What is the role of Seattle wash in managing esophageal strictures in a patient with Dystrophic Epidermolysis Bullosa (DEB)?

Seattle Wash in Dystrophic Epidermolysis Bullosa with Esophageal Strictures

The "Seattle wash" technique is not mentioned in any available guidelines or literature for managing esophageal strictures in RDEB, and there is no evidence supporting its use in this population. The term appears to be either a misnomer or refers to a technique not documented in the medical literature for this specific condition.

Evidence-Based Management of RDEB Esophageal Strictures

First-Line Treatment: Fluoroscopically-Guided Balloon Dilation

Fluoroscopically-guided balloon dilation without endoscopy is the preferred approach for RDEB esophageal strictures, as it minimizes trauma to the fragile oropharyngeal mucosa. 1, 2

• Avoid endoscopic guidance in RDEB patients because the endoscope itself carries significant risk of oropharyngeal trauma and blister formation in this fragile tissue 1, 3
• Perform balloon dilation under general anesthesia with fluoroscopic control only, eliminating the need for endoscope passage 1, 4
• Use inflatable balloon dilators that produce vertical pressure rather than tangential shearing forces, which are less harmful to the friable esophageal mucosa 2
• Position the balloon dilator over an angiographic guidewire under fluoroscopic visualization 4

Technical Approach and Safety

The fluoroscopic-only technique has demonstrated excellent safety with zero procedure-related complications in 92 dilations across 25 RDEB patients over 11 years. 1

• Most patients report immediate symptom relief and resume adequate food intake within 1 day post-procedure 1
• The mean interval between required dilations is approximately 1 year, with 24% of patients requiring only a single dilation 1
• Through-the-scope balloon dilation (when endoscopy is used) shows 75% of patients have single strictures, most commonly in the proximal esophagus at 20 cm from incisors 3
• Endoscopic approaches, while effective, carry higher theoretical risk due to instrument passage through the oropharynx 3

Adjunctive Conservative Management

Combine balloon dilation with conservative measures to reduce stricture recurrence and optimize outcomes. 2

• Consider oral phenytoin to inhibit collagenase formation and reduce epithelial detachment 2
• Prescribe pureed or semiliquid diet, as hard food particles induce blistering and scarring of the upper esophagus 2
• Implement long-term nasogastric tube feeding for tight strictures that may relieve obstruction over time 2
• Avoid rigid bougienage due to tangential shearing forces that cause more tissue damage 2

Anesthesia Considerations

Use face mask anesthesia (propofol or general anesthesia) specifically adapted to avoid skin and mucous membrane damage. 3, 4

• Careful attention must be paid to prevent any trauma during intubation or mask placement 4
• Propofol anesthesia via face mask is effective and minimizes airway trauma 3

Outcomes and Expectations

Balloon dilation improves dysphagia scores in 97% of patients and leads to significant weight gain. 3

• Mean weight increase of 2.9 kg (95% CI [2.0,3.8]; p<0.001) over median 29 days post-procedure 3
• Median of 2 dilations per patient over 3.5 years follow-up period 3
• Some patients remain dilation-free for extended periods (up to 5 years documented) 1
• Dilations typically performed every 1-20 months depending on symptom recurrence 4

Alternative Nutritional Support

For patients with severe dysphagia or frequent stricture recurrence, consider non-endoscopic percutaneous gastrostomy placement. 5

• Use image-guided approach combining ultrasound, contrast enema, and gastric insufflation to avoid endoscopy 5
• This minimizes trauma to skin and pharyngoesophageal mucosa compared to traditional PEG placement 5
• Replace with low-profile button gastrostomy tube 10-12 weeks postoperatively 5
• All patients tolerate feedings by postoperative day 1 with no perioperative complications reported 5

What NOT to Do

Avoid colonic interposition surgery as first-line treatment, as conservative management with balloon dilation is effective and far less morbid. 2, 4

• Total esophageal replacement was historically recommended but is unnecessarily aggressive given success of balloon dilation 2
• Repeated balloon dilations can be performed safely without serious complications 4
• Reserve surgical intervention only for complete esophageal occlusion refractory to all conservative measures 2