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Stricture dilation
The overall perforation rate: 0.1 % per session
Risk factors
-Malignant stricture
-Severeoesophagitis
-Prior radiation therapy
-A history of caustic ingestion
-Eosinophilicoesophagitis
-Complex (tortuous) or long strictures
-Presence ofoesophageal diverticula
-Inexperienced operator
-A large hiatal hernia
-Use of high inflation pressures with balloon
dilation
-A history of previousoesophageal perforation
-A history of prioroesophageal surgery (such as
for trauma or a congenital abnormality)
Chest pain
Pain can happen during
dilatation. If suspect a
perforation, then keep in for
observation and barium
swallow prior to discharge
Haemorrhage
Blood transfusions needed in
0.2 % ofoesophageal dilations
with mechanical dilators, and
2% with balloon dilation.
Bacteraemia-
45%
No need for prophylac
-
tic antibiotics
Contraindications To Dilatation
Consider specific features of oesophageal stricture
acute or incompletely healedoesophageal perforation.
Caution if pharyngeal or cervical deformity, recent
surgery, a large thoracic aneurysm, or an impacted
food bolus.
Endpoint Of Dilatation
At18 mm (54 French) allows intake of a regular
diet unless there is a coexisting motility
disturbance.
At 45 French (15 mm) are able to eat a
modified regular diet.
< 13 mm (39 French) will usually experience
solid food dysphagia
Refractory Strictures
Self-dilation
Motivated patients with simple
strictures benefit from a schedule of
regular self-dilation with a Maloney
dilator.
Intralesional Steroids
Intralesional 0.2 mL of triamcinolone
acetonide into all four quadrants
.-impedes collagen deposition and
enhance its breakdown locally, thereby
reducing scar formation
Can be combined with oral steroids
Nonmetal stents
Nonmetal expandable stents can be
effective in management of refractory
benign strictures- effective in 40%
Other methods
Electrosurgical incision of peptic and
postoperative strictures and Schatzki's
rings.
Mitomycin C has been used in a case
report
Technique
No > three dilators of progressively
increasing diameter should be passed in a
single session
Luminal stenosis should be increased by no >
2 mm (6 French).
For very tight or for long strictures, only one
or two dilators is passed at each session.
Complications
Cervical perforation
Neck pain
Tenderness of the SCM,
Dysphonia, hoarseness,
Cervical subcutaneous
emphysema.
Intrathoracic perforation
Chest, back, or epigastric pain,
which is exacerbated with
inspiration and swallowing.
Dysphagia, odynophagia,
dyspnea, hematemesis and
cyanosis.
Pericardial tamponade (rare) if
posterior pericardium perf.
Hammans sign (auscultatory
crunch with mediastinal
emphysema)
Hoarse
Clinical manifestations
Diagnosis
1. CXR- (95% positive in cervical and 40%
thoracic perf.)
Pneumomediastinum or
Density adjacent to the descending aorta in the
left cardiophrenic angle resulting in loss of
contour of the descending aorta in
2. Barium in left lateral position more sensitive
3. CT even better
Perforation
No screening
Peptic strictures
Screening
Complex strictures
Long, narrow, or
tortuous, anatomically
complicated
Balloon dilators
1.Through-the-scope dilator (down the
biopsy channel)
2. Over-the-guidewire balloon dilator.
Initial balloon size corresponds to the
estimated stricture diameter :
A 10 mm balloon for diameters 2 -4 mm
A 12 mm balloon for diameters 5 -9 mm
A 15 mm balloon for a diameter >9 mm
Dilate over 30-60 seconds
Mechanical dilators
Types of dilators
No guidewire:
1. The Maloney (common, no guidewire needed)
2. Hurst -rounded tip, which is more difficult to
pass, and is rarely used.
Guidewire assissted dilators:
1. Savary-Gilliard- most common
2. American Dilatation System
3. Eder-Puestow olive dilators
Diameter of the initial dilator should be the
same width as the stricture.
Technique
Treatment:
Criteria for selecting patients for nonsurgical management:
-Containment of perforation within neck/ mediastinum with no thoracic / peritoneal/ pleural extension.
-No preexisting oesophageal conditions with distal obstruction.
-Not systemically unwell.
Medical management
-Avoidance of all oral intake for 10 to 14 days
-TPN
-IVs broad spectrum antibiotics (eg, ticarcillin-clavulanate)
-Drainage of fluid collections
-No NG tube
-If deteriorate clinically, then for surgery
-Repeat contrast after 10 to 14 days
Written by Dr Sebastian Zeki
