What are the next steps in managing an esophageal stricture if dilation is unsuccessful?

Management of Refractory Esophageal Strictures

When standard dilation fails to maintain adequate esophageal patency, the first step is to optimize acid suppression with high-dose PPI therapy and ensure the stricture truly meets criteria for being refractory (inability to maintain ≥14 mm diameter after five sequential dilations 1-2 weeks apart), then proceed with intralesional steroid injections combined with dilation for inflammatory strictures, followed by temporary fully covered stent placement if steroids fail, and ultimately surgery for patients who remain refractory to all endoscopic measures. 1

Define True Refractoriness Before Escalating

Before labeling a stricture as refractory and pursuing advanced interventions, you must:

• Ensure the patient has failed to maintain a luminal diameter of ≥14 mm after five sequential dilation sessions performed 1-2 weeks apart, OR cannot maintain the target diameter for 4 weeks once achieved 1
• Maximize high-dose PPI therapy to control any ongoing inflammation—this is critical and often overlooked 1
• Evaluate for alternative neuromuscular causes (achalasia, esophageal spasm) in patients with persistent dysphagia despite seemingly adequate esophageal diameter on imaging 1
• Refer to or discuss with centers experienced in managing refractory strictures, as the evidence quality for most interventions is poor 1

Stepwise Approach to Refractory Strictures

Step 1: Optimize Dilation Technique

• Use fluoroscopic guidance for all refractory stricture dilations to improve safety and success 1
• Choose between bougie or balloon dilators based on stricture characteristics (length, location, etiology)—no clear superiority of one over the other 1
• For complex strictures (>2 cm, angulated, irregular, severely narrowed), fluoroscopy is particularly important 1

Step 2: Intralesional Steroid Therapy

This is your first-line adjunctive therapy for refractory strictures with evidence of inflammation:

• Inject 0.5 mL aliquots of triamcinolone 40 mg/mL into all four quadrants of the stricture immediately before bougie dilation 1
• Leave the needle in place for at least 1 minute to minimize drug leakage and ensure full dose delivery 1
• This approach has HIGH-quality evidence (GRADE: high) showing reduction in repeat dilation frequency and increased dysphagia-free periods 1
• Only use this after maximizing anti-reflux therapy with no benefit 1

Common pitfall: Using steroids in strictures without documented inflammation (macro- or microscopically) reduces efficacy. 1

Step 3: Incisional Therapy (Stricture-Type Specific)

Consider needle knife incision for specific stricture types at experienced centers:

• Refractory Schatzki's rings respond well to incisional therapy 1
• Anastomotic strictures can be treated with needle knife incision as an alternative to repeated dilation 1
• This technique has only VERY LOW quality evidence (GRADE: very low) and should only be performed by experienced endoscopists 1

Step 4: Temporary Fully Covered Self-Expanding Metal Stents (SEMS)

When previous methods fail to maintain adequate patency:

• Offer temporary placement of fully covered removable stents—this is your next escalation 1
• Optimal duration is 4-8 weeks, though this varies by stricture etiology, length, and stent type 1
• Biodegradable stents can be considered to reduce dilation frequency in selected cases 1
• Evidence quality is LOW (GRADE: low), but this is a reasonable bridge before surgery 1

Important caveat: Stent migration, tissue ingrowth, and chest pain are common complications. Patients need close follow-up. 2, 3

Step 5: Self-Bougienage (Highly Selected Patients)

• Teach self-motivated patients with short proximal strictures to perform self-bougienage at home 1
• This requires careful patient selection, extensive training, and close follow-up 1
• Evidence is VERY LOW quality (GRADE: very low) but can improve quality of life in appropriate candidates 1

Step 6: Surgery as Final Option

• Offer surgery to patients who do not respond to or are intolerant of all endoscopic measures 1
• Surgical options include esophageal resection with reconstruction, though stricture recurrence at anastomotic sites remains a risk 4, 5
• Evidence quality is LOW (GRADE: low), and surgery carries significant morbidity 1

Special Considerations by Stricture Etiology

Anastomotic Strictures

• Steroid injections (four quadrants, triamcinolone 40 mg/mL) reduce repeat dilation frequency 1
• Needle knife incision is an effective alternative 1
• Complication rates (bleeding, rupture) can reach 30%, though perforation rates are similar to other stricture types 1

Post-Radiation Strictures

• These are frequently refractory and progressive due to tissue ischemia and mediastinal fibrosis 1
• For completely occluded esophagus, consider Combined Anterograde and Retrograde Dilation (CARD) under general anesthesia 1, 6
• CARD requires biplanar fluoroscopy or cone-beam CT, and should only be performed by experts as a last resort 1
• Prior gastrostomy placement should be considered for nutrition and to provide retrograde access 1

Caustic Strictures

• Avoid dilation within 3 weeks of initial caustic ingestion due to higher perforation risk 1
• Maintain dilation intervals of <2 weeks once stricture forms 1
• Perforation rates are higher (0.4-32%) compared to standard benign strictures 1
• If endoscopic measures fail, surgical resection may be necessary 1, 5

Eosinophilic Esophagitis (EoE) Strictures

• Whenever possible, perform diagnostic endoscopy with biopsy followed by medical therapy (PPI, topical steroids, elimination diet) BEFORE dilation 1
• Risk of mucosal tearing and perforation is higher in EoE—inspect mucosa after dilation for lacerations 1
• Residual strictures unresponsive to medical therapy may be more safely dilated after inflammation is controlled 1

Key Pitfalls to Avoid

• Failing to maximize PPI therapy before declaring a stricture refractory—this is the most common error 1
• Not considering alternative diagnoses (achalasia, esophageal spasm, EoE) when dysphagia persists despite adequate luminal diameter 1
• Attempting advanced techniques (CARD, incisional therapy) without appropriate expertise and fluoroscopic guidance increases perforation risk 1
• Using systemic steroids before dilation in EoE may increase perforation risk—topical therapy is preferred 1

Patient Counseling

• Inform patients about the poor quality of evidence for most refractory stricture treatments 1
• Set realistic expectations: most refractory strictures require ongoing repeat dilations every 2-3 months even after advanced interventions 1
• Discuss risks including perforation (up to 30% in some series), bleeding, chest pain, and need for potential surgery 1