What is the recommended approach for dilating esophageal strictures following cancer?

Dilation of Esophageal Strictures After Cancer

Do not perform dilation of potentially malignant strictures until recurrent cancer has been excluded or the multidisciplinary team (MDT) has approved this approach. 1

Pre-Dilation Requirements

• Obtain MDT approval before any dilation procedure in patients with cancer-related strictures to ensure recurrent disease has been excluded and the patient is on an appropriate curative or palliative pathway 1
• Perform early endoscopic evaluation with careful inspection and biopsy to rule out recurrent malignancy before proceeding with dilation 1
• Recognize that fibrotic strictures occur in approximately 30% of patients after radiotherapy for esophageal cancer, and also develop after radiotherapy for lung and oropharyngeal cancers 1

Dilation Technique and Approach

Initial Dilation Strategy

• Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all cancer-related strictures to enhance safety, as these are high-risk strictures 1
• Apply fluoroscopic guidance for all post-radiation strictures since these are classified as high-risk and prone to perforation and fistula formation 1
• Limit the initial dilation to 10-12 mm diameter (30-36F) for very narrow strictures that do not allow passage of an adult gastroscope 1, 2
• For filiform strictures, target an even lower initial diameter (≤9 mm) 1, 2

Incremental Dilation Protocol

• Follow the "Rule of Three" by using no more than three successively larger diameter increments in a single session to reduce perforation risk, though recognize this is based on low-quality evidence 1, 2
• Perform serial dilations by cautiously increasing the size of dilators over multiple procedures rather than aggressive single-session dilation 1
• Schedule repeat dilation sessions at 1-2 week intervals until achieving a target diameter of ≥14-15 mm with symptomatic improvement 1, 2
• Expect an average of two dilations to achieve success in >80% of patients, manifesting as improvement in dysphagia 1

Special Considerations for Post-Radiation Strictures

• Proceed with extreme caution due to elevated risk of perforation and fistula formation in radiation-induced strictures 1
• Recognize that success rates are lower for radiation-induced strictures compared to peptic strictures (typically <85% vs 85-93%) 1, 2
• Consider that expandable metal stents should be avoided except in cases of fistula formation or in the palliative setting 1
• Use biodegradable or removable stents when stenting is necessary rather than permanent metal stents 1

Management of Refractory Strictures

• Define a stricture as refractory when unable to maintain a luminal diameter of ≥14 mm after five sequential dilation sessions performed 1-2 weeks apart 1, 2
• Consider intralesional steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to four quadrants) immediately before bougie dilation for anastomotic strictures refractory to initial approaches 1
• Leave the injection needle in place for at least 1 minute to minimize drug leakage and ensure full dose delivery 1
• Consider endoscopic needle knife stricturoplasty as an alternative for resistant strictures, though prospective trials demonstrating significant benefit are lacking 1

Stent Placement Considerations

• Avoid high esophageal stents that impinge on the cricopharyngeus as these are poorly tolerated 1
• In a preoperative setting, only consider stenting after MDT discussion, as stent presence may make surgical resection more difficult, compromise margins, or impact radiotherapy planning 1
• Reserve expandable metal stents for fistula management or palliative settings only 1

Monitoring for Complications

• Suspect perforation immediately if patients develop persistent pain, breathlessness, fever, or tachycardia following dilation 1, 2
• Recognize that transient chest pain is common and not concerning, but persistent pain mandates immediate chest x-ray and water-soluble contrast study 1
• Understand that perforation rates are higher for malignant strictures (6.4% with 2.3% mortality) compared to benign strictures (1.1% with 0.5% mortality) 1
• Perform immediate endoscopic reinspection or contrast injection if perforation is suspected to enable early treatment with fully covered self-expandable metal stent 1
• Monitor patients for at least 2 hours in the recovery room and ensure they tolerate water before discharge 3, 2

Common Pitfalls to Avoid

• Never use weighted (Maloney) bougies with blind insertion in cancer-related strictures, as safer wire-guided alternatives are available 1
• Do not proceed with dilation without first excluding recurrent malignancy through the MDT process 1
• Avoid aggressive single-session dilation in radiation-damaged tissue due to high perforation and fistula risk 1
• Do not place permanent stents in potentially curable patients without MDT approval 1