From the Guidelines
The stepwise management of oesophageal stricture should begin with endoscopic dilation using wire-guided or endoscopically controlled techniques, with an initial dilatation limited to 10-12 mm in diameter, and no more than three successively larger diameter increments in a single session, as recommended by the UK guidelines on oesophageal dilatation in clinical practice 1. The management approach should prioritize the identification of the underlying cause of the stricture, which may include conditions such as gastroesophageal reflux disease (GERD), eosinophilic esophagitis, radiation therapy, caustic ingestion, or malignancy.
- Initial treatment should focus on addressing the underlying condition, with medications such as proton pump inhibitors (PPI) like omeprazole or pantoprazole for GERD-related strictures.
- Endoscopic dilation is the mainstay of treatment, with the choice between bougie dilators (Savary-Gilliard) or balloon dilators depending on the stricture characteristics and patient factors.
- The use of fluoroscopic guidance is recommended for high-risk strictures, such as those that are post-radiation, caustic, long, angulated, or multiple, to enhance safety during dilatation 1.
- Repeat endoscopy or injection of contrast after dilatation should be performed in cases where perforation is suspected, to consider immediate treatment with a fully covered self-expanding metal stent (SEMS) 1.
- Carbon dioxide insufflation instead of air should be used during endoscopy whenever possible, to minimize luminal distension and postprocedural pain 1. The goal of therapy is to achieve a lumen diameter of at least 13-15mm, which typically allows for comfortable swallowing of a normal diet, while prioritizing the safety and well-being of the patient, and minimizing the risk of complications such as perforation or bleeding.
From the Research
Stepwise Management for Oesophageal Stricture
- The management of oesophageal stricture involves a stepwise approach, starting with endoscopic dilation using bougies or balloons 2, 3, 4, 5.
- The choice of dilator depends on the severity and location of the stricture, as well as the patient's overall health status 5.
- For simple strictures, endoscopic dilation with bougies or balloons is often sufficient 3, 4.
- For complex strictures, additional endoscopic treatments such as steroid injection, incisional therapy, and stent placement may be necessary 3, 4.
- In cases where endoscopic management is unsuccessful, surgical intervention may be required 6.
Endoscopic Dilation Techniques
- Bougie dilation is a commonly used technique for esophageal stricture dilation 2, 5.
- Balloon dilation is also effective, particularly for strictures that are resistant to bougie dilation 2, 5.
- A study comparing bougie and balloon dilation found that bougie dilation was associated with better clinical success and lower recurrence rates 5.
Surgical Management
- Surgical management is typically reserved for cases where endoscopic management is unsuccessful or not possible 6.
- The type of surgical procedure depends on the severity and location of the stricture, as well as the underlying cause 6.
- Options include esophageal resection, colonic interposition, and bile diversion 6.