Esophageal Dilation and Stenting

Balloon dilation and stent placement for esophageal lesions

Your esophagus is the muscular tube connecting the back of your mouth to your stomach. When you swallow, the muscles of your esophagus contract. They propel food and liquids, including saliva, into your stomach. Narrowing (stricture) of the esophagus can cause problems. These include trouble swallowing.  This is called dysphagia.

In most instances, the problem is a mechanical one with an obstruction acting like a dam across a stream. Therefore, the treatment must be mechanical. The dam must be broken. After a diagnosis is made, the physician determines the method of treatment that is in the patient’s best interest. The physician has a variety of techniques available. Each has benefits and is appropriate in specific cases. The physician will always discuss these options with the patient.

Esophageal Dilation procedure

As mentioned, there are a number of dilating techniques available to the physician. Simple bougie dilation may be done in the office in a sitting position and with only an anesthetic spray of the throat. If endoscopy is performed at the same time then it will be done in an outpatient endoscopy facility/lab usually under sedation. If x-ray fluoroscopy equipment may be needed the procedure may also be performed in the x-ray unit. Simple bougie dilation may take only a few minutes. The other techniques require 20 to 30 minutes. Recovery is usually quick and the patient can soon begin eating and drinking to test the effectiveness of the procedure.

Esophageal Dilation and Stenting

Several problems can be treated with esophageal dilation. They include:

• Peptic stricture. This is caused by reflux esophagitis. With this problem, the esophagus is irritated by acid reflux (heartburn). This occurs when acid from your stomach flows back up into the esophagus. Stomach acid damages the lining of the esophagus. This leads to a buildup of scar tissue. As a result, the esophagus is narrowed.
• Schatzki’s ring. This is an abnormal ring of tissue. It forms where the esophagus meets the stomach. It can cause trouble swallowing. It can also cause food to get stuck in the esophagus. The cause of this condition is not known. This condition stops food and liquids from moving into your stomach from the esophagus. It affects the lower esophageal sphincter (LES). The LES is a muscular ring that opens (relaxes) when you swallow. With achalasia, the LES does not relax. This condition can also cause problems with peristalsis. This is the normal muscular action of the esophagus that moves food into the stomach.
• Eosinophilic esophagitis. This is a redness and swelling (inflammation) in the esophagus. It is caused by an environmental trigger such as a food allergy. It can lead to pain, trouble swallowing, and strictures.
• Tumors–Various forms of tumors, benign and malignant can block the esophagus. This condition is obviously very important to diagnose and treat promptly.
• Heredity–The esophagus may be partially or completely blocked at birth.
• Less common causes of stricture. Other causes of stricture include radiation treatment and cancer.

Esophageal dilation is the careful stretching of the wall of the esophagus in order to provide relief from narrow areas in your esophagus.

Before Your Procedure

Ask about your medications

You may need to stop taking some of your medications before your procedure. Talk with your healthcare provider about which medications are safe for you to stop taking. We have included some common examples below.

• Blood thinners
• Medications for diabetes
• Diuretics (water pills)

Don’t stop taking your medication without talking with your healthcare provider.

If you’ve had an allergic reaction to contrast dye in the past, tell the doctor doing your biliary drainage catheter procedure. They may tell you to take medication before your procedure.

On the day of intervention

Do not eat anything after midnight the night before your procedure. This includes hard candy and gum. You can drink a total of 400ml (2 glasses) of water between midnight and 2 hours before your scheduled arrival time. Do not drink anything else.

Bring all of your usual medication(s) (or a complete list) with you.

If you wear any of the following devices on your skin, the manufacturer recommends you remove it before your scan or procedure:

• Continuous glucose monitor (CGM)
• Insulin pump

Talk with your healthcare provider about scheduling your appointment closer to the date you need to change your device. Make sure you have an extra device with you to put on after your scan or procedure.

If you’re not sure how to manage your glucose while your device is off, talk with the healthcare provider who manages your diabetes care before your appointment.

If you wear contact lenses, wear your glasses instead, if possible. If you don’t have glasses, please bring a case for your contacts.

It is also recommended that you bring any recent X-rays or scans with you if you have copies at home.

A relative or friend must be available to drive you home after the procedure, as you will not be allowed to drive after sedation or anaesthesia.

During the procedure

• An intravenous (IV) catheter will be placed into your arm so that medications can be given for sedation. It is generally not a painful exam, but the sedation helps you to relax.
• Most of the effects of the sedation persist for 15-60 minutes, and you may not be able to recall the procedure afterwards.
• Your throat is usually anesthetized with a spray or liquid to minimize the gag reflex.
• A tube called an endoscope (scope) is used. This is a narrow tube with a tiny light and camera at the end. The scope is inserted through your mouth and into your esophagus. The endoscope is small compared to the airway and does not interfere with normal breathing. It lets your provider see inside your esophagus. To help guide your provider, an imaging method called fluoroscopy may also be used. This creates a moving X-ray image on a computer screen. 
• You will be monitored closely throughout the exam.
• As the exam takes place, additional necessary procedures may be performed:

Mercury-Weighted Dilation

When your physician uses a mercury-weighted dilator, the dilator is blindly inserted into the esophagus and is passed in sequentially increasing sizes in order to expand the obstructed area. The dilators are passed in sequentially increasing sizes in order to expand the obstructed area.

Dilator over Guidewire

The dilator over guidewire procedures is performed during an upper endoscopy by passing a guidewire into the stomach past the obstruction. After the guidewire is in place, the dilators are introduced over the guidewire in sequentially increasing sizes. An upper endoscopy is sometimes used to evaluate the anatomy as well as to pass the guidewire.

Pneumatic Dilation

Pneumatic or balloon dilation is performed during an upper endoscopy when the doctor first inserts a deflated balloon into the area of the narrowing and then uses air to inflate the balloon to a certain pressure that is pre-set for a given circumference.

After the procedure

• You will remain in the recovery room area for one half to one hour after the procedure depending on your vital signs and level of consciousness.
• You may feel bloated from the air used during the procedure.
• The medication given to you during the procedure may affect your reflexes and judgment.
• Following the exam, your physician will discuss the results with you and your loved ones. Your physician will also be able to inform you if you will need to repeat the procedure. Repeat procedures are common.
• You may have a sore throat for the rest of the day.
• You may have pain behind your breastbone for a short time afterwards.
• You can start drinking fluids again after the numbness in your throat goes away. You can resume eating the same day or the next day.
• You should not drive a car, operate machinery, or make legally-binding decisions for the rest of the day.

Risks and possible complications

Complications

Esophageal dilation is usually performed effectively and without problems. However, some complications can occur. Risks and possible complications for esophageal dilation include:

• Infection
• A tear or hole in the esophagus lining, causing bleeding and possibly needing surgery to fix
• Risks of anesthesia

Follow-up

You may need to have the procedure repeated one or more times. This depends on the cause and extent of the narrowing. Repeat procedures can allow the dilation to take place more slowly. This reduces the risks of the procedure.

If your stricture was caused by reflux esophagitis, you’ll likely need to take medicine to treat that condition. Your provider will tell you more.

When to call your provider

Call your healthcare provider right away if you have any of the following after the procedure:

• Fever of 100.4°F (38.0°C)
• Chest pain
• Trouble swallowing
• Vomiting blood or material that looks like coffee grounds
• Bleeding
• Black, tarry, or bloody stools

Esophageal stenting

An esophageal stent is a tube placed in the esophagus to keep a blocked area open so the patient can swallow soft food and liquids. Esophageal stents are made of metal mesh, plastic, or silicone, and may be used in the treatment of esophageal cancer.

The procedure might take place under general anesthesia or conscious sedation. If it takes place under general anesthesia, you will sleep through the procedure and feel no pain. If it takes place under conscious sedation, you will get medicines to make you relaxed and sleepy. The surgeon may numb the area under surgery so that you won’t feel much pain.

During the procedure, the surgeon places a long, thin tube (catheter) down the back of your mouth and into your esophagus. Next, the surgeon places a folded-up hollow tube (stent) over the catheter in the correct position across the blockage. The stent expands against the walls of your esophagus, giving support. Then the surgeon removes the catheter and leaves the stent in place.

Why might I need an esophageal stent procedure?

You might need an esophageal stent for a number of health problems. Traditionally, healthcare providers have most often used esophageal stents to treat esophageal cancer. That is still the most common reason. But these stents are also used to treat:

• Cancer of the top part of the stomach
• Narrowing of the esophagus as it’s pushed from the outside by a cancer (such as lung cancer) or enlarged lymph nodes
• Narrowing of the esophagus from an ulcer
• Narrowing of the esophagus from radiation treatment
• Abnormal opening between the trachea (wind pipe) and esophagus
• A hole in the esophagus

Any of these health problems can cause dysphagia. Dysphagia is serious because it can lead to aspiration. During aspiration, you inhale food and stomach contents into your lungs. That can lead to complications like pneumonia. Dysphagia also lowers your quality of life. An esophageal stent can help ease these problems.

Even if you have esophageal cancer, you may not need an esophageal stent. In some cases, your healthcare provider may be able to treat your cancer with surgery or chemotherapy instead. If these therapies won’t work for you, an esophageal stent may be another option. In other cases, a gastrostomy tube or jejunostomy tube might make more sense for you. These tubes go straight from your outer abdomen to your stomach or small intestine. Talk with your healthcare provider about all your treatment choices.

What are the risks of an esophageal stent procedure?

Esophageal stent procedures are relatively safe. But they do sometimes cause problems later. These might include:

• Pain in the esophagus
• Bleeding (usually mild)
• New hole in the esophagus (rare)
• Movement of the stent
• Tumor growth into the stent
• Gastroesophageal reflux (GERD or heartburn)

There is also a risk that you will need a repeat procedure because of one of these complications. Your own risks may vary based on the nature of your esophageal problem, your other health problems, and the type of stent used. Talk with your healthcare provider about all your concerns.