COMMENTARY

10 Considerations When Dilating Benign Esophageal Strictures

David A. Johnson, MD

Disclosures

March 10, 2022

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Esophageal strictures are something that we routinely deal with in general gastroenterology. Kudos to Dr Todd Baron, therefore, for recently publishing his top 10 tips for dilation of benign esophageal strictures.

I wanted to highlight Dr Baron's tips and augment them with some anecdotal comments based on my own 40-plus years of performing dilation, in order to potentially keep us all out of harm's way.

1. Have a Variety of Endoscope Options

The first tip is to choose the endoscope appropriately based on what you expect the luminal diameter of the stricture to be. The standard upper endoscope is 10 mm in diameter. Comparatively, the smaller-caliber scopes are ≤ 6 mm.

You can start with the standard endoscope but have smaller options available. You can switch to these options as needed if you get into a complex stricture that you cannot traverse, and you still want to go through the stricture again.

It's important to understand that the caliber makes a difference.

2. Situations When General Anesthesia Is Necessary

Patients with esophageal obstructions are typically clinically identified if they can't handle their secretions. We often see this in patients that come into our clinics after a food bolus obstruction.

As it relates to tip number two, I'm in agreement with Dr Baron that the best thing to do in these patients is proactively perform anticipatory endotracheal intubation using general anesthesia, rather than getting in and having the patient suddenly at risk of potentially sustaining an aspiration.

3. Avoid Force in Tight Strictures

Tip number three, is don't apply excessive force in an attempt to pass the endoscope past a stricture. If you meet some resistance with a stricture, don't push through it but rather back off it. If you don't know the dynamics of the stricture — the length, the angulation — you may have to come back another day if you can't traverse it with a smaller-diameter scope. Don't try and push your way through these strictures.

4. Make Fluoroscopy Available

The fourth tip is regarding having fluoroscopy available if the patient has a complex esophageal stricture. Here, we're talking about patients who have angulation due to radiation. I've also seen this in patients on a nasogastric tube; in those who have received chemotherapy; or in those with drug-induced type of esophagitis, where the long strictures tend to have more of a transmural fibrosis.

You really need to understand where you're going with these when you start to pass the guidewire. If you don't have a barium study, then back out.

Dr Baron recommends that you may want to start with a barium study before you re-approach these patients, advice with which I wholeheartedly agree.

5. Remember the "Rule of Three"

The fifth tip is to use the so-called "rule of three." This will be familiar to those of us who were privileged back in the 1980s to work with Dr Worth Boyce, one of the "godfathers" of the esophagus, who credited this rule to his mentor, Dr Eddy Palmer.

The rule of three says that you should apply no more than two subsequent dilators > 1 mm in size once you start to meet resistance. Please note that Dr Baron's tip about using the rigid dilators when assessing benign stricture dilation does not apply to balloon dilation, which is something we're using more of these days. This rule only reflects on the passage of a bougie dilator.

Use this rule to think about setting appropriate targets. In my practice, I'll assess the dynamics of the stricture, and then discuss with the patient what my targets would be in order to get them to adopt a diet that they can enjoy. Sometimes perfect is the enemy of good. That applies here, where you're not looking for a luminal size so much as you're trying to assess what the patient can go forward with.

We know that an esophageal lumen ≤ 13 mm will uniformly create dysphagia for patients. That's why we give a barium tablet when we do a cine study. However, most people at 15 mm can tolerate a soft diet, and almost everybody at 18 mm can tolerate a regular diet. So, I set some parameters for patients.

It's not mentioned by Dr Baron, but I also would recommend a 2- to 4-week interval if you're needing to dilate these people sequentially, to let them heal up a little bit. You don't need to go so quickly.

6. Use a Stiff Guidewire

Dr Baron's sixth tip is to use a stiff guidewire when passing a rigid scope, which is something I would concur with.

I use fluoroscopy in these patients, particularly if it's a rigid dilator. What I want to see is the bow of the tip of that rigid wire. I don't want it in the fundus, and I don't want it into the greater curvature. What I'm looking for is a gentle bow along the greater curvature stretching into the antrum.

With that being said, we must note that the stiff wire will come back when you draw off of it by withdrawal of the endoscope. So, I'll have my assistant watch when I'm coming back, and with close communication, we'll do a to-and-fro; I'll come back 10 mm, and they'll push in 10 mm. We perform fluoroscopy to confirm. Then, we maintain that gentle bow along the greater curvature.

7. Consider Underlying Eosinophilic Esophagitis (EoE)

The seventh tip is to always consider EoE when evaluating patients with suspected benign esophageal strictures. We see EoE more and more. It's not just a disease of young males anymore.

This is something that you need to understand because these patients tend to have a mucosal tear with dilation of any type, very deep and very early. Thereby, it's something that we need to be a little bit more conservative by which we perform dilations and set appropriate guidance for subsequent dilation.

I prefer the bougie dilators in these patients, particularly if they have concentric rings. Balloons just don't seem to provide that longitudinal dilation as you go down the length of the esophagus.

To reiterate Dr Baron's point about EoE: Don't forget it, understand it, and think about it, particularly as you look at your dilation strategy.

8. When Large-Diameter Dilators Are Necessary

The next tip is to use larger-diameter balloons or bougies when you start to look outside of the diagnosis of EoE.

Specifically, we're talking about a Schatzki ring, which requires very membranous-type dilation targets. The typical dilation size is ≥ 18 mm. With the target here being greater size, we commonly use the 18-mm to 20-mm balloon.

You need to factor in this consideration from the start, although the risk for perforation in these rings is low.

9. Evaluating After Endoscopy

The ninth tip is that postendoscopic evaluation should be performed to assess response and adverse events.

I wholeheartedly agree with this tip. I use this when performing dilations in complicated strictures and EoE, because I want to look for those deep mucosal tears. That's my bailout point. I'm not looking at the rule of three. I'm not looking at anything other than if I see a mucosal tear that's deep, I want to stop at that point. And for that, the endoscopic reevaluation is important.

What I would add from my own experience is a recommendation to deflate the stomach as you go forward when you're doing sequential dilation. If you're using a balloon dilator, you may be, either consciously or subconsciously, insufflating air. You don't want the stomach distended, where the patient may now retch or belch when they have a balloon dilator in their esophagus. Basically, it's about creating an esophageal obstruction via a dilation balloon, creating risk for barotrauma, which you would see proximal to that balloon.

So, deflate as you go forward. Don't forget: Take your finger off the insufflation button and put it on the suction button going forward before dilation.

10. Chest Pain Should Cause Concern

The tenth and final tip is that severe chest pain after uncomplicated dilation of benign stricture should prompt evaluation for possible perforation.

I would add that the exception here is in patients with EoE. I recommend that patients with EoE be forewarned that they may have a little bit of chest pain or discomfort. I find this is almost universal in these patients. Warning them beforehand precludes at least some of the anticipatory concerns.

Deep pain and concerns of perforation obviously would prompt an evaluation with the idea of either re-endoscopy and fixing it at the time if you saw a perforation, or if the patient comes back, obviously to evaluate them with a water-soluble contrast; Gastrografin followed by a thin barium swallow if initial study is negative. Alert the radiologist of the concern to evaluate for perforation. Don't let the patient go unattended if they're having chest pain.

Kudos again to Dr Baron for sharing his top 10 tips. It's given me an opportunity to reflect on my 40 years of doing this as well.

Hopefully, we can optimize our patient outcomes, keeping away from the complications that are part and parcel of anything we do, in particular those related to esophageal dilation.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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