Gastrointestinal Radiology > Procedures > Balloon Dilation > Balloon Dilation (3)


Fluoroscopically Guided Balloon Dilation of GI Tract Strictures

Esophagus

Benign Inflammatory Strictures

  • Inflammatory strictures are usually caused by reflux and generally present as focal areas of narrowing, most commonly in the distal one-third of the esophagus.  In relatively mild strictures, a single, large diameter balloon can be used to dilate the stricture without resorting to a sequence of progressively larger balloons.  The maximum diameter balloon we use for esophageal strictures is usually 20 mm.  In patients with tight strictures, the procedure is performed initially with smaller diameter balloons, followed by larger caliber balloons.  In a significant number of patients, the length of the stricture can extend over several centimeters.  For these strictures, we prefer to use a relatively long balloon ( 8 cm), as it is more likely to remain in position during the procedure and not slide away from the stricture.  The use of a long balloon is also useful in patients with a hiatal hernia who have strictures of the gastroesophageal (GE)junction.  Because of the hiatal hernia, the position of the GE junction may change when the balloon is introduced, being lower or higher than expected.  When a long balloon is used, the chances are better that the balloon will straddle the stricture.

  • When multiple inflammatory strictures are present, it may be difficult to position the guide wire, and, on occasion, a steerable catheter (Biliary Stone Removal, Medi-tech Inc., Watertown, MA) may have to be used to guide the wire. The multiple strictures can be dilated simultaneously when a relatively long balloon catheter is used.

Malignant Strictures

  • The technique of balloon dilation in cases with an esophageal stricture from carcinoma is similar to the basic procedure described earlier.  Care must be taken in choosing a balloon of appropriate size, as a balloon that is too large increases the risk of perforation.  Also, the balloon must be inflated slowly with small increments in pressure to diminish the risks of perforation.  In our experience, even the dilation of malignant strictures can be safe if the procedure is carefully performed.

Anastomotic Strictures

  • The technique for balloon dilation of an esophageal anastomotic stricture is similar to the basic technique described earlier.  In these patients it is frequently difficult to pass a guide wire across the strictured anastomosis because this type of stricture is less tapered than a benign inflammatory stricture.  Frequently, the esophageal wall is deformed.  A quantity of heaped up mucosa may be. present as a result of the surgery and may prevent smooth advance of the guide wire.  Also, the anastomosis may lie at an angle to the longitudinal axis of the esophagus if an end-to-side anastomosis was created.  Therefore, it may take considerable manipulation to negotiate the stricture and pass the guide wire.  On occasion a steerable catheter may have to be used to position the guide wire.

  • In patients with anastomotic strictures, the choice of balloon size is based on two factors: the diameter of the anastomosis originally created at surgery (if known) and the diameter of the normal lumen above and below the stricture, as determined from a predilation barium examination.  In practice, however, a tight stricture may sometimes prevent distention of the gut distal to the narrowing, and it may not be possible to measure the cross-sectional diameter on the barium study.  We usually base our choice of the maximum balloon diameter on our projection of the desirable anastomotic diameter to be achieved.

  • In our experience, high inflation pressures of the balloon are usually required to dilate anastomotic strictures, and the strictures may sometimes be quite resistant to dilation.  This is because a significant amount of scar tissue frequently forms around the stricture.  It is probably because of this scar tissue that the chances of perforation are quite low, even when inflations are performed at high pressures.

Webs

  • Webs of the upper esophagus are uncommon lesions that may be detected incidentally on esophagograms.  In some patients, symptoms such as dysphagia may occur and treatment may be required.  Historically, symptomatic webs have been treated with bougienage during esophagoscopy, but can also be successfully treated with fluoroscopically guided balloon dilation.  In our experience, the procedure is very simple and can usually be performed in 10 minutes.

  • The procedure is best performed when the patient is placed in a lateral position.  Dilation is usually done with a 20 mm diameter balloon.  To make the procedure as comfortable as possible for the patient, the shortest balloon catheter possible (3 cm or less) should be used; a longer balloon may press on the cricopharyngeus muscle during inflation, increasing the patient's tendency to swallow reflexively and displace the centered balloon.  After the balloon is positioned over the web, it is quickly inflated to maximum pressure to dilate the stenosis.  Fluoroscopically, one frequently sees an abrupt disappearance of the “waist” on the balloon, and the patient may feel a snap when the web tears open.  In the majority of patients, only one dilation is necessary to treat the web.  A postprocedure barium examination of the esophagus is performed by injecting barium suspension through the partially withdrawn, deflated balloon catheter; typically the esophagus shows no residual abnormalities.

Anastomotic Leaks

  • Disruption of a surgical anastomosis is a common complication of cervical esophagogastrostomy or esophagocolonic interposition, occurring in 6-33% of cases.  The leak usually occurs within a few days to 2 weeks after surgery and may persist for several weeks or months.  It has been reported that empirical bougienage of the leaking cervical anastomosis often stops drainage from the cervical fistula within a few days.  A reasonable explanation for the effectiveness of this therapy is that there is a narrowing of the leaking anastomosis that is relieved by the dilation.  The narrowing may be caused by spasm, edema, or inflammation associated with the leak or may result from the surgeon's failure to create a sufficiently large orifice.  The narrowing obstructs the flow of secretions through the esophagus and forces them into the fistula.  Healing of the fistula is delayed as long as the esophageal stenosis persists. dilation increases the luminal diameter of the anastomosis, thus improving esophageal emptying.  This in turn reduces intraluminal pressure and facilitates healing of the disruption (Fig. 3).

Fig. 3.      Effect of dilation on leaking anastomosis.
(A)  When there is a leak of the anastomotic suture line, esophageal secretions are forced to escape chiefly through the leak (large arrow) because of the partial obstruction caused by the narrowed anastomosis. The flow of secretions keeps the disruption open.
(B)  dilation with the balloon increases the anastomotic diameter.
(C)  After dilation, flow in the esophageal lumen is better (large arrow), and secretions are no longer forced through the fistula. This promotes more rapid healing.
(de Lange, Shaffer, & Holt, ref. 2.  Reproduced by permission.)

  • Bougienage is done blindly and may further disrupt the anastomosis.  Complications are less likely to occur when the dilation is preformed under fluoroscopic control.  We now routinely perform a balloon dilation in patients with these leaking anastomoses and, on the average, healing of the fistula occurs within a few days after the procedure.

  • Before the dilation procedure, the anastomotic fistula is visualized with a contrast study.  Because many patients aspirate shortly after surgery as a result of neuromuscular incoordination or edema surrounding the surgical site, barium suspension is used as contrast medium because it leads to fewer complications when aspirated and provides better anatomic detail than a water soluble contrast.  The extravasated barium is not retained but rather escapes through the cutaneous fistula or gradually drains back into the lumen of the gut.

  • Once the anastomotic leak is identified, the patient is rotated into the position that permits optimal fluoroscopic visualization.  The patient's throat is sprayed with a topical anesthetic, and premedication with a systemic sedative may be required.  Patients usually do not experience significant pain because the tissues of the anastomosis are denervated by the surgery and are therefore less sensitive.  A systemic analgesic is not ordinarily required.

  • The balloon technique is similar to the general technique described earlier.  The diameter of the balloon used for dilation should correspond to the diameter of the anastomosis created at surgery, which is 20 mm in most cases.  The balloon is positioned across the anastomosis with the central portion of the balloon at the leak.  Upon inflation one can frequently identify the waist-like contour at the middle of the balloon that corresponds to the narrowed anastomosis.  In general, the narrowing can easily be stretched with little pressure of the balloon.  The balloon is left maximally inflated for approximately 3 minutes, after which it is deflated for a minute.  We usually repeat the inflation 2-3 times during the same session, and the whole procedure usually takes approximately 30 minutes.

 


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