Dilation of the Esophagus: Wire-guided Bougie (Savary, American) and Balloon Dilators
Chanakyaram A. Reddy, MD
Joan W. Chen, MD, MS
The two most common types of esophageal dilators used in endoscopy suites are fixed-diameter push-type “bougies” and balloons. Bougie dilators apply radial and axial forces along the entire stricture length, while balloon dilators apply radial force to portions of the stricture that come into contact with the balloon.
Wire-guided, compared to non-wire-guided, dilation offers the ability to dilate difficult and convoluted strictures with some control over the path of the bougie. Both of the two available systems, the Savary-Gilliard and the American endoscopy systems, offer a wire with a spring tip for insertion into the stomach. Neither system has been demonstrated to be superior to the other with respect to safety or quality of the dilation.
There are several esophageal balloon dilators with a variety of designs, lengths, and calibers. These include single-diameter or multiple sizes that can be used over a guidewire or through-the-scope (TTS). This chapter will focus on the use of TTS balloon dilators as this method allows for dilation at multiple sizes with one instrument and is more commonly used than other types of balloon dilators in current endoscopy practices. Balloons are expanded by injection of liquid (water or radiopaque contrast to facilitate fluoroscopic visualization if needed) with use of a handheld accessory.
Both wire-guided bougie and TTS esophageal dilators are commonly used without clear data indicating significant differences in efficacy or adverse events between the two techniques.1 Decision-making in regards to which dilation method to use may vary based on institutional practice, operator experience, or the location and characteristics of the stricture. Balloon dilators are usually limited to short-segment, mid to
distal esophageal strictures; whereas, bougie dilators can be used in long-segment and proximal strictures and in a diffusely narrowed esophagus. TTS balloon dilators require a 2.8 mm working channel and are not compatible with the majority of smaller-caliber endoscopes such as a neonatal endoscope. Furthermore, bougie dilators are reusable while majority of balloon dilators are single-use only. Lastly, TTS balloon dilators lack tactile feel that can be appreciated while using push-type bougie dilators but do offer direct endoscopic visualization of the dilation, and the use of multidiameter balloon dilators may shorten procedure time.
distal esophageal strictures; whereas, bougie dilators can be used in long-segment and proximal strictures and in a diffusely narrowed esophagus. TTS balloon dilators require a 2.8 mm working channel and are not compatible with the majority of smaller-caliber endoscopes such as a neonatal endoscope. Furthermore, bougie dilators are reusable while majority of balloon dilators are single-use only. Lastly, TTS balloon dilators lack tactile feel that can be appreciated while using push-type bougie dilators but do offer direct endoscopic visualization of the dilation, and the use of multidiameter balloon dilators may shorten procedure time.
INDICATIONS
1. To provide relief of dysphagia in subjects with esophageal strictures secondary to most commonly acid-peptic disease or variety of other causes including eosinophilic esophagitis, caustic injury, radiation injury, pill-induced esophagitis, postendoscopic therapy, or postsurgical anastomosis scarring
2. To dilate esophageal webs or rings
3. Congenital esophageal anomalies such as tracheoesophageal fistula
4. Cricopharyngeal bar
5. Some cases of achalasia (pneumatic dilation should be used in this setting)
6. As short-term palliation in esophageal malignancy
CONDITIONS UNLIKELY TO BENEFIT FROM DILATION
1. Extrinsic malignant compression
2. Motility disorders
CONTRAINDICATIONS
1. Cardiac instability, respiratory insufficiency, or other life-threatening cardiopulmonary conditions
2. Significant bleeding diathesis
3. Warfarin, heparin, or thienopyridine (e.g., clopidogrel) antiplatelet therapy
4. Lack of patient cooperation
5. An impacted food bolus (however, dilation may be performed after disimpaction)
6. Severe cervical spinal arthritis
7. Acute or incompletely healed esophageal perforation
8. Severe acute esophagitis (e.g., from untreated reflux or infection) may be a relative contraindication
PREPARATION
1. Subjects should be NPO for 6 hours prior to the examination.
2. Obtain written consent.
3. Administer a topical anesthetic for pharyngeal anesthesia.
4. Start an intravenous line for the administration of systemic sedation.
WIRE-GUIDED BOUGIE (SAVARY OR AMERICAN) DILATION
Equipment
1. Upper endoscope
2. Spring-tipped wire
3. Appropriate range of dilator sizes, generally up to 18 to 20 mm (54 to 60 French)
4. Lubricant
5. Gloves
6. Available fluoroscopy, for complex or tight strictures
Procedure
1. Perform diagnostic upper endoscopy. If the esophageal stricture is too tight to allow passage of the adult upper endoscope, a pediatric or neonatal scope may be necessary to traverse the stricture. Special note should be made of any tortuosity, diverticula, or angulation, as these conditions may increase the risk of adverse event or ineffective bougienage. The approximate minimal diameter of the stricture should be noted by comparing it to the scope tip or to an open forceps.Related posts:
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