Management of Esophageal Strictures
Endoscopic dilatation using either balloon or bougie dilators is the first-line treatment for esophageal strictures, with the choice individualized based on stricture characteristics and etiology. 1, 2
Initial Approach to Esophageal Strictures
- Perform graded esophageal dilatation as a stepwise approach to achieve a diameter between 13-20 mm, which provides good symptomatic relief in 85-93% of benign reflux-induced strictures 2
- Conduct dilatation sessions at intervals of 1-2 weeks until achieving adequate luminal diameter (≥14 mm) 2, 1
- Follow the "Rule of Three" - avoid using more than three successive diameter increments in a single session to reduce perforation risk 1
- For very narrow strictures, limit initial dilatation to 10-12 mm diameter, and for filiform strictures, target an even smaller initial diameter (≤9 mm) 1
Management Based on Stricture Etiology
Benign Peptic Strictures
- Ensure optimal management with proton pump inhibitors (PPIs) as standard therapy, with twice-daily dosing required when restenosis occurs rapidly 2
- Consider antireflux surgery for patients who need frequent dilatation despite PPI treatment or those technically difficult to dilate 2
Caustic Strictures
- Avoid dilatation within 3 weeks of initial caustic ingestion to reduce perforation risk 2
- Use shorter time intervals between dilatations (<2 weeks) for caustic strictures 2
- Be aware that perforation rates are higher in caustic strictures (0.4-32%) compared to standard benign stricture dilatation 2
Malignant Strictures
- Consider expandable metal stents for palliation, often combined with dilatation 2
- Use temporary placement of fully covered self-expanding removable stents when previous methods have failed to maintain adequate esophageal patency 1
- For patients with good performance status and expected survival >3 months, consider brachytherapy for prolonged dysphagia improvement 3
Management of Refractory Strictures
A stricture is considered refractory when unable to maintain a luminal diameter of ≥14 mm after five sequential dilatation sessions 1-2 weeks apart or maintain the target diameter for 4 weeks once reached 2
- Use fluoroscopic guidance during dilatation of refractory esophageal strictures to improve safety 2, 1
- Consider intralesional steroid therapy combined with dilatation in refractory strictures with evidence of inflammation 2, 1
- Discuss with or refer to centers with expertise in treatment and follow-up of patients with refractory strictures 2
- For complex strictures (>2 cm, angulated, irregular, severely narrowed), consider temporary stent placement as an alternative approach 2, 4
- Consider surgical intervention for strictures that fail endoscopic management despite multiple attempts 2, 5
Monitoring and Complications
- Monitor patients for at least 2 hours in the recovery room after dilatation procedures 1
- Suspect perforation if patients develop pain, breathlessness, fever, or tachycardia following dilatation 2, 1
- Perform a chest x-ray if perforation is suspected; if clinical suspicion remains despite normal x-ray, proceed with a water-soluble contrast study 2
- Be aware that perforation is a medical emergency requiring immediate assessment by experienced physicians and surgeons 2
- The overall perforation risk is 0-7% (mostly 3-4%) with a mortality of <1% in achalasia dilatation 2
Follow-up and Outcomes
- Most patients respond well to esophageal dilatation, but outcomes are influenced by underlying pathology 2
- Predictors for repeated dilatation include non-peptic causes of stricture, fibrous strictures, and maximum dilator size less than 14 mm 2
- Dilatation appears less effective in radiation or corrosive induced strictures compared to peptic strictures 2, 5
- Consider teaching carefully selected patients with recurrent benign strictures self-dilatation techniques 2
By following these evidence-based guidelines, clinicians can effectively manage esophageal strictures while minimizing complications and improving patient outcomes.