What is the next step for a patient with esophageal stricture or web who has failed dilatation?

Management of Failed Dilatation in Esophageal Stricture/Web

For patients with esophageal stricture or web who have failed dilatation, the next step should be intralesional steroid injection combined with repeat dilatation, followed by temporary stent placement if this fails, and ultimately surgical intervention for refractory cases. 1

Initial Management After Failed Dilatation

Optimize Medical Therapy

• Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as truly refractory 1
• Consider alternative neuromuscular causes in patients with ongoing dysphagia despite adequate dilatation 1

Repeat Dilatation with Modifications

1. Use fluoroscopic guidance for refractory strictures to enhance safety 1
2. Consider changing dilator type - either bougie or balloon dilators based on stricture characteristics (length, location, cause) 1
3. Modify dilatation technique:
   • For very tight strictures, limit initial dilatation to 10-12 mm diameter
   • Consider shorter intervals between dilatations (<2 weeks) 1
   • Aim for weekly or two-weekly sessions until passage of ≥15 mm dilator is achieved 1

Advanced Interventions for Refractory Strictures

Intralesional Steroid Therapy

• First-line advanced intervention: Combine intralesional steroid injection with dilatation in refractory strictures with evidence of inflammation 1
• This approach has strong evidence support (high-grade evidence with strong recommendation) 1

Incisional Therapy

• Consider for specific types of strictures:
  • Refractory Schatzki's rings
  • Anastomotic strictures
• Should be performed at centers experienced in these techniques 1

Stent Placement

• Temporary fully covered self-expanding removable stents when previous methods have failed to maintain adequate esophageal patency 1
• Optimum duration of stent placement: 4-8 weeks (varies by stricture etiology, length, and stent type) 1
• Consider biodegradable stent placement to reduce frequency of dilatation in selected cases 1
• Caution: Recent evidence shows potential serious complications in post-radiation strictures 2

Self-Bougienage

• Consider teaching selected, self-motivated patients with short proximal strictures to perform self-bougienage 1
• This can be effective for maintaining patency in appropriate candidates 3

Surgical Options

When to Consider Surgery

• Offer surgery to patients who do not respond to or cannot tolerate other measures 1
• Surgery becomes the next step when all endoscopic approaches have failed 3

Type of Surgical Intervention

• Esophageal bypass is recommended for extensive, refractory corrosive strictures as it preserves the native esophagus while creating an alternative food passage 4
• Complete esophageal resection is usually reserved for cases with malignancy concern or complete esophageal destruction 4

Special Considerations for Corrosive Strictures

Corrosive strictures are particularly challenging:

• Higher risk of perforation and lower success rate with dilatation alone 4
• May require more aggressive management earlier in treatment course
• Esophageal bypass shows good long-term results in patients with refractory corrosive strictures 4

Follow-up and Monitoring

• Monitor for complications after each intervention, especially perforation (persistent chest pain, fever, breathlessness, tachycardia) 1
• Provide patients with contact information for the on-call team 1
• Schedule regular follow-up to assess response to therapy
• Long-term follow-up is essential due to increased risk of complications and potential malignancy in certain cases 4

Treatment Algorithm for Failed Dilatation

1. Verify true refractoriness:

   • Optimize PPI therapy
   • Rule out alternative causes
   • Ensure proper dilatation technique

2. First advanced approach:

   • Intralesional steroid injection + repeat dilatation with fluoroscopic guidance

3. If still failing:

   • Temporary stent placement (4-8 weeks)
   • Consider biodegradable stents for specific cases

4. If continued failure:

   • Consider incisional therapy for appropriate stricture types
   • Evaluate for surgical intervention

5. Surgical options:

   • Esophageal bypass (preferred for extensive strictures)
   • Resection (reserved for specific indications)

Remember that a scheduled program of repeated dilations may be more effective than on-demand dilations, with evidence showing higher probability of final success and shorter treatment duration 5.