Dilation of malignant esophageal strictures followed by endosonography (EUS) is safe and clinically important

It has been suggested that dilation of esophageal strictures prior to EUS has a high morbidity and a low clinical yield and should not be routinely performed. We report our prospective experience with esophageal dilation for EUS staging. 93 patients with esophageal malignancies underwent EUS (Olympus GF-UM20). 29 (31%) had malignant strictures (Adeno-19, Squamous-8, Other-2) precluding safe passage of the EUS scope (estimated lumen diameter=8.7 ± 1.9 mm, mean ± SD). Esophageal dilation was performed with wire guided Savary dilators (n=27) or TTS balloons (n=2) to a median 15 mm (range 11-16) using a median 4 dilators (range 1-6). Following dilation, the EUS scope was able to be passed beyond the stricture in 26 patients (90%), and in all patients dilated to at least 14 mm. There were no procedure-related complications. EUS stages were: T2-8 (28%), T3-11 (38%), T4-6 (21%), Tx-4 (14%), N1-23 (79%), M1-5 (celiac nodes)(17%). 14 patients had complete surgical staging; one had partial operative staging. There was only one T2 lesion (7%); the remainder were T3-11 (79%) and T4-2 (14%). EUS understaged 5 Surgical-T3 as T2, and one surgical-T4 as T3 (accuracy=57%). There were no EUS overstages. 12 surgical patients were N1 and 5 M1. EUS N-stage accuracy was 80%, however, when 3 patients who received preoperative chemo/XRT were excluded, N stage accuracy was 92%. Of 5 surgical-M1 patients, 2 had celiac nodes correctly identified on EUS, and 3 had distant metastases not seen on EUS. Conclusions: 1. Esophageal dilation prior to EUS is safe. 2. Approximately 1/3 of patients with esophageal cancer require dilation prior to EUS. 3. Dilation to at least 14 mm is needed to safely pass the GF-UM20. 4. The majority of patients requiring dilation have high-stage lesions, and EUS tends to under T-stage. 5. The primary utility of EUS in these patients is in detecting T4 tumors and regional (N1) and celiac (M1) adenopathy which may alter treatment to preoperative neoadjuvant therapy or non-operative palliation.