Response

Abstract

We commend Vermeulen et al 1 for their article on endoscopic dilation of benign esophageal strictures. Although we generally agree with their conclusions, some points need comment.Our major concern is breaching the "rule of 3." Richter 2 and Johnson 3 recommend that the rule of 3 should not be abandoned. The contrary view by Grooteman et al, 4 that breaching the rule of 3 was not associated with an increase in perforation rates, needs to be interpreted with caution. Esophageal perforations may be rare but can have disastrous adverse events. We believe that this rule should not be broken, especially in strictures with transmural fibrosis such as radiation and complex strictures.The authors classified radiation strictures as benign strictures. It is worth emphasizing that many of these strictures often have residual or recurrent disease, and this may influence the outcome of endoscopic dilation. 5 Measurement of stricture by the diameter of the first dilator has a fallacy. The diameter of the first dilator is decided by visual impression, and 1 size larger than the estimated stricture size is recommended to start with. 6 The authors found no difference in the outcomes of dilation for strictures <1 cm or >1 cm, which is in contradiction to earlier studies. 7 A quarter of the patients in this study who underwent endoscopic stent placement experienced clinical success, which is lower than in other reported studies. 8 One reason could be that, unlike in previous studies, the authors treated a heterogenous group of patients with various causes of stricture (higher proportion of patients with anastomotic stricture) and performed a wide range (1 to 25) of dilation sessions before resorting to stent placement.Finally, a small statistical point: instead of providing the mean number of dilations as decimals, providing median numbers would have been more appropriate.