0016-5107/91/3701-0122$03.00GASTROINTESTINAL ENDOSCOPYCopyright © 1991 by the American Society for Gastrointestinal Endoscopy

Esophageal dilation

Guidelines for clinical application

I. INDICATIONS AND CONTRAINDICATIONS

Esophageal dilation is performed for treatment ofsymptomatic anatomical or functional narrowing ofthe esophagus caused by a variety of conditions.1, 2

Established indications for dilation include peptic,neoplastic, corrosive, radiation, post-surgical, andpost-sclerotherapy strictures, as well as rings, webs,and achalasia. Dilation may be of benefit in oropha­ryngeal dysphagia and diffuse esophageal spasm.1 Di­lation generally does not improve dysphagia caused byexternal compression of the esophagus. One controlledtrial of dilation has shown no benefit in nutcrackeresophagus.3 Initial dilation should not be performeduntil the esophagus and accessible upper gastrointes­tinal tract have been evaluated with contrast radiog­raphy and/or endoscopy with biopsy and brushing asindicated.3 Repeat endoscopy, biopsy, and brushingmay be necessary after a stricture has been dilated toassure complete evaluation of the stricture and uppergastrointestinal tract.2 Esophageal dilation should beconsidered only one aspect of management of theunderlying disease (e.g., reflux, neoplasm, motilitydisorder).

Acute or incompletely healed esophageal perfora­tion is a contraindication to esophageal dilation. Rel­ative contraindications include bleeding disorders, se­vere pulmonary disease, recent myocardial infarction,recent esophageal perforation or surgery, pharyngealor cervical deformity, recent laparotomy, and largethoracic aneurysm. If the clinical situation warrantspatients with all of these conditions may be dilated:Concomitant radiation therapy is not a contraindica­tion to dilation.4

II. EQUIPMENT

Available dilation equipment includes mercury­weighted rubber bougies (blunt-tipped and tapereddilators), wire-guided metal olives, wire-guided ta­pered polyvinyl bougies, and balloons. Endoscopicallydirected balloon dilators may also be used without a

AISIGIE Publication No. 1023.

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guide wire. There are few published data and no con­trolled trials which help in choosing one dilationmethod over another. Mercury-weighted bougies canbe used for many benign peptic strictures. Mercurybougies smaller than 30 French tend to be too flexibleto dilate most tight strictures. Wire-guided or endo­scopically guided methods are usually needed for long,tight, and/or tortuous strictures as well as those as­sociated with large hiatal hernias, esophageal divertic­ula, or tracheo-esophageal fistulas. Fluoroscopic mon­itoring is useful in most of these situations, but maynot be required where the anatomy is straight, well­defined, and/or an endoscope can pass through thestricture.

III. TECHNIQUE

Prior to bougie dilation the patient should have anempty stomach and esophagus. Topical pharyngealanesthesia is often used. Sedation may be helpful insome circumstances, especially when dilation involvesendoscopy and/or guide wires. To achieve an adequateesophageal lumen by dilation, several sessions may berequired. It is recommended that once moderate re­sistance is encountered, no more than three dilatorsof progressively increasing diameter (2 to 3 Frenchunits) be passed in a single session.1, 5 Resistance isdifficult to judge with balloon dilators. Filling hydro­static balloons with a 1/3 dilution of water-solublecontrast facilitates fluoroscopic visualization. It is fre­quent practice and appears to be safe to performdilation immediately after flexible endoscopic mucosalbiopsy of the esophagus.6

IV. RESULTS

Dilation results in improvement or resolution ofdysphagia in 80 to 90% of benign strictures.? If aluminal diameter of at least 13 to 15 mm (41 to 47French) can be achieved, nearly all patients will ber~lieved of dysphagia. In contrast to benign strictures,rmgs or webs are treated by disruption by passage ofa single large bore dilator (greater than 48 French),

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which usually achieves adequate results. If a loweresophageal ring cannot be distinguished from a shortpeptic stricture, graded stepwise dilation is appropri­ate. Most malignant strictures respond to dilation, butrelief from dysphagia is usually transient. Dilation ofa malignant stricture is helpful preceding laser orother ablative endoscopic procedures, and prior toplacement of an endoprosthesis. After successful di­lation, both benign and malignant strictures may re­cur.? Retreatment may be required at variable inter­vals. Carefully selected, highly motivated patientswith chronic, benign strictures requiring frequentperiodic dilation can be taught self-dilation.8

V. COMPLICATIONS

The principal complications of dilation include per­foration, pulmonary aspiration, and bleeding. Tran­sient chest pain is frequent during dilation of tight orneoplastic strictures. Persistant pain or developmentof fever warrants an evaluation for complications. Inan A/S/G/E survey,9 both perforation and bleedingoccurred at a rate of approximately 0.3% per proce­dure. The risk is higher in complex strictures (longer,narrower, more angulated), particularly those causedby lye. Bacteremia is more common after esophagealdilation than after most other gastroenterologic pro­cedures,lO and endocarditis has been reported,l1 Dis­infection of dilators prior to use has been reported toeliminate bacteremia in some,12 but not all studies.13

Prophylactic antibiotics may be indicated in selectedpatients.14

VI. ACHALASIA

Esophageal dilation for achalasia is unique in thatit involves forceful disruption of the lower esophagealsphincter.15 It is critical that an accurate diagnosis bemade before dilation. Esophageal manometry is animportant confirmatory test. Although a classic ap­pearance on barium esophagogram may be present, anendoscopic examination should be performed as neo­plasms of the esophagogastric junction can clinicallymimic achalasia. 16 Abdominal CT of the esophagogas­tric junction may also be helpful when neoplasm issuspected.

Although treatment with calcium channel-blockingdrugs and dilation with mercury-filled bougies mayprovide partial or temporary relief of symptoms ofachalasia, sustained relief of symptoms usually re­quires disrupting the lower esophageal sphincter withspecialized dilators or surgery. Several types of dila­tors can be used for treating achalasia. A detaileddescription of these instruments and their use is be­yond the scope of this guideline. The choice of dilatorand technique should be based on training and expe-

GASTROINTESTINAL ENDOSCOPY

rience as there are no comparative studies. Inexperi­enced operators should not perform these procedureswithout skilled supervision.

The usual cautions related to esophageal dilationapply to forceful dilation of achalasia. Dilation in asigmoid esophagus can be safely done if one of theguide wire techniques is used. Despite an overnightfast, a dilated esophagus may still retain fluid anddebris requiring evacuation through a tube. Adminis­tration of a sedative and/or an analgesic is importantas the procedure is often painful. Fluoroscopic guid­ance for placement of the dilator is mandatory. Fol­lowing the procedure an esophagogram is often doneto evaluate for perforation. Patients should be ob­served for several hours after the procedure. Hospi­talization for observation is appropriate in selectedpatients. Clinical success is ultimately reflected byimprovement in dysphagia, weight gain, and a de­crease in esophageal caliber during follow-up. Sixty to80% of patients will have good long-term results fromdilation. The risk of perforation after forceful dilationfor achalasia is reported to be 1 to 6%, with a mortalityrate of less than 1%. Post-dilation reflux may occur.If a single dilation session does not produce satisfac­tory relief, a second attempt may be warranted. If thisfails, surgery is usually indicated. Surgical myotomyprovides a 10 to 20% higher rate of long-term relief ofdysphagia but is attended by higher risks of operativemortality and significant reflux. I?, 18

REFERENCES1. Boyce HW, Palmer ED. Techniques ofclinical gastroenterology.

Section III. Springfield, IL: Charles C Thomas, 1975.2. Graham DY. Dilation for the management of benign and malig­

nant strictures of the esophagus. In: Silvis SE, ed. Therapeuticgastrointestinal endoscopy. Chap. 1. New York: Igaku-Shoin,1985.

3. Winers C, Artnak EJ, Benjamin SB, Castell DO. Esophagealbougienage in symptomatic patients with the nutcracker esoph­agus. A primary esophageal motility disorder. JAMA1984;252:363-6.

4. Palmer ED. Peroral prosthesis for the management of incurableesophageal carcinoma. Am J Gastroenterol 1973;59:487-98.

5. Tulman AB, Boyce HW. Complications of esophageal dilationand guidelines for their prevention. Gastrointest Endosc1981;27:229-34.

6. Barkin JS, Taub S, Rogers AI. The safety of combined endos­copy, biopsy, and dilation in esophageal strictures. Am J Gas­troenteroI1981;76:234.

7. Patterson DJ, Graham DY, Smith JL, et al. Natural history ofbenign esophageal strictures treated by dilatation. Gastroenter­ology 1983;85:346-50.

8. Grobe JL, Kozarek RA, Sanowski RA. Self-bougienage in thetreatment of benign esophageal stricture. J Clin Gastroenterol1984;6:109-12.

9. Silvis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. En­doscopic complications. Results of the 1974 American Societyfor Gastrointestinal Endoscopy survey. JAMA 1976;235:928­30.

10. Botoman VA, Surawicz CM. Bacteria with gastrointestinalendoscopic procedures. Gastrointest Endosc 1986;32:342-6.

11. Niv Y, Bat L, Motro M. Bacterial endocarditis after Hurstbougienage in a patient with a benign esophageal stricture andmitral valve prolapse. Gastrointest Endosc 1985;31:265-7.

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12. Raines DR, Branche WC, Anderson DL, Boyce HW. The oc­currence of bacteremia after esophageal dilation. GastrointestEndosc 1975;22:86-7.

13. Welsh JD, Griffiths WJ, McKee J, Wilkinson D, Flournoy DJ,Morh JA. Bacteria associated with esophageal dilatation. J ClinGastroenteroI1983;5:109-12.

14. Infection control during gastrointestinal endoscopy. Guidelinesfor clinical application. American Society for GastrointestinalEndoscopy. Gastrointest Endosc (suppI)1988;34:37S-40S.

15. Vantrappen G, HelJemans J. Treatment ofachalasia and related

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motor disorders. Gastroenterology 1980;79:144-54.16. Tucker HJ, Snape WJ, Cohen S. Achalasia secondary to carci­

noma: manometric and clinical features. Ann Intern Med1978;89:315-8.

17. Vantrappen G, Janssens J. To dilate or operate? That is thequestion. Gut 1983;24:1013-9.

18. Csendes A, Braghetto I, Henriquez A, Cortes C. Late results ofa prospective randomized study comparing forceful dilatationand oesophagomyotomy in patients with achalasia. Gut1989;30:299-304.

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