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

Background: Little is known about esophageal dilation as a long-term treatment approach for eosinophilic esophagitis (EoE). We examined the impact of a "dilate and wait" strategy on symptom management and safety of patients with EoE.

Methods: This retrospective cohort study included two patient groups: those who underwent a dilation-predominant approach (≥ 3 dilations as sole therapy or for histologically refractory disease [> 15 eos/hpf]); and those who had routine care (< 3 dilations or histologic response). Group characteristics were compared and outcomes for the dilation-only group assessed.

Results: 53/205 patients (26 %) received the dilation-predominant strategy (total 408 dilations), predominantly for histologic treatment nonresponse (75 %). These patients were younger (33 vs. 41 years;  = 0.003), had a narrower baseline esophageal diameter (9.8 vs. 11.5 mm;  = 0.005), underwent more dilations (7.7 vs. 3.4;  < 0.001), but achieved a smaller final diameter (15.7 vs. 16.7 mm;  = 0.01) vs. routine care. With this strategy, 30 patients (57 %) had ongoing symptom improvement, with esophageal caliber change independently associated with symptom response (adjusted odds ratio 1.79, 95 % confidence interval 1.16-2.78); 26 (49 %) used the strategy as a bridge to clinical trials. Over a median follow-up of 1001 days (interquartile range 581-1710), no deaths or dilation-related perforations occurred, but there were nine emergency room visits, including one for post-dilation bleeding and four for food impaction.

Conclusions: A dilation-predominant long-term treatment strategy allowed for symptom control or bridge to clinical trials for patients with difficult-to-treat EoE. Close follow-up and monitoring for complications are required.