The tight esophagus-Bougies or balloons

Esophageal strictures can be managed with a variety of techniques. 
Each device for dilation has its advantages and disadvantages which are 
important in selecting the appropriate one for each situation. Stricture management 
with dilation may require many sessions over a prolonged time. Complications 
of dilation are infrequent, but perforation must be watched for closely since 
its consequences are so serious. The most important factor in stricture management 
with dilators is physician familiarity with the method selected.

E SOPHAGEAL NARROWLNG WHICH causes dysphagia can usually he treated by dilation with a variety of tech, niques.Narrowings that are potentially treatable include peptic, neoplastic, corrosive, anastomotic, radiation and post sclerotherapy strictures, plus rings, webs, diffuse esophageal spasm, cricopharyngea 1 achalasia and achalasia.These lesions should be diagnosed by barium radiography, endoscopy and manomecry used singly or in combination before treatment is undertaken.ln the treatment plan, esophageal dilation is only a portion of the care and should be individualized for each disorder and patient.
A variety of dilating devices arc available to the physician for stretching an esophageal narrowing.The Eder-Puestow technique employs metal o lives that are passed over a gu1<lewire (Figure l ).
Mercury-filled rubber bougies come with either a taper tip (Maloney; Pilling, Pennsylvania) or a blunt tip (Hurst; Pilling, Pennsylvania) (Figure 2).The Celestin c.Jilator is usually passed over a guidewire and has severa l graded d iameters per dilator, while the Savary (Wilson-Cook Medical.North Caro lina) and Savary-like tapered c.Jilators are each a different size (Figure Uni11ersicy  2).Cruntzig (M1crovas1vc, Massachusetts) balloon dilators can be used solely over a guidewire, over a guidewire alongside an endoscope, or pu rely through the endoscope (Figure 3 ).
The choice of method is difficult.The Eder-Puestow (Eder Instruments, Illinois) technique has been used for a long time, but the instrument 1s somewhat d ifficult for the patient to tolerate and the outcome tends to be splitting of the esophageal lesion rather than stretching it (1).This technique requires multiple passes through the pharynx over a guidewire.The flexible metal shaft of the dilator can traumatize the pharynx.The o li ves that are changed with each passage are short and fat, which b a distinctly disadvantageous shape fo r dilation of an esophageal stricture.The lack of taper on the olive ( wide angle of mcidence) means that there 1s conside rable axial instead of radial force delivered to the stricture.Thus, the nsk of tearing is higher.A lso, the length of the point of maximal diameter on the o live is very short, which is undesirable for long strictures.
Effective stretching can be achieved by use of any of the tapered dilating systems.Mercury bougies are less effective than polyvinyl d ilators at small sizes because they are too flimsy.Tapered-tip mercury-filled soft rubber dilators are most commonly used for simple benign esophageal stnctures.Blunt mercury-filled bougies ( Hurst; Pilling, Pennsylvama) are best for di~ruption of esophageal rings and webs.The flexibility of the mercury-filled hougie adds a degree of safety since 1t will bend more easily.This allows for Figure 1) Eder-Puescow dilator shown with interchangeable metal olives.The very flexible spring tip precedes the olive and the more rigid pushing shaft over the guidewire ( not shown) into the esophagus arul stomach Figure 2) Bougies or dilators.The wp two are rubber and filled with mercury.The blunt-tip/Jed mercury-filled dilator is a Hurst dilator and che caper-tipped one is a Maloney.The third dilator from the cop is a Celestin dilator, which passes over a guidewire ( not shown) and has four separate dilating segments each a bit larger chan the preceding one.The bottom dilator is a polyvinyl caper-upped dilator primarily designed to be passed o,,er a guidewtre, although it can be used cautiously withottt safer passage through the pharynx and may make perforation less likely, since the bougic will flex when pushed against an obstructing surface.The disadvantage, as mentioned above, is rhe lack of creation of any stretching force with the small diameter hougies.They easily buckle in the esophagus, which can give the physician the false sense of effectively dilating the stricture.Larger bougics can also buckle, and if the physician b nm familiar with the feel of the difference between stretching a stricture and buck I ing in the esophageal lumen, he or she may push too hard and rupture the esophageal wall with the bowed dilator.
Long Esophageal dilation should be performed on fasted patients.Most patients will require some topical pharyngeal anesthesia.Parenteral analgesics or sedatives may be used but are not necessary for most simple dilatJOns, especially if they are repeat (maintenance) proceJures.The patient is kept in the sitting position for dilation with the mercury-filled bougics, while the left lateral dccubitus or supine positions arc best for guidewire-or endoscope-guideJ dilations.
Fluoroscopy may be used to assist m the correct performance of an esophageal dilation, but is used less today with the increased use of the endoscope e1rher to place the guidewire or to place the balloon dilator directly.Any difficult stricture can be more safely dilated with the aid of fluoroscopy no matter which system is being used.The added visual dimension of fluoroscopy will help prevent perforation from misdirected dilators, dilators passed too far mto the stomach, or excessively bowed dilators (7).Fluoroscopy also allows the physician to assess whether a balloon dilator has fully expanded or not when it is inflated in a stricture.The choice of the initial dilator size shou Id be based on an estimated diameter of the narrowing by either prior barium swallow or endoscopy.
Ideally, one should try co achieve a final esophageal lumen diameter of between 40 and 50 French.This diameter b recommended since symptomatic deterioration seems to recur less quickly after these larger diameters have been reached (8-10).The final desired diameter may not be reached at the initial session because of pain or excessive blood on the dilators.
No specific testing needs to be perfonued.on the patient after an uneventful dilation; however, if there is any suspicion that perforation has occurred, a water-soluble contrast esl)phagram should be dl)ne immediately.This is followed by a barium esophagram if no leak is seen, since barium may show a leak not seen with water-soluble cont rast.It is very important co do these studies at the first suspicion of a perforation; every minute is critical in the management of esophageal perforation; (surgery in the first few hours is easier, more effective, and assoc iated with fewer complications than a delayed operation).
Rupturing of rings and webs with a large (greater than 48 French) blunt bougie will usually take care of the problem in one session, though occasionally they may recur.Dilation of malignant strictures requires frequent repetition Gut 1984;25:l l00-02.The m,iin complications encountered after csophagccil dibt1on arc perforation, bleeding, and aspiration pneumonia.The frequency of these complirntions ranges from 0.3 to 1.0% (7).Bactercmia during and after esophageal dilation has heen reported in five to 100% of pciuents studied ( 11 ).

Cox
Consequently, one must consider antibiotic prophylaxis for patients with increased risk of en<locarditis.
Esophageal d ilation is a safe and effective method for relieving dysphagia secondary to mechanical narrowing of the esophageal lumen.Given the array of dilators available, one should he able to manage any narrowing using one device or another alone or in combination.However, the potential for serious complications is ve ry high if the operator is not experienced in the use of these instruments.

Figure 3 )
Figure 3) Microvasive through-the-scope balloon dilator.The catheter has a soft, flexible tip and ,s suffened throughout with a built in gurdewire.The balloon rs inflated w the desired pressure, which is monitored by the pressure gauge once the balloon 1s positioned withm the stricture lumen Lye-induced strictures are notoriously difficu lt to treat anJ often require repeated dilations for many years.Patients who have frequently recurring strictures may be caught co self-dilate at home.