schatzki s ring is irecte towar achieving rupture of the ring; therefore, larger caliber ilators (16-20 mm) may be neee. 33 If a lower esophageal ring 756 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 6 :

3 Esophageal ilation cannot be istinguishe from a short peptic stricture, grae stepwise ilation is recommene. During esophageal ilation the enoscopist shoul be supporte by assistants who are familiar with the enoscopic an ilating evices consiere for use an are capable of monitoring patient comfort an safety throughout the examination. Patients shoul be closely observe after esophageal ilation, with pulse, bloo pressure, an temperature measure regularly etect complications. Steroi injection into benign strictures immeiately before or after ilation has been avocate to improve outcomes by ecreasing the nee for repeat ilation in strictures that have not respone to initial ilation. Most of the publishe stuies to ate have been small, nonranomize, an uncontrolle. 34,35 Aitionally, not all causes of stricture respon similarly to steroi injection. A recent ranomize trial of intralesional steroi injection with PPI therapy versus sham injection with PPI therapy in patients with recalcitrant peptic esophageal strictures showe that the nee for repeat ilation was significantly iminishe in the steroi group. 36 RESULTS Regarless of the specific metho of ilation, early improvement in the ability to swallow is achieve in virtually all patients; however, longer-term outcomes are influence by the unerlying pathologic conition. If a luminal iameter of at least 13 to 15 mm can be achieve, nearly all patients will be relieve of ysphagia. In patients with benign peptic strictures, a grae stepwise ilating approach between 13 an 20 mm yiels relief in 85% to 93%. 4 Bougie-type ilators exert not only raial forces as they are passe but also longituinal forces as the result of a shearing effect. 37 Longituinal forces are not transmitte with balloon ilators because the entire ilating force is elivere raially an simultaneously over the entire length of the stenosis rather than progressively from its proximal to istal extent. 37 Despite these ifferences, no clear avantage has been emonstrate between the two ilator types Factors associate with a poor response to balloon ilation of benign strictures are a length of O8 cm an a small preilation luminal iameter. 41 In patients with benign peptic strictures, the long-term benefits of ilation appear greatest when a luminal iameter of greater than 12 mm is achieve. 42 Several clinical features are associate with outcome. For peptic strictures, smaller lumen iameter, presence of a hiatal hernia O5 cm, persistence of heartburn after ilation, an number of ilations neee for initial ysphagia relief were significant preictors of early symptomatic recurrence. 43 A multivariate analysis reveale that a nonpeptic etiology of strictures was a significant preictor of early symptomatic recurrence within 1 year of initial ilation. 41 One stuy suggeste that patients with peptic strictures but without heartburn or patients with weight loss may be more likely to require frequent ilations. 44 Patients with peptic strictures shoul be treate with PPI therapy. Compare with histamine receptor antagonist therapy, PPI use ecreases stricture recurrence an the nee for repeat stricture ilation Recent stuies suggest that aci suppression may prevent recurrence of Schatzki s rings after ilation. 50 ACHALASIA Esophageal ilation for achalasia involves the forceful isruption of the lower esophageal sphincter (LES). This is usually accomplishe with 30- to 40-mm iameter pneumatic balloon ilators. Several balloon types are available. Although short-term relief of ysphagia is goo, recurrence occurs in approximately one thir 51 an, in some series, long-term resolution of symptoms after initial response may be as low as 40% to 50%. 52,53 The risk of perforation with balloon ilation in achalasia is in the range of 3% to 4% with a mortality rate of!1%. 54,55 Dilation is generally performe over a wire uner fluoroscopic guiance initially using a 30-mm balloon, 56 although nonfluoroscopically guie ilation using enoscopic visualization alone has been reporte. 57,58 An alternative to ilation is the enoscopic injection of botulinum toxin. Botulinum toxin acts by inhibiting the calcium-epenent release of acetylcholine from nerve terminals. The propose mechanism of action is relaxation of the LES, but the effect on manometrically etermine LES pressure is variable. 59 Botulinum toxin is injecte at 4 to 5 sites at the enoscopically ientifie LES. The usual total ose is 100 units ilute in 5 to 10 ml. Injection of botulinum toxin into the LES is effective in relieving symptoms in about 85% of patients. This response, however, is short live, with symptom recurrence in greater than 50% by 6 months. 58 In ranomize stuies, pneumatic balloon ilation is more effective than botulinum toxin injection with significantly higher cumulative remission rates (70%-89% compare with 32%-38%). 59,60 Surgical treatment of achalasia has yiele greater therapeutic efficacy than either pneumatic ilation or botulinum toxin injection. Myotomy offers goo to excellent symptom improvement in 83% of patients. 55 Laparoscopic cariomyotomy has shown similar results; however, longerterm follow-up is continuing. 61 Cariomyotomy may be more ifficult an less effective in patients treate previously with botulinum toxin ue to submucosal scarring. 62 A ranomize controlle trial comparing laparoscopic myotomy an botulinum toxin injection showe similar safety, but with better outcomes achieve with surgery. 61 Before enoscopic treatment, patients with achalasia shoul be informe of the various therapeutic options available. Symptomatic patients with achalasia who are goo surgical caniates shoul be given the option of Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 757

4 Esophageal ilation either grae pneumatic ilation or cariomyotomy. Open surgical repair with myotomy of early recognize enoscopic perforation offers an outcome similar to that of elective open myotomy. 63 However, if enoscopic perforation occurs after pneumatic ilation, laparoscopic myotomy is usually not technically feasible. 63 In patients with faile myotomy, pneumatic ilation can be safely performe. 64,65 The subset of patients in whom this approach has faile may require esophagectomy. In patients who are poor caniates for surgery, initial therapy with botulinum toxin may be the preferre approach. In prohibitive operative caniates, pneumatic ilation is not recommene. Cost analysis moels inicate that, for otherwise healthy patients with achalasia, initial pneumatic ilation was the least costly strategy compare with botulinum toxin injection 66 or laparoscopic Heller myotomy. 67 CONTRAINDICATIONS AND COMPLICATIONS The principal complications of esophageal ilation are perforation, bleeing, an aspiration. The most serious complication of esophageal ilation is perforation. The perforation rate for esophageal strictures after ilation has been reporte to be 0.1% to 0.4%. 16 The risk of perforation is lower in simple strictures an higher in more complex strictures. 16 Perforation may be more common an severe with raiation-inuce strictures. 68 The perforation rate may be influence by enoscopist experience level; one stuy inicate that the perforation rate was 4 times greater when the operator ha performe fewer than 500 previous iagnostic upper enoscopic examinations. 69 Perforation after esophageal ilation usually occurs at the site of the stricture, either intraabominally or intrathoracically. This complication shoul be suspecte if severe or persistent pain, yspnea, tachycaria, or fever evelops. The physical examination may reveal subcutaneous crepitus of the chest or cervical region. Although a chest raiograph may inicate a perforation, a normal stuy result oes not exclue this iagnosis an a water-soluble contrast esophagram or contrast chest compute tomogram may be necessary to elineate a perforation. 70 The use of large-iameter covere metal stents an the use of expanable, removable plastic stents have been shown to be effective in the management of perforations after ilation of benign an malignant esophageal strictures, although the routine use of these evices in benign isease is not recommene. 71,72 Esophageal ilation shoul be performe with caution in patients who have ha a recent, heale perforation or upper gastrointestinal surgery. Continuing esophageal perforation is an absolute contrainication to esophageal ilation. SUMMARY For the following points: (A), prospective controlle trials; (B), observational stuies; (C), expert opinion. Dilation is inicate in patients with symptomatic esophageal strictures (B). Fluoroscopy is recommene when using non-wireguie ilators uring ilation of complex esophageal strictures or in patients with a tortuous esophagus (B). Bougie an balloon ilators are equally effective in relief of ysphagia in patients with esophageal strictures (A). The rule of 3 shoul be followe when ilation of esophageal strictures is performe with bougie ilators (B). Injection of corticosterois into recurrent or refractory benign esophageal strictures may improve the outcome after esophageal ilation (B). Pneumatic ilation with large-iameter balloons is effective for the treatment of achalasia (A). Botulinum toxin therapy is the preferre enoscopic treatment for achalasia in poor operative an nonoperative patients (B). Aministration of PPIs is effective in preventing recurrence of esophageal strictures an the nee for repeat esophageal ilation (A). REFERENCES 1. Lew RJ, Kochman ML. A review of enoscopic methos of esophageal ilation. J Clin Gastroenterol 2002;35: Richter JE. 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5 Esophageal ilation 16. Hernanez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, an savary ilation of esophageal strictures. Gastrointest Enosc 2000;51: Colon VJ, Young MA, Ramirez FC. The short- an long-term efficacy of empirical esophageal ilation in patients with nonobstructive ysphagia: a prospective, ranomize stuy. Am J Gastroenterol 2000;95: Scolapio JS, Gostout CJ, Schroeer KW, et al. Dysphagia without enoscopically evient isease: to ilate or not? Am J Gastroenterol 2001; 96: Lavu K, Mathew TP, Minocha A. Effectiveness of esophageal ilation in relieving nonobstructive esophageal ysphagia an improving quality of life. South Me J 2004;97: Lan LC, Wong KK, Lin SC, et al. Enoscopic balloon ilation of esophageal strictures in infants an chilren: 17 years experience an a review of the literature. J Peiatr Surg 2003;38: Wilsey MJ Jr, Scheimann AO, Gilger MA. The role of upper gastrointestinal enoscopy in the iagnosis an treatment of caustic ingestion, esophageal strictures, an achalasia in chilren. Gastrointest Enosc Clin North Am 2001;11:767-87, vii-viii. 22. Pfau PR, Ginsberg GG, Lew RJ, et al. Esophageal ilation for enosonographic evaluation of malignant esophageal strictures is safe an effective. Am J Gastroenterol 2000;95: Wallace MB, Hawes RH, Sahai AV, et al. Dilation of malignant esophageal stenosis to allow EUS-guie fine neele aspiration: safety an effect on patient management. Gastrointest Enosc 2000;51: Aler DG, Baron TH. Enoscopic palliation of malignant ysphagia. Mayo Clin Proc 2001;76: Ho SB, Cass O, Katsman RJ, et al. Fluoroscopy is not necessary for Maloney ilation of chronic esophageal strictures. Gastrointest Enosc 1995;42: McClave SA, Bray PG, Wright RA, et al. Does fluoroscopic guiance for Maloney esophageal ilation impact on the clinical enpoint of therapy: relief of ysphagia an achievement of luminal patency? Gastrointest Enosc 1996;43: Wang YG, Tio TL, Soehenra N. Enoscopic ilation of esophageal stricture without fluoroscopy is safe an effective. Worl J Gastroenterol 2002;8: Eisen GM, Baron TH, Dominitz JA, et al. Guieline on the management of anticoagulation an antiplatelet therapy for enoscopic proceures. Gastrointest Enosc 2002;55: Hirota K, Petersen K, Baron TH, et al. Antibiotic prophylaxis for GI enoscopy. Gastointest Enosc 2003;58: Petrini J, Egan J. Risk management regaring seation/analgesia. Gastroinest Enosc Clin North Am 2004;14: Langon DF. The rule of three in esophageal ilation. Gastrointest Enosc 1997;45: Kozarek RA, Patterson DJ, Ball TJ, et al. Esophageal ilation can be one safely using selective fluoroscopy an single ilating sessions. J Clin Gastroenterol 1995;20: Jalil S, Castell DO. Schatzki s ring: a benign cause of ysphagia in aults. J Clin Gastroenterol 2002;35: Zein NN, Greseth JM, Perrault J. Enoscopic intralesional steroi injections in the management of refractory esophageal strictures. Gastrointest Enosc 1995;41: Altintas E, Kacar S, Tunc B, et al. Intralesional steroi injection in benign esophageal strictures resistant to bougie ilation. J Gastroenterol Hepatol 2004;19: Ramage JI Jr, Rumalla A, Baron TH, et al. A prospective, ranomize, ouble-blin, placebo-controlle trial of enoscopic steroi injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 2005;100: McLean GK, LeVeen RF. Shear stress in the performance of esophageal ilation: comparison of balloon ilation an bougienage. Raiology 1989;172: Scolapio JS, Pasha TM, Gostout CJ, et al. A ranomize prospective stuy comparing rigi to balloon ilators for benign esophageal strictures an rings. Gastrointest Enosc 1999;50: Saee ZA, Winchester CB, Ferro PS, et al. Prospective ranomize comparison of polyvinyl bougies an through-the-scope balloons for ilation of peptic strictures of the esophagus. Gastrointest Enosc 1995;41: Joyce A, Ginsberg G, Katzka DA, et al. Esophageal ilation at a tertiary referral center [abstract 36]. Gastrointest Enosc 2005;61: Chiu YC, Hsu CC, Chiu KW, et al. Factors influencing clinical applications of enoscopic balloon ilation for benign esophageal strictures. Enoscopy 2004;36: Saee ZA, Ramirez FC, Hepps KS, et al. An objective en point for ilation improves outcome of peptic esophageal strictures: a prospective ranomize trial. Gastrointest Enosc 1997;45: Sai A, Brust DJ, Gaumnitz EA, et al. Preictors of early recurrence of benign esophageal strictures. Am J Gastroenterol 2003;98: Agnew SR, Panya SP, Reynols RP, et al. Preictors for frequent esophageal ilations of benign peptic strictures. Dig Dis Sci 1996;41: Barbezat GO, Schlup M, Lubcke R. Omeprazole therapy ecreases the nee for ilatation of peptic oesophageal strictures. Aliment Pharmacol Ther 1999;13: Marks RD, Richter JE, Rizzo J, et al. Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture an esophagitis. Gastroenterology 1994;106: Silvis SE, Farahman M, Johnson JA, et al. A ranomize bline comparison of omeprazole an ranitiine in the treatment of chronic esophageal stricture seconary to aci peptic esophagitis. Gastrointest Enosc 1996;43: Stal JM, Gregor JC, Preiksaitis HG, et al. A cost-utility analysis comparing omeprazole with ranitiine in the maintenance therapy of peptic esophageal strictures. Can J Gastroenterol 1998;12: Smith PM, Kerr GD, Cockel R, et al. A comparison of omeprazole an ranitiine in the prevention of recurrence of benign esophageal stricture: Restore Investigator Group. Gastroenterology 1994;107: Sgouros SN, Vlachogiannakos J, Karamanolis G, et al. Long-term aci suppressive therapy may prevent the relapse of lower esophageal (Schatzki s) rings: a prospective, ranomize, placebo-controlle stuy. Am J Gastroenterol 2005;100: Ghoshal UC, Kumar S, Saraswat VA, et al. Long-term follow-up after pneumatic ilation for achalasia caria: factors associate with treatment failure an recurrence. Am J Gastroenterol 2004;99: West RL, Hirsch DP, Bartelsman JF, et al. Long term results of pneumatic ilation in achalasia followe for more than 5 years. Am J Gastroenterol 2002;97: Karamanolis G, Sgouros S, Karatzias G, et al. Long-term outcome of pneumatic ilation in the treatment of achalasia. Am J Gastroenterol 2005;100: Metman EH, Lagasse JP, Alteroche L, et al. Risk factors for immeiate complications after progressive pneumatic ilation for achalasia. Am J Gastroenterol 1999;94: Vaezi MF, Richter JE. Current therapies for achalasia: comparison an efficacy. J Clin Gastroenterol 1998;27: Mikaeli J, Bishehsari F, Montazeri G, et al. Pneumatic balloon ilation in achalasia: a prospective comparison of safety an efficacy with ifferent balloon iameters. Aliment Pharmacol Ther 2004;15: Lambroza A, Schuman RW. Pneumatic ilation for achalasia without fluoroscopic guiance: safety an efficacy. Am J Gastroenterol 1995; 90: Rai RR, Shene A, Joshi A, et al. Rigiflex pneumatic ilation of achalasia without fluoroscopy: a novel office proceure. Gastrointest Enosc 2005;62: Bansal R, Nostrant TT, Scheiman JM, et al. Intrasphincteric botulinum toxin versus pneumatic balloon ilation for treatment of primary achalasia. J Clin Gastroenterol 2003;36: Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 759

6 Esophageal ilation 60. Vaezi MF, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic ilatation in the treatment of achalasia: a ranomise trial. Gut 1999;44: Zaninotto G, Annese V, Costantini M, et al. Ranomize controlle trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg 2004;239: Vaezi MF, Richter JE. Diagnosis an management of achalasia: American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol 1999;94: Hunt DR, Wills VL, Weis B, et al. Management of esophageal perforation after pneumatic ilation for achalasia. J Gastrointest Surg 2000;4: Guarino JM, Vela MF, Connor JT, et al. Pneumatic ilation for the treatment of achalasia in untreate patients an patients with faile Heller myotomy. J Clin Gastroenterol 2004;38: Vela MF, Richter JE, Wachsberger D, et al. Complexities of managing achalasia at a tertiary referral center: use of pneumatic ilatation, Heller myotomy, an botulinum toxin injection. Am J Gastroenterol 2004;99: Panaccione R, Gregor JC, Reynols RP, et al. Intrasphincteric botulinum toxin versus pneumatic ilatation for achalasia: a cost minimization analysis. Gastrointest Enosc 1999;50: Imperiale TF, O Connor JB, Vaezi MF, et al. A cost-minimization analysis of alternative treatment strategies for achalasia. Am J Gastroenterol 2000;95: Clouse RE. Complications of enoscopic gastrointestinal ilation techniques. Gastrointest Enosc Clin North Am 1996;6: Quine MA, Bell GD, McCloy RF, et al. Prospective auit of perforation rates following upper gastrointestinal enoscopy in two regions of Englan. Br J Surg 1995;82: Faoo F, Ruiz DE, Dawn SK, et al. Helical CT esophagography for the evaluation of suspecte esophageal perforation or rupture. AJR Am J Roentgenol 2004;182: Siersema PD, Homs MY, Haringsma J, et al. Use of large-iameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Enosc 2003;58: Gelbmann CM, Ratiu NL, Rath HC, et al. Use of self-expanable plastic stents for the treatment of esophageal perforations an symptomatic anastomotic leaks. Enoscopy 2004;36: Disclosure: This article was not subject to the peer review process of GIE. Prepare by: STANDARDS OF PRACTICE COMMITTEE James V. Egan, MD To H. Baron, MD, Vice Chair Douglas G. Aler, MD Raquel Davila, MD Douglas O. Faigel, MD, Chair Seng-lan Gan, MD William K. Hirota, MD Jonathan A. Leighton, MD Davi Lichtenstein, MD Waqar A. Qureshi, MD Elizabeth Rajan, MD Bo Shen, MD Marc J. Zuckerman, MD Trina VanGuiler, RN, SGNA Representative Robert D. Fanelli, MD, SAGES Representative 760 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 6 :