In an adult with a refractory benign esophageal stricture (including caustic injury) after failed repeated bougienage or balloon dilation, how should Mitomycin C be applied as an adjunctive topical therapy?

Mitomycin C Application for Refractory Esophageal Strictures

Apply topical Mitomycin C (0.1 mg/mL) directly to the stricture site for 2-5 minutes immediately after balloon or bougie dilation, using a soaked pledget or specially designed catheter delivery system, with the patient kept nil per os for 2-3 hours post-procedure. 1, 2, 3

When to Consider Mitomycin C

Define the stricture as refractory before proceeding with Mitomycin C therapy when you cannot maintain a luminal diameter ≥14 mm after five sequential dilatation sessions performed 1-2 weeks apart, or when you cannot maintain the target diameter for 4 weeks once achieved. 4

Before labeling any stricture as truly refractory, ensure you have maximized high-dose proton pump inhibitor therapy, as inadequate acid suppression is a common reason for apparent treatment failure. 5, 4

Application Technique

Preparation and Concentration

• Use Mitomycin C at a concentration of 0.1 mg/mL (this is the standard concentration across all studies). 1, 2, 3
• Perform standard balloon or wire-guided bougie dilation first to achieve the maximum safe diameter (typically targeting 14-15 mm). 4, 2

Application Method

• Apply the Mitomycin C solution directly to the stricture site using cotton pledgets soaked in the solution, or use a specially designed Nelaton catheter delivery system for more precise application. 1, 6
• Maintain contact time of 2-5 minutes (most studies used 2-3 minutes, though some extended to 3.5 minutes). 1, 2, 3
• Apply the solution circumferentially to all areas of the stricture. 6
• Keep the patient nil per os (nothing by mouth) for 2-3 hours following the procedure to maximize tissue contact time. 3

Treatment Schedule

• Plan for a median of 3-4 Mitomycin C application sessions (range 1-12 sessions depending on stricture severity and response). 1, 7
• Space sessions at intervals consistent with your dilation protocol, typically every 1-2 weeks initially. 4, 2
• Continue applications until you achieve sustained patency (ability to maintain ≥14 mm diameter for at least 4 weeks). 4

Expected Outcomes

The evidence demonstrates substantial benefit for Mitomycin C in refractory strictures:

• Major success (both endoscopic and clinical improvement or cure) occurs in approximately 60-80% of patients. 1, 2
• The number of required dilation sessions decreases dramatically from a mean of 6.9 sessions to 3.85 sessions in caustic strictures. 2
• The frequency of dilations drops from approximately 1.5 dilations per month to 0.39 dilations per month. 7
• Patients can remain symptom-free for up to 5 years following successful treatment. 1

Stricture-Specific Considerations

Caustic Strictures

Mitomycin C shows particularly strong evidence in caustic-induced strictures, with randomized controlled trial data demonstrating 80% complete resolution compared to 35% with placebo. 2 These strictures are especially prone to refractoriness and carry perforation risks of 0.4-32%, making Mitomycin C an attractive option to reduce repeated trauma from frequent dilations. 8, 4

Anastomotic Strictures

Mitomycin C is effective for post-surgical anastomotic strictures, which are classified as complex strictures with high rates of refractoriness. 8, 7 Consider this approach when intralesional steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to four quadrants) have failed or are not suitable. 9

Radiation-Induced Strictures

Apply Mitomycin C for radiation strictures, which are frequently refractory to standard dilation due to surrounding mediastinal fibrosis. 8, 7 These strictures respond less effectively to dilation alone compared to peptic strictures. 8

Critical Safety Considerations

Always use fluoroscopic guidance when dilating strictures that will receive Mitomycin C, as these are by definition high-risk, refractory strictures with complex anatomy. 4

Use wire-guided bougie dilators (particularly Savary-Gilliard type) as the preferred approach for these complex strictures, though balloon dilators remain acceptable alternatives. 4, 3

Monitor for perforation signs (persistent pain, breathlessness, fever, tachycardia) following the procedure, as refractory strictures carry substantially higher perforation rates than standard benign strictures. 4

No significant Mitomycin C-specific complications have been reported in the available case series, suggesting the agent is safe when applied topically for short durations. 1, 2, 3, 6

Alternative Approaches if Mitomycin C Fails

If Mitomycin C application does not achieve adequate sustained patency after multiple sessions:

• Consider temporary placement of fully covered self-expanding metal stents for 4-8 weeks (though migration occurs in ~30% and adverse events in ~20%). 5
• Refer to specialized centers with expertise in refractory stricture management for advanced techniques such as combined anterograde-retrograde dilation (CARD procedure). 9
• Reserve surgical resection (esophagectomy) as the final option when all endoscopic interventions have failed. 4

Common Pitfalls to Avoid

Do not apply Mitomycin C before confirming the stricture is truly refractory—premature use before optimizing standard therapy (adequate PPI dosing, appropriate dilation intervals) wastes resources and exposes patients to unnecessary interventions. 5, 4

Do not use blind Maloney bougies for any refractory stricture that will receive Mitomycin C, as these carry unacceptable safety risks in complex strictures. 4

Do not assume the stricture is the sole problem if restenosis occurs rapidly despite adequate treatment—obtain further biopsies and imaging to exclude occult malignancy or consider alternative neuromuscular causes of dysphagia such as achalasia or esophageal spasm. 5