Benign strictures of the esophagus usually result from scarring and subsequent tissue contraction secondary to esophageal wall injury. This pathology is caused in most cases by long-standing gastroesophageal reflux disease (GERD), often in association with one of the esophageal motility disorders (e.g., achalasia, diffuse esophageal spasm, or aperistalsis).^1,2 Endoscopic dilation of benign esophageal strictures that are refractory to medical management is a less morbid alternative to surgery. Approximately 20% to 30% of cases are unrelated to GERD, and their treatment usually is more challenging. Examples include strictures arising from complications of surgical anastomosis,³ injuries caused by caustic ingestions, early and late consequences of external-beam radiation, esophageal sclerotherapy, laser or photodynamic therapy, medication- or pill-induced esophagitis that is associated with numerous medications (e.g., alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs, phenytoin, potassium chloride, quinicline, tetracycline, and ascorbic acid) but most often aspirin, and rare dermatologic diseases, including epidermolysis bullosa dystrophica, among others.

Benign strictures also may result from external compression of the esophagus caused by mediastinal fibrosis induced by tuberculosis, fungal infection, radiation therapy, or idiopathic fibrosing mediastinitis. These conditions may give rise to long, narrow strictures that are difficult to dilate and in which dilation may be associated with a higher rate of complications.

Dysphagia is the most common presenting symptom of benign esophageal stricture. The degree of dysphagia is proportional to the scope (e.g., length) of the stricture and the luminal diameter of the esophagus (<13-mm diameter is associated with dysphagia to solids, >18-mm luminal diameter for normal swallowing). As the stenosis worsens over time, the dysphagia progresses from solid to semisolid to liquid foods. The etiology of the esophageal stricture usually can be identified using radiographic modalities and is confirmed by endoscopic visualization and tissue biopsy. Manometry is the defining diagnostic procedure when esophageal dysmotility is suspected as the primary inciting process. CT scan and endoscopic ultrasound are valuable diagnostic aids that can distinguish benign from malignant strictures. Fortunately, most benign esophageal strictures are amenable to single or combined pharmacologic, endoscopic, or surgical intervention.

The goal of therapy for benign esophageal stricture is twofold: to relieve the patient’s dysphagia and to prevent recurrence of the stricture.⁴ Conservative and surgical approaches to management are recommended depending on the etiology of the inciting injury. Surgical and medical issues related to esophageal dilation in patients with primary esophageal motility disorders are discussed in Part 4 (see Chapter 33). Medical and surgical issues related to GERD are the topic of this part and are summarized in the Overview (see Chapter 37). This chapter focuses on surgical instrumentation and techniques for the less common or complex benign esophageal stricture.

Dysphagia is the cardinal symptom of esophageal stricture. In most cases, when a stricture is suspected, the patient is evaluated radiographically with a barium swallow. The goals of this imaging modality are to establish the location, length, and number of strictures; to determine the maximal or minimal luminal diameter in normal and strictured regions; and to identify the presence of associated pathologies, such as esophageal diverticula, including Zenker diverticula, or hiatal hernia. This information is helpful for selecting instrumentation, devising strategies for treatment, estimating the number of sessions that will be required to relieve the patient’s symptoms, and counseling patients about the expected risks of dilation. If barium studies raise suspicion for malignancy, a diagnostic endoscopy may be required. Usually, however, endoscopy and dilation are combined in the initial session.

In addition to specific features of esophageal stricture that contraindicate dilation (e.g., extremely long and tortuous strictures), several comorbidities also can increase the patient’s risk. Dilation should not be attempted in the setting of an acute or incompletely healed esophageal perforation. As with any other surgical procedure, the benefits of esophageal dilation should outweigh the risks of the procedure in all patients with bleeding disorders or severe pulmonary or cardiovascular disease. Such patients may not tolerate endoscopy, with or without dilation. Dilation should be performed cautiously in patients with a pharyngeal or cervical deformity, recent surgery, a large thoracic aneurysm, or an impacted food bolus.

There are two basic types of dilators, mechanical and balloon, and each may be fitted with a guidewire (Figs. 44-1 and 44-2). Studies comparing mechanical (bougie) and balloon dilation have reported varying results.^5,6 The success of one instrument over the other depends largely on the endoscopist’s experience and familiarity with a particular product. However, for strictures with complex features, a guidewire-based mechanical or balloon dilating system, such as the Savary esophageal dilator (Wilson-Cook Medical, Inc., Winston-Salem, NC), should be used exclusively. The mechanics of esophageal luminal dilation are not known precisely, but the results probably are affected by circumferential stretching or frank splitting of the stricture. Mechanical and balloon dilators differ in the way they accomplish this goal. Mechanical dilators exert a longitudinal and radial force, dilating progressively from the proximal to the distal extent of the stricture. In contrast, balloon dilators deliver the force radially and uniformly across the entire length of the stricture, which significantly reduces shear stress.

Mechanical Dilators

Mechanical dilators are classified as those that can be passed freely through the stricture and those that are inserted over a guidewire. The Maloney dilator (Medovations, Inc., Germantown, WI) is the most commonly used freehand dilator.⁵ Maloney dilators have a tapered heavy tip and come in multiple sizes. Several versions of guidewire-assisted dilators are available, but the Savary-Gilliard device (Wilson-Cook, Inc., Winston-Salem, NC) is probably used most commonly. This dilator is made from plastic, has a tapered tip, and comes in multiple sizes. Bard Interventional Products, Inc. (Tewksbury, MA), has a similar product called the American Dilatation System. An older system, the Eder-Puestow Olive dilators (Eder Instruments Co., Chicago, IL), uses progressively larger elliptical metal dilators that are passed over a guidewire. We prefer the Savary dilators for their flexibility and ease of use in our practice, and these generally have supplanted the metal Olive dilators.