Esophageal Strictures

Esophageal Dilation

Evaluation Prior to Esophageal Dilation

Barium Studies

• General Use: Not typically required before endoscopy in suspected esophageal stricture cases.
• Specific Cases: Recommended for complex strictures, such as those from radiation therapy or caustic ingestion.
• Goals: Identify stricture location, length, number, esophageal lumen diameter, and any associated pathology.
• Purpose: Helps in selecting dilating techniques, estimating session numbers, and informing patients about risks.

Endoscopy

• Role in Malignancy: Necessary for diagnosis if barium studies suggest malignancy.
• Typical Procedure: Often performed along with dilation in the initial session.

Contraindications to Dilation

• Acute Conditions: Avoid in acute or incompletely healed esophageal perforation.
• Malignancy Concerns: Postpone if the stricture might be malignant, until confirmed benign.
• Comorbid Illnesses: Consider risks in patients with bleeding disorders or severe pulmonary/cardiovascular disease.
• Special Cases: Use caution in patients with pharyngeal or cervical deformities, recent surgery, large thoracic aneurysms, or impacted food bolus.
• Eosinophilic Esophagitis: Extreme care needed due to higher perforation risk.

Types of Esophageal Dilators

Mechanical Dilators

• Categories: Push-type (Bougie) and balloon dilators.
• Mechanism: Increase esophageal lumen size through stretching or splitting.
• Types:
  • Freely Passed Dilators: Maloney (common, tapered tip, multiple sizes, mercury or tungsten-filled), Hurst (rounded tip, less common).
  • Guidewire-Assisted Dilators: Savary-Gilliard (plastic, tapered, multiple sizes), American Dilatation System, Eder-Puestow olive dilators (metal, less used).
  • Flexible Bougie: Transparent, over endoscope, allows sequential dilation.

Balloon Dilators

• Types: Through-the-scope (TTS) and over-the-guidewire (OTW).
• Features: Greater radial force, retain maximum diameter predictably.
• Sizes: Initially in 2 mm increments, newer TTS balloons expand to three diameters at 1.0 to 1.5 mm increments.

Therapeutic Approach to Esophageal Stricture

Approach Based on Stricture Characteristics

• Dependency: Treatment varies depending on the stricture’s nature and the endoscopist’s experience.
• Simple vs. Complex: Simple strictures differ significantly from complex ones in terms of management.

Treatment of Simple Strictures

• Characteristics: Typically associated with prolonged reflux esophagitis, they are smooth, short, straight, and located in the distal esophagus.
• Diameter Consideration: Can be traversed with an endoscope (>10 mm in diameter).
• Dilation Techniques: Use of Maloney dilators, balloon dilators, or mechanical dilators passed over a guidewire, based on preference.

Treatment of Complex Strictures

• Nature: Long, narrow, tortuous, or associated with other complications like hiatal hernias or diverticula.
• Risk Mitigation: Use of a guidewire-based system or a balloon dilator to prevent complications like esophageal perforation.
• Combination Therapy: Initial dilation with guidewire or balloon dilators, followed by Maloney dilators for further sessions if feasible.

Special Considerations

• Proximal Strictures: May require a barium swallow for detailed assessment. Treated with guidewire-based dilators, sometimes under fluoroscopic guidance.
• Eosinophilic Esophagitis (EoE): Dilation as adjunctive therapy after medical treatment fails. Increased risk of tearing and perforation. Both mechanical and balloon dilators are used without a clear superiority. Aim for symptomatic relief with a maximum diameter of 13 to 14 mm.

Perforation Risk in EoE

• Systematic Review Findings: Relative risk of perforation in EoE dilation is 0.1 percent, similar to other indications.

Dilation Technique

Procedure Overview

• Setting: Performed as an ambulatory procedure using conscious sedation and topical pharyngeal anesthesia.
• Patient Preparation: Fasting, avoidance of antiplatelet agents and anticoagulants, no longer requiring antibiotic prophylaxis.
• Positioning: Left lateral decubitus position; seated position possible for Maloney dilators.
• Initial Dilator Size: Based on the estimated stricture diameter.

Mechanical Dilation

• Maloney Dilator: Passed blindly after endoscope removal. Assess for resistance and blood to gauge success.
• Guidewire-Based Dilators: Passed over the guidewire; the guidewire is fed through the endoscope into the stomach.

Balloon Dilation (TTS)

• Procedure: Passed through the endoscope channel, with inflation under direct visualization or fluoroscopy.
• Observation: Fluoroscopic observation helps assure maximum diameter achievement.
• Dilation Protocol: Typically two to three dilations per session, each lasting 30 to 60 seconds.

Number of Dilations Per Session

• Guidelines: Limiting the number of dilations and incremental increases helps reduce adverse effects.
• Bougie Dilators: No more than three dilators per session, increasing luminal stenosis by no more than 6 French.
• Balloon Dilators: Limit to three incremental inflations.

Repeated Sessions

• Frequency: Depends on initial success and patient response.
• Shrinkage Consideration: Reassess stricture diameter as shrinkage is common.

Safety of Mucosal Biopsy Prior to Dilation

• General Practice: Biopsies are typically performed after dilation, but doing them beforehand is likely safe.

Post-Dilation Acid Control

Proton Pump Inhibitors (PPIs)

• Purpose: Decrease the risk of stricture recurrence post-dilation.
• Effectiveness: PPIs are more effective than H2 antagonists in reducing the need for subsequent dilation in patients with peptic strictures.
• Practice: Omeprazole 20 mg twice daily for one year is common, increasing to 40 mg if necessary.
• Importance of Adequate Dilation: Even with PPI treatment, ensuring proper dilation is crucial.

Studies on PPIs

• Example: In a study comparing omeprazole and ranitidine, omeprazole-treated patients required fewer repeated dilation sessions and had improved dysphagia scores.
• Stricture Diameter and Esophagitis: Dysphagia in peptic strictures relates to both stricture diameter and presence of esophagitis.

Ambulatory pH Monitoring

• Use: For patients with recurrent peptic strictures despite PPI use.
• Purpose: To ensure adequate acid suppression.

Surgical Consideration

• Indication: Young patients with peptic strictures frequently requiring dilation or dependent on PPIs.

Refractory Strictures

Challenges in Management

• Issue: Patients not achieving symptom relief despite intensive dilation and reflux therapy.
• Surgical Candidacy: Often poor candidates for surgery, yet successful antireflux surgery depends on adequate preoperative dilation.

Self-Dilation

• Suitability: For motivated patients with simple strictures, though risks exist.

Endoscopic Techniques

• Corticosteroid Injections: Commonly used but with unestablished efficacy.
• Removable Esophageal Stents: Another option, though with mixed experiences and potential risks.

Studies on Corticosteroids and Stents

• Corticosteroid Injections: Showed a reduction in repeat dilation need.
• Nonmetal Stents: Mixed results, with potential complications like stent migration and pain.
• Metal Stents: Not recommended for benign strictures due to complications.