Oesophageal Dilatation/Stenting
Balloon dilatation and/or stenting of the oesophagus may be indicated for malignant and non-malignant reasons. Non-malignant indications include Achalasia, a rare condition characterised by impaired peristalsis and failure of the lower oesophageal sphincter to relax; and benign strictures, arising from oesophageal reflux, oesophageal resection surgery, radiation injury or ingestion of corrosive substances.
The presenting features of malignant disease may be indistinguishable from non-malignant causes and include dysphagia, regurgitation, chest pain and weight loss. Work-up for oesophageal obstruction must therefore consider the possibility of cancerous lesions. Benign lesions typically undergo dilatation, malignant oesophageal tumours are typically stented, using partially or fully covered self-expanding metal stents – covered stents reduce the possibility of tumour ingrowth.
Proximal lesions, for example, lesions at the pharyngo-oesophageal level are less commonly stented due to the chance of stent migration causing laryngeal irritation. Proximal stents are also associated with a higher risk of tracheo-oesophageal fistulae formation. Distal obstructing lesions and long-standing obstructing lesions are more likely to have debris behind them – airway protection should be considered when these patients present for dilatation/stenting.
Operator Considerations
Indications: symptomatic obstruction of the oesophagus. Achalasia, reflux-induced strictures and malignant strictures are the most common indications.
Contraindications: active oesophageal perforation is an absolute contraindication. Relative contraindications include coagulopathy. Anticoagulants should be discontinued pre-procedure.
Planning: a barium swallow test will help to establish size, level and extent of the oesophageal lesion. Oesophageal manometry and oesophagogastroduodenoscopy (OGD) will help to rule out other disorders.
Duration: 30-60 minutes.
Position: supine, for the airway-protected patient, left lateral if the airway is unprotected
Access: trans-oral approach – shared airway, mouth guard advisable.
Technique: Achalasia: a catheter is introduced into the oesophagus over a guidewire. The size and length of the narrowed segment is defined by injecting contrast medium into the oesophagus via the catheter. A balloon is passed to the level of the oesophagogastric junction and inflated for 1-3 minutes. A second and third inflation may be performed. Stent selection: the stent is chosen so that at least 2 cm of normal oesophagus is covered both above and below the stricture. Long strictures may require more than one stent.
Complications: the procedure has a low complication rate. Main complications include perforation, bleeding and bacteraemia. Aspiration, prolonged chest pain and stent migration may also occur.
Post-procedure: water-soluble contrast study to screen for perforation. Oesophageal dilatation is often performed as a day case procedure. The patient should be observed for a minimum of 2 hours before discharge. A barium oesophagogram is performed at 4-6 hours post-procedure to screen for a mucosal tear or perforation. The patient must be able to tolerate water orally before discharge.