Esophageal strictures are abnormal narrowings of the esophagus that present with symptoms that include difficulty swallowing (dysphagia), painful swallowing (odynophagia) or the regurgitation of food and weight loss. 75% of all esophageal strictures are caused by gastroesophageal reflux disease (GERD).
Esophageal dilations are performed to treat both benign and malignant esophageal strictures and can offer potential relief for those suffering from the resulting dysphagia. In cases with malignant esophageal strictures, dilation is used in endoscopic procedures to help in the placement of an esophageal stent.
After a stricture has been confirmed, esophageal dilation is often considered as the primary treatment option. During an esophageal dilation procedure, a dilator is opened in the esophagus in order to open strictures. Dilators are passed in sequentially increasing sizes to dilate the obstructed area.
A variety of techniques is available; each has benefits and is appropriate in specific cases.
SIMPLE DILATORS (BOUGIES): A series of flexible dilators of increasing thickness, the bougie is the simplest and quickest method of opening the esophagus. One or more bougie is passed down through the esophagus at a time.
GUIDED WIRE BOUGIE: Through endoscopy a flexible wire is placed across the stricture. The endoscope is removed and the wire left in place. A dilator with a hole through it from end to end is guided down the esophagus and across the stricture. One or more of these dilators are passed over the wire. At the end of the procedure, the wire is removed. This type of treatment may be performed in the x-ray department under fluoroscopy.
BALLOON DILATORS: Deflated balloons are placed through the endoscope and across the stricture. When inflated, they become sausage-shaped, stretch, and break the stricture.
ACHALASIA DILATORS: Achalasia is a special situation which requires a larger, balloon-type dilator. The procedure is frequently done under x-ray control. In this procedure, the spastic muscle fibers in the lower esophagus are stretched and broken, which in turn allows easier passage of food and liquid into the stomach.
The choice of dilator is a matter of physician preference where one type does not appear to be more effective or safe if proper technique is followed.
Balloon dilation is done directly through an endoscope. Balloons can be inflated to sizes from 6 to 30 mm. “In the case of a known esophageal stricture, the endoscope is placed, we visualize the stricture through the endoscope and then we pass the balloon through the instrument channel while it’s still deflated,” says Ken Lee, MD, FAAP, pediatric gastroenterologist at Children’s Hospital of Wisconsin, and assistant professor of pediatrics and director of pediatric endoscopy for the division of pediatric gastroenterology, Medical College of Wisconsin. “We keep the stricture in the middle of the balloon and then we inflate it to a given diameter.” Once the balloon has been inflated to the desired diameter, it is kept in place for a short time before deflating, anywhere between 30 seconds and 2 minutes.
“We then take the balloon out and look through the endoscope to see what effect it’s had—did it dilate, how much bleeding is there and of course did we cause a perforation, which is always a risk.” Lee explains that minimal bleeding is a positive sign. “Actually, to achieve a good result with dilation, you do want to see bleeding,” he says. “That means you’ve broken the tissue and stretched the stricture.
Bougies, or savaries, are rigid rubber tubes. Progressively larger bougies are passed through the mouth and down the esophagus using a wire in order to dilate the stricture. The lack of an endoscope during bougie dilation can be a disadvantage. It is not done under any direct visualization, but it may be done under fluoroscopy.
Bougies have advantages in certain circumstances. “They’re often useful for long strictures,” Lee continues. “If an esophagus is strictured for, say, 10 cm, balloon dilation doesn’t work very well.”
However, risk of complication using bougies may be higher. “When you bougie somebody, you’re dilating their whole esophagus, so you can tear anywhere along the esophagus because there are shearing forces the whole way, but it depends on a lot of factors such as the length, tightness and cause of the stricture.”
About 60% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce the duration.
A 2002 study suggested that dilation may help correct swallowing problems that can occur after fundoplication. In the study dilation improved dysphagia in 67% of the surgical patients who had experienced it.
See video of Esophageal Dilation.
GERD Surgery - Esophageal Dilation: References
By Mortin - Copyright 2009
Last modification 30/12/2009