Initial Treatment for Esophageal Stricture
The initial treatment for esophageal stricture is endoscopic dilatation using either balloon or wire-guided bougie dilators, with the choice individualized based on the stricture characteristics. 1
Approach to Dilatation
Initial Assessment and Technique
- Choose the initial dilator size based on the estimated stricture diameter, with very narrow strictures initially limited to 10-12 mm diameter (30-36F) and filiform strictures to ≤9 mm 1
- Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques to enhance safety rather than weighted (Maloney) bougies with blind insertion 1
- Consider using no more than three successively larger diameter increments in a single session (the "rule of three") to minimize risk of complications 1
- Perform dilatation without fluoroscopy for simple strictures, but use fluoroscopic guidance for high-risk strictures (post-radiation, caustic), long, angulated, or multiple strictures 1
Dilatation Protocol
- Perform dilatations weekly or biweekly until achieving a luminal diameter of ≥15 mm along with symptomatic improvement 2
- Offer intravenous sedation with a benzodiazepine and an opioid analgesic as a minimum for patient comfort 1
- Use carbon dioxide insufflation instead of air during endoscopy whenever possible in complex strictures to minimize luminal distension and postprocedural pain 1
Management Based on Stricture Type
Simple Strictures
- Simple strictures (short <2 cm, concentric, straight) typically require only 1-3 dilatation sessions to relieve dysphagia 1
- Only 25-35% of patients with simple strictures require additional sessions, with a maximum of five dilatations needed in >95% of patients 1
Complex Strictures
- Complex strictures (≥2 cm, angled, irregular, severely narrowed) are more difficult to treat and tend to be refractory or recur despite dilatation 1
- For completely obstructed esophagus, consider a combined anterograde and retrograde dilatation (CARD) approach under general anesthesia with fluoroscopic guidance 1, 3
- Use a guidewire to navigate through the obstruction when using the CARD approach to re-establish luminal patency 1
Refractory Strictures
- A stricture is considered refractory when unable to maintain a luminal diameter of ≥14 mm after five sequential dilatation sessions with 1-2 weeks between sessions 2
- Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory 1
- Use intralesional steroid therapy (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) combined with dilatation in refractory strictures with evidence of inflammation 1
- Consider incisional therapy for refractory Schatzki's rings and anastomotic strictures 1
- Offer temporary placement of fully covered self-expanding removable stents (typically for 4-8 weeks) when previous methods have been unsuccessful 1, 2
Post-Procedure Care
- Monitor patients for at least 2 hours in the recovery room 2
- Provide clear written instructions about liquids, diet, and medications after the procedure 2
- Ensure patients are tolerating water before discharge 2
- Suspect perforation if patients develop persistent pain, breathing difficulty, fever, or tachycardia 2
- Perform repeat endoscopy or injection of contrast after dilatation in cases where perforation is suspected 1
Special Considerations
Caustic Strictures
- Perform upper gastrointestinal tract endoscopy within the first 12-48 hours after caustic ingestion 1
- Consider avoiding dilatation within 3 weeks of initial caustic ingestion 1
- Consider a time interval between dilatations of <2 weeks for caustic strictures 1
- Note that perforation rates for caustic strictures (0.4% to 32%) are higher than for standard benign esophageal stricture dilatation 2