Esophageal Dilatation Antegrade

Esophageal dilatation antegrade

Antegrade esophageal dilatation is a technique of enlarging a constricted (stricture) portion of the esophagus by placing dilators in the mouth and pushing them downward towards the stomach, the way a normal person would swallow.

What is Antegrade Esophageal Dilatation?

Antegrade dilatation is done by passing an endoscope or guidewire in the mouth and expanding the constriction of the esophagus step by step with balloons or bougies. It is the common and most desirable method in case of the ability to reach the lumen of the esophagus through the top.

Indications

Antegrade dilatation is usually done in:

• Strictures of the anastomosis of the esophagus following a repair of esophageal atresia.
• GERD peptic strictures.
• Inborn esophagus stenosis.
• Strictures caused by ingesting caustic.
• Narrowing of esophagus after surgery.
• Children and adults benign esophageal strictures.

The benefits of Antegrade Dilatation

• Travels through the natural esophagus.
• Improved visualization of the stricture.
• Reduced rate of complications when compared to the blind techniques.

Can be combined with:

• Steroid injection
• Use of mitomycin-C (in case of refractory strictures)

Antegrade esophageal dilation

The following is a procedure oriented, step wise account of Antegrade Esophageal Dilatation:

Pre-Procedure Preparation

• Nil orally (NPO) 6-8 hours.
• Carried out under general (children) or deep sedation (adults).
• Baseline vitals recorded
• Antibiotics which are normally not necessary as prophylaxis.

Endoscopy / contrast checked to examine:

• Location
• Length
• Diameter of stricture

Endoscopic Access

• An endoscope that is flexible is inserted into the mouth.
• The esophagus is examined to a point of the stricture.

Stricture characteristics evaluated:

• Diameter
• Length
• Mucosal condition

Guidewire Placement

• The stricture is carefully dilated by passing a soft-tipped guidewire under direct vision.
• The proper intraluminal position is verified using endoscope, or fluoroscopically.

Dilatation Technique

Balloon Dilatation

• Balloon catheter rolled over the guidewire.
• Balloon placed over the stricture.
• Slow inflation using saline/contrast:
• Held for 30–60 seconds
• Diameter grew progressively.
• Balloon taken out and deflated.

Bougie (Savary-Gilliard) Dilatation

• Guidewire bougies were then sequentially passed.
• Small increments of dilators were added.
• Opposition is experienced but coercion is not.

Post-Dilatation Assessment

• Endoscope reinserted

Mucosa inspected for:

• Tears
• Bleeding
• Perforation signs
• Termination of the procedure when sufficient lumen had been reached safely.

Duration of Procedure

• Typically 15–30 minutes

Post-Procedure Care

• Observation for 4–6 hours
• Begin with clear liquids, proceed with feeds slowly.
• Analgesics if needed
• Discharge same day if stable

Follow-Up

• The repetition of dilatation might be necessary after every 2-4 weeks.

Adjunct treatment of the recurrent strictures:

• Intralesional steroids injection.
• Mitomycin-C application
• Antireflux therapy

Antegrade esophageal stricture treatment

Antegrade esophageal dilatation is mainly applied in patients who have esophageal strictures which make them experience dysphagia (difficulty swallowing), regurgitation or malnutrition. Common causes include:

• Strictures in the postoperative period (e.g. in the case of esophageal atresia repair)
• Strictures peptic or caustic in nature.
• Radiation-induced strictures
• Congenital or inflammatory strictures.

Principle

It is a process that entails successively enlarging the constriction of the esophagus by the use of dilators via the mouth (antegrade method). The aim is to reinstitute sufficient luminal luminal diameter to swallow and reduce the chances of perforation.

Procedure:

Pre-procedure Assessment

• History & physical examination.
• Diagnosis Imaging: Barium swallow or contrast esophagogram to define stricture location, stricture length and stricture severity.
• Endoscopy: Diagnostic endoscopy of the esophagus can be performed in order to observe the stricture.

Patient Preparation

• Fasting (usually 6–8 hours)
• Depending on the age and cooperation of patients, sedation or general anesthesia.
• Intravenous access

Procedure Technique

• Endoscopic Guidance: A flexible endoscope is inserted in the mouth into the esophagus.
• Detection of Stricture: The constriction is found.

Dilation: Using either:

Bougie dilators (e.g., Savary-Gilliard)

• Dilators are placed across a guidewire across the stricture of growing diameter.

Balloon dilators

• The arrangement of a deflated balloon is at the stricture, which is under endoscopic or fluoroscopic guidance.
• This is done by increasing the balloon to stretch the stricture.
• Gradual Increment: Commence with smaller diameters and progressively increase to the smallest trauma.

Post-dilation Assessment

• Mucosal tear or perforation visualization.
• In high-risk cases, immediate contrast study can be carried out.

Post-procedure Care

• Observation: Watch complications like chest pain, bleeding or perforation.
• Diet: Liquid to progressive levels.
• Follow-up Dilations: The numerous strictures need sequential dilations with a time interval of 2-4 weeks.
• Adjunct Therapy: Proton pump inhibitors or anti-reflux therapy can be considered in case of reflux as one of the factors.

Best hospital for antegrade esophageal dilation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Antegrade esophageal dilation is a reliable and safe minimally invasive intervention in the management of esophageal constriction. It reinstates swallowing by progressively expanding the tapered segment using the mouth by means of an endoscope or a fluoroscope to enhance nutrition. Recurring or long strictures may require serial dilations. Its success rate is quite high and this is achieved when it is done with caution and pre-procedure evaluation and post procedure follow-up. Such complications as perforation or bleeding are uncommon but have to be identified and treated immediately.

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FAQ

How many sessions are needed?

• Serial dilations at 2-4-week intervals are required to some strictures until the esophagus is wide enough and the swallowing is normal.

What is the recovery like?

• Liquid diet may generally be commenced after several hours, which are changed to solids as the patient is able to pass solids.
• It is vital to observe complications immediately after the procedure.

Is it effective in children?

• Yes it is the desirable initial-line treatment of pediatric esophageal strictures, and that too after repair of esophagus atresia, but taking special care with balloon dilators and anaesthetic care.

On what occasions do we require surgery?

• In case the stricture is long, severe, and does not respond to repeated dilations, a surgical reconstruction can be taken into consideration.