What is the management plan for a patient with a stricture and a history of dilation?

Management of Esophageal Stricture with History of Dilation

Continue serial endoscopic dilations at 1-2 week intervals until achieving and maintaining a luminal diameter ≥14 mm, while optimizing acid suppression therapy and monitoring closely for complications. 1, 2

Immediate Assessment and Planning

Determine Stricture Characteristics

• Identify the underlying etiology (peptic, post-radiation, caustic, anastomotic, or malignant) as this fundamentally determines your management strategy and prognosis 1, 2
• Assess whether the stricture is becoming refractory, defined as inability to maintain ≥14 mm diameter after five sequential dilation sessions 1-2 weeks apart, or inability to maintain target diameter for 4 weeks once achieved 1, 2
• Obtain biopsies if not recently done to exclude occult malignancy, particularly if restenosis occurs rapidly despite adequate acid suppression 1

Optimize Medical Management Based on Etiology

For peptic strictures:

• Prescribe twice-daily proton pump inhibitor therapy if restenosis occurs rapidly after initial dilation, as standard-dose PPI is clearly more effective than H2 receptor antagonists but may be insufficient 1, 2
• This is critical because inadequate acid suppression is a primary driver of recurrent peptic strictures 1

For radiation-induced strictures:

• Recognize these have significantly worse outcomes with success rates <85% compared to 85-93% for peptic strictures 3
• Be aware that 43% become refractory to dilation therapy and have delayed onset >30 days from radiation injury 4

Dilation Technique and Safety Measures

Technical Approach

• Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques exclusively—never use blind weighted Maloney bougies as safer alternatives are available 1, 2
• Apply fluoroscopic guidance for high-risk strictures including post-radiation, caustic, long, angulated, multiple, or those that cannot be passed endoscopically 1, 3
• Follow the "Rule of Three": limit dilation to three successive diameter increments (3×1 mm for bougies or 3×2 mm for balloons) in a single session to reduce perforation risk 1, 2

Session Planning

• For tight strictures with history of dilation, you can safely use larger increments (4×1 mm or 3×2 mm) compared to initial presentations, as these strictures have completely recurred after first dilation 1
• Schedule repeat sessions every 1-2 weeks until achieving adequate luminal diameter 1, 2
• Target diameter of 13-20 mm provides good symptomatic relief in 85-93% of benign reflux-induced strictures 1, 2

Specific Considerations by Etiology

Caustic strictures require modified approach:

• Use shorter intervals between dilations (<2 weeks) as these strictures behave differently 1, 2
• Be prepared for higher perforation rates (0.4-32% versus standard 1.1% for benign strictures), particularly if you are less experienced 1

Radiation strictures demand extreme caution:

• Use fluoroscopy routinely as these are classified as high-risk with elevated perforation and fistula formation risk 3
• Proceed with more conservative dilation increments given the compromised tissue integrity 3

Management of Recurrent Strictures

Predictors Requiring Attention

Your patient likely has one or more high-risk features for repeated dilation:

• Non-peptic cause of stricture 1, 2
• Fibrous stricture characteristics 1, 2
• Maximum dilator size achieved was <14 mm 1, 2

Escalation Strategy for Refractory Cases

If approaching refractory definition (five sessions without maintaining ≥14 mm):

1. Add intralesional steroid injections immediately before dilation for strictures with evidence of inflammation, particularly anastomotic strictures 1, 2, 5

2. Consider incisional therapy (needle knife) as an alternative for anastomotic strictures or Schatzki rings 6, 2, 7

3. Discuss temporary placement of fully covered self-expanding removable stents when previous methods fail to maintain adequate patency 6, 2, 5

4. Refer to centers with expertise in refractory stricture management before proceeding to more aggressive interventions 2

5. Consider surgical intervention (antireflux surgery for peptic strictures, or esophageal resection for other etiologies) only after exhausting endoscopic options 1, 2

Post-Procedure Monitoring

Immediate Recovery

• Monitor for at least 2 hours in recovery room before discharge 1, 6, 2
• Ensure patient tolerates water before allowing discharge 1, 6
• Provide clear written instructions regarding fluids, diet, medications, and warning signs 1, 6

Complication Surveillance

Suspect perforation immediately if the patient develops:

• Persistent chest pain (transient pain is common and not concerning) 1, 3
• Breathlessness 1, 6
• Fever 1, 6
• Tachycardia 1, 6

If perforation suspected:

• Obtain chest x-ray immediately looking for pneumomediastinum, pneumothorax, subdiaphragmatic air, or pleural effusion 1
• Perform water-soluble contrast study if clinical suspicion persists despite normal chest x-ray, as normal imaging does not exclude perforation 1
• Involve experienced physician and surgeon immediately to formulate management plan, as iatrogenic perforation is a medical emergency 1

Common Pitfalls to Avoid

• Do not perform routine imaging after uncomplicated procedures—only image if symptoms develop during recovery 1
• Do not assume adequate acid suppression with standard-dose PPI—escalate to twice-daily dosing if rapid restenosis occurs 1
• Do not delay referral for refractory strictures—after five failed sessions, additional standard dilations are unlikely to succeed 1, 2
• Do not use expandable metal stents in radiation strictures except for fistula or palliation—they complicate future management 3