Patient preparation

1. Predilatation investigations

   • 1.1 Obtain biopsy specimens from all strictures for histological analysis to exclude malignancy and eosinophilic oesophagitis (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.2 Repeat biopsy after cross-sectional imaging (computed tomography (CT) or endoscopic ultrasound (EUS)) in cases where biopsies are negative, but clinical or endoscopic features are atypical or suspicious for malignancy (GRADE of evidence: low; strength of recommendation: strong).

   • 1.3 Obtain oesophageal biopsy specimens in young patients with dysphagia or history of food impaction to exclude eosinophilic oesophagitis (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.4 Perform barium swallow in patients with suspected complex strictures (such as post-radiation therapy or history of caustic injury) in order to establish the location, length, diameter and number of strictures (GRADE of evidence: low; strength of recommendation: strong).

2. Information and consent

   • 2.1 Counsel all patients about the benefits and risks of dilatation and the likely need for multiple sessions before symptom resolution can be achieved (GRADE of evidence: low; strength of recommendation: strong).

   • 2.2 Tailor information to the individual patient’s risk profile, based on the underlying cause, location, length and diameter of the stricture and coexistent adverse health problems (GRADE of evidence: low; strength of recommendation: strong).

   • 2.3 Provide all patients with written information on oesophageal dilatation before the procedure and obtain written, signed consent. Inform patients about the perforation risk and the potential need for endoscopic or operative intervention should a perforation occur (GRADE of evidence: low; strength of recommendation: strong).

   • 2.4 Inform patients— whenever appropriate—of any alternatives to dilatation, such as parenteral feeding or surgery in some cases (GRADE of evidence: low; strength of recommendation: strong).

   • 2.5 Do not perform oesophageal dilatation in patients with active or incompletely healed oesophageal perforation as it may extend the oesophageal defect and promote mediastinal soiling (GRADE of evidence: low; strength of recommendation: strong).

   • 2.6 Perform dilatation in patients with a recent, healed perforation; recent upper gastrointestinal surgery; pharyngeal or cervical deformity; or bleeding disorders after careful consideration of the benefits, risks and alternatives of the procedure (GRADE of evidence: low; strength of recommendation: strong).

3. Fasting

   • 3.1 Advise patients to fast for at least 6 hours before the procedure in order to ensure emptying of the oesophagus and stomach. Patients with achalasia are likely to have oesophageal stasis and are therefore required to fast for a longer time based on the clinician’s judgement (GRADE of evidence: low; strength of recommendation: strong).

4. Patient premedication

   • 4.1 Inform patients that dilatation is likely to be uncomfortable, in particular, when push dilators are used rather than dilatation balloons (GRADE of evidence: low; strength of recommendation: strong).

   • 4.2 Offer patients intravenous sedation with a benzodiazepine and an opioid analgesic as a minimum. Propofol sedation (delivered by a suitably qualified person), or a general anaesthetic are valid alternatives based on the clinician’s and patient’s preference, procedure complexity as well as local availability and expertise (GRADE of evidence: low; strength of recommendation: strong).

The dilatation procedure

1. Personnel, training and equipment

   • 1.1 Oesophageal dilatation should be undertaken only by (or under direct supervision of) an experienced operator who performs sufficient numbers to maintain their skills. The operator should be supported by at least two assistants (one of whom must be a trained nurse) in the endoscopy/radiology room (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.2 Ensure that trainees performing dilatation have adequate knowledge and understanding of the indications for, contraindications to, and complications of, this therapeutic procedure. An understanding of the steps for recognition and management of complications is required. Trainees should be familiar with different dilatation techniques as well as alternative and complementary treatment options (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.3 Perform the procedure in a dedicated, fully equipped endoscopy room with access to X-ray screening and surgical support, or a similarly equipped radiological suite (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.4 Units must have an agreed protocol to follow in case of a perforation with clear identification of a qualified surgeon (on or off site) to manage this complication in cases where luminal treatment, such as a covered stent, is not feasible or appropriate (GRADE of evidence: low; strength of recommendation: strong).

2. Oesophageal dilators

   • 2.1 Use either balloon or wire guided bougie dilators to perform oesophageal dilatation (GRADE of evidence: high; strength of recommendation: strong).

3. The dilatation technique

   • 3.1 Consider limiting the initial dilatation to 10–12 mm in diameter (corresponding to 30–36F) in cases of very narrow strictures not passable by the adult gastroscope. The target for filiform strictures should be even lower (≤9 mm) (GRADE of evidence: very low; strength of recommendation: weak).

   • 3.2 Consider using no more than three successively larger diameter increments in a single session for both bougie and balloon dilators. The precise restriction of 3×1 mm diameter increments is not evidence based (GRADE of evidence: low; strength of recommendation: low).

   • 3.3 Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients to enhance safety (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.4 Do not use weighted (Maloney) bougies with blind insertion, because safer dilators are available (GRADE of evidence: high; strength of recommendation: strong).

   • 3.5 Perform dilatation without fluoroscopy for simple strictures as efficacy and safety have been shown in several studies (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.6 Use fluoroscopic guidance to enhance safety during dilatation of strictures that are either high risk (such as post-radiation and caustic); cannot be passed endoscopically and are long; angulated; or multiple (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.7 Perform repeat endoscopy or injection of contrast after dilatation in cases where perforation is suspected, to consider immediate treatment with a fully covered self-expanding metal stent (SEMS) (GRADE of evidence: low; strength of recommendation: strong).

   • 3.8 Use carbon dioxide insufflation instead of air during endoscopy whenever possible, in complex strictures to minimise luminal distension and postprocedural pain (GRADE of evidence: high; strength of recommendation: strong).

   • 3.9 Consider upper oesophageal sphincter dilatation in the treatment of dysphagia with disordered upper oesophageal sphincter opening, post-cricoid web, cricopharyngeal bar with or without the presence of a Zenker’s diverticulum, or to permit passage of radiofrequency ablation (RFA) catheters (GRADE of evidence: moderate; strength of recommendation: strong).

4. Aftercare and follow-up

   • 4.1 Monitor patients for at least 2 hours in the recovery room and provide clear written instructions with advice on fluids, diet and medications after the procedure (GRADE of evidence: moderate; strength of recommendation: strong).

   • 4.2 Do not perform imaging and contrast studies routinely after the procedure, unless patients—during recovery—develop persistent chest pain, fever, breathlessness or tachycardia (GRADE of evidence: very low; strength of recommendation: weak).

   • 4.3 Ensure that patients are well and tolerating water on leaving the hospital (GRADE of evidence: low; strength of recommendation: strong).

   • 4.4 Suspect perforation when patients develop pain, breathlessness, fever or tachycardia. Transient chest pain is not uncommon following dilatation but persistent pain should prompt a CT scan with oral contrast to look for perforation (GRADE of evidence: low; strength of recommendation: strong).

   • 4.5 Perform endoscopic re-inspection if the patient becomes symptomatic while in the procedure room, in order to assess for the presence of perforation and to undertake treatment which may include immediate endoscopic stent placement (GRADE of evidence: low; strength of recommendation: strong).

   • 4.6 Provide patients with contact information for the on-call team should they experience chest pain, breathlessness or become unwell (GRADE of evidence: low; strength of recommendation: strong).

   • 4.7 Perform weekly or two-weekly dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement (GRADE of evidence: moderate; strength of recommendation: strong).

Disease-specific considerations

1. Achalasia dilatation

   • 1.1 Perform dilatation with pneumatic balloons 30–40 mm in diameter starting at 30 mm in the first session to reduce the risk of complications (GRADE of evidence: high; strength of recommendation: strong).

   • 1.2 Perform a second dilatation session 2–28 days later with a larger size balloon of 35 mm (GRADE of evidence: high; strength of recommendation: strong).

   • 1.3 Consider repeat dilatation (after the initial series) during follow-up to maintain symptom response (GRADE of evidence: high; strength of recommendation: strong).

   • 1.4 Perform dilatation under endoscopic or fluoroscopic control based on clinician’s preference and local expertise (GRADE of evidence: moderate; strength of recommendation: strong).

   • 1.5 Consider proton pump inhibitor (PPI) therapy after dilatation as the technique has 10–40% rate of symptomatic gastro-oesophageal reflux disease (GORD) or ulcerative oesophagitis after treatment (GRADE of evidence: high; strength of recommendation: strong).

   • 1.6 Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, but it is not essential (GRADE of evidence: moderate; strength of recommendation: weak).

2. Peptic strictures

   • 2.1 Offer PPI therapy to patients with GORD and dysphagia, as this treatment has been shown to reduce the need for oesophageal dilatation (GRADE of evidence: high; strength of recommendation: strong).

   • 2.2 Offer PPI therapy after endoscopic dilatation for peptic strictures in order to reduce recurrence rate (GRADE of evidence: high; strength of recommendation: strong).

   • 2.3 Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation (stricture recurrence), less effective in healing of oesophagitis and in providing symptom relief from GORD and dysphagia (GRADE of evidence: high; strength of recommendation: strong).

3. Schatzki’s ring

   • 3.1 Do not offer dilatation for asymptomatic Schatzki’s rings incidentally discovered on diagnostic endoscopy or contrast studies (performed for unrelated indication) (GRADE of evidence: low; strength of recommendation: strong).

   • 3.2 Consider exclusion of eosinophilic oesophagitis by distal, mid and proximal oesophageal biopsies in symptomatic Schatzki’s ring (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.3 Offer a single dilatation session using graded dilatation to a relatively large diameter (16–20 mm) to treat dysphagia related to Schatzki’s ring (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.4 Offer PPI therapy after dilatation, as this reduces the risk of relapse of Schatzki’s ring (GRADE of evidence: moderate; strength of recommendation: strong).

   • 3.5 Consider electrosurgical incision as an effective alternative treatment to oesophageal dilatation for relieving dysphagia related to Schatzki’s ring (GRADE of evidence: high; strength of recommendation: strong).

4. Post-endoscopic therapy strictures

   • 4.1 Inform patients of up to ~50% chance of developing symptomatic stricture requiring endoscopic dilatation after endoscopic resection (ER) either following endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in any of the following situations: resection size >75% of the oesophageal circumference; and a longitudinal resection length of >40 mm (GRADE of evidence: high; strength of recommendation: strong).

   • 4.2 Offer dilatation for the management of symptomatic post-mucosal resection strictures (GRADE of evidence: moderate; strength of recommendation: strong).

   • 4.3 Inform patients that perforation rates of dilatation for post-ER strictures in the oesophagus can be up to 1.1% (GRADE of evidence: moderate; strength of recommendation: strong).

   • 4.4 Offer fully covered SEMS in carefully selected patients for the dilatation of refractory strictures after ER (GRADE of evidence: low; strength of recommendation: weak).

   • 4.5 Consider steroid injection at the resection site or oral prednisolone therapy in patients at high risk after large EMR or ESD to reduce stricture formation (GRADE of evidence: moderate; strength of recommendation: weak).

   • 4.6 Offer fully covered SEMS in carefully selected patients for the prevention of refractory strictures after ESD of large lesions, placing the stent at the same time as the first stricture dilatation (GRADE of evidence: moderate; strength of recommendation: weak).

   • 4.7 Inform patients that stricture formation requiring dilatation is significantly higher in the following situations: after photodynamic therapy (PDT) (36%) compared with other forms of ablation; where ER has preceded ablation (12% vs 6%); with use of higher doses of energy with RFA for Barrett’s oesophagus (BO); and after RFA for early squamous cell neoplasia (14–23%) (GRADE of evidence: moderate; strength of recommendation: strong).

   • 4.8 Offer dilatation in patients with clinically significant stricture formation after RFA, with or without previous ER (GRADE of evidence: moderate; strength of recommendation: strong).

   • 4.9 Offer PPI therapy after ER or ablation to reduce stricture occurrence (GRADE of evidence: low; strength of recommendation: strong).

5. Eosinophilic oesophagitis

   • 5.1 Offer dilatation along with other forms of disease modification using diet, topical steroids or other drugs (GRADE of evidence: moderate; strength of recommendation: strong).

   • 5.2 Start other treatments for eosinophilic oesophagitis (EoE) before dilatation if possible, and those may be continued afterwards to prevent or delay recurrence of symptoms (GRADE of evidence: moderate; strength of recommendation: strong).

   • 5.3 Offer preliminary topical steroids followed by dilatation as this is more cost-effective than using dilatation alone as first-line treatment (GRADE of evidence: moderate; strength of recommendation: strong).

   • 5.4 Offer dilatation as first-line treatment in patients with acute symptoms such as food bolus obstruction and daily dysphagia (GRADE of evidence: moderate; strength of recommendation: strong).

   • 5.5 Offer dilatation to patients with established tight stricture, narrow calibre oesophagus and those who do not respond to diet or drugs (GRADE of evidence: high; strength of recommendation: strong).

   • 5.6 Reassure patients that dilatation of EoE is no more dangerous than dilatation for other oesophageal diseases, and the perforation rates are similar (GRADE of evidence: high; strength of recommendation: strong).

   • 5.7 Inform patients with EoE that chest pain after dilatation is common (GRADE of evidence: high; strength of recommendation: strong).

   • 5.8 Inform patients that symptom response after dilatation usually lasts up to 1 year (GRADE of evidence: moderate; strength of recommendation: strong).

   • 5.9 Repeat dilatation if needed (GRADE of evidence: high; strength of recommendation: strong).

   • 5.10 Consider the use of special techniques such as EndoFLIP and Balloon pull through to judge the optimal calibre and position of dilatation (GRADE of evidence: low; strength of recommendation: weak).

6. Postoperative strictures

   • 6.1 Consider performing upper GI endoscopy, manometry, pH studies and barium swallow first in patients with post-fundoplication dysphagia, to understand the mechanism of dysphagia before dilatation or repeat surgery (GRADE of evidence: low; strength of recommendation: weak).

   • 6.2 Consider treatment of concurrent delayed gastric emptying in order to reduce the need for redilatations (GRADE of evidence: low; strength of recommendation: weak).

   • 6.3 Consider the use of balloon dilatation to 30–40 mm (as with achalasia) in patients with post-Nissen dysphagia (GRADE of evidence: low; strength of recommendation: weak).

   • 6.4 Use steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) to reduce the frequency of repeat dilatations in anastomotic strictures refractory to initial dilatation approaches. This can be performed with a 4mm-long, 23-gauge needle immediately before bougie dilatation while leaving the needle in for at least 1 min to minimise leakage of the drug and ensure delivery of the full dose to the target area (GRADE of evidence: moderate; strength of recommendation: weak).

   • 6.5 Consider using needle knife incision for anastomotic strictures as an alternative to dilatation (GRADE of evidence: moderate; strength of recommendation: weak).

7. Post-radiation strictures

   • 7.1 Consider a combined anterograde and retrograde dilatation (CARD) or rendezvous approach under general anaesthetic as an alternative to surgery in treatment of the completely obstructed oesophagus, where local expertise is available (GRADE of evidence: moderate; strength of recommendation: weak).

   • 7.2 Use fluoroscopic guidance to assist with the rendezvous procedure (GRADE of evidence: moderate; strength of recommendation: strong).

   • 7.3 Use a guidewire to navigate through the obstruction when using the CARD approach to re-establish luminal patency (GRADE of evidence: low; strength of recommendation: strong).

   • 7.4 After gaining luminal patency using the CARD procedure, perform subsequent dilatation using either balloon or bougie (GRADE of evidence: moderate; strength of recommendation: strong).

8. Caustic strictures

   • 8.1 Perform upper gastrointestinal tract endoscopy within the first 12–48 hours after caustic ingestion (GRADE of evidence: moderate; strength of recommendation: strong).

   • 8.2 Ensure timely management of oesophageal strictures with dilatation as this plays a key role in affecting patient outcomes (GRADE of evidence: moderate; strength of recommendation: strong).

   • 8.3 Consider avoiding dilatation within 3 weeks of initial caustic ingestion (GRADE of evidence: low; strength of recommendation: weak).

   • 8.4 Consider a time interval between dilatations of <2 weeks (GRADE of evidence: very low; strength of recommendation: weak).

9. Refractory strictures

   • 9.1 Inform patients about the lack of good quality evidence for best approach to treatment of refractory strictures (GRADE of evidence: low; strength of recommendation: strong).

   • 9.2 Consider discussion with, and/or referral to, centres with expertise in treatment and follow-up of patients with refractory strictures (GRADE of evidence: low; strength of recommendation: weak).

   • 9.3 Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory (GRADE of evidence: high; strength of recommendation: strong).

   • 9.4 Consider alternative neuromuscular causes in patients with ongoing dysphagia despite a seemingly adequate oesophageal diameter (GRADE of evidence: low; strength of recommendation: strong).

   • 9.5 Use fluoroscopic guidance during dilatation of refractory oesophageal strictures (GRADE of evidence: very low; strength of recommendation: weak).

   • 9.6 Use either bougie or balloon dilators with the decision individualised on a case by case basis dependent on the nature (length, location, cause) of the stricture (GRADE of evidence: low; strength of recommendation: weak).

   • 9.7 Use intralesional steroid therapy combined with dilatation in refractory strictures with evidence of inflammation (macro- or microscopically) on the assumption that anti-reflux therapy has been maximised previously with no benefit (GRADE of evidence: high; strength of recommendation: strong).

   • 9.8 Consider incisional therapy in patients with refractory Schatzki’s rings and anastomotic strictures at centres experienced in the use of such techniques (GRADE of evidence: very low; strength of recommendation: weak).

   • 9.9 Offer temporary placement of fully covered self-expanding removable stents in patients where previous methods have been unsuccessful in maintaining adequate oesophageal patency (GRADE of evidence: low; strength of recommendation: weak).

   • 9.10 The optimum duration of stent placement is usually between 4 and 8 weeks, but may vary depending on stricture aetiology and length, and type of stent (GRADE of evidence: very low; strength of recommendation: weak).

   • 9.11 Consider biodegradable stent placement to reduce the frequency of dilatation in selected cases (GRADE of evidence: low; strength of recommendation: weak).

   • 9.12 Consider teaching selected, self-motivated patients, with short proximal strictures to self-bougienage (GRADE of evidence: very low; strength of recommendation: weak).

   • 9.13 Offer surgery to patients who do not respond or are intolerant to other measures (GRADE of evidence: low; strength of recommendation: weak).

Assessing the quality of guidelines: AGREE II instrument

The purpose of the AGREE II instrument is to provide a framework to assess the quality of the guideline, provide a methodological strategy for its development and inform the reporting process of the guideline. It includes the following six domains which were used by our guideline development group (GDG): scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability and editorial independence.

Predilatation investigations

(a) Should all strictures be biopsied before dilatation?

• Obtain biopsy specimens from all strictures for histological analysis to exclude malignancy and eosinophilic oesophagitis7–9 (GRADE of evidence: moderate; strength of recommendation: strong).

Obtaining a definitive diagnosis before dilatation is desirable, because this will influence the overall management and estimation of perforation risk.8–10 Oesophageal biopsy samples can be safely obtained immediately before oesophageal dilatation7; however, if the stricture is tight or when the endoscopic features suggest malignancy, the results of biopsies are best awaited.4

• Repeat biopsy after cross-sectional imaging (CT or with endoscopic ultrasound (EUS) in cases where biopsies are negative, but clinical or endoscopic features are atypical or suspicious for malignancy11 (GRADE of evidence: low; strength of recommendation: strong).

EUS may be a more sensitive test than CT, but passage of the EUS probe is often not successful in the case of a stricture.11

• Obtain oesophageal biopsy specimens in young patients with dysphagia or history of food impaction to exclude eosinophilic esophagitis8 9 (GRADE of evidence: moderate; strength of recommendation: strong).

(b) Are there any other recommended tests?

• Perform barium swallow in patients with suspected complex strictures (such as post-radiation therapy or history of caustic injury) in order to establish the location, length, diameter and number of strictures12 13 (GRADE of evidence: low; strength of recommendation: strong).

Barium swallow is also useful to evaluate the presence of associated pathology such as an oesophageal diverticulum or a hiatus hernia.12 13 This information will aid selection of the dilating technique, estimation of the number of sessions required and counselling the patient about the expected risks.13

Information and consent

The overall consent process should be in line with the published BSG guidance.14

(a) What information should patients be given?

• Counsel all patients about the benefits and risks of dilatation and the likely need for multiple sessions before symptom resolution can be achieved (GRADE of evidence: low; strength of recommendation: strong).

• Tailor information to the individual patient’s risk profile, based on the underlying cause, location, length and diameter of the stricture and coexistent adverse health problems (GRADE of evidence: low; strength of recommendation: strong).

Our patient representatives suggested that the use of a diagram to illustrate the location, length and shape of the stricture is desirable to enhance the patient’s understanding of the procedure. Moreover, the presence of a relative or a caregiver should be encouraged if deemed appropriate during the consent process.

• Provide all patients with written information on oesophageal dilatation before the procedure and obtain written, signed consent. Inform patients about the perforation risk and the potential need for endoscopic or operative intervention should a perforation occur (GRADE of evidence: low; strength of recommendation: strong).

• Inform patients— whenever appropriate—of any alternatives to dilatation, such as parenteral feeding or surgery in some cases (GRADE of evidence: low; strength of recommendation: strong).

(b) What are the possible complications?

Complications include pulmonary aspiration, bleeding, perforation, risks of sedation and chest pain15; the last of these being more common in patients with eosinophilic oesophagitis.16 17 A UK regional audit published in 1995 reported an overall perforation rate of 2.6% with a 30-day mortality of 1%.10 Perforation was less common following dilatation of benign strictures (1.1% with a mortality of 0.5%) than following dilatation and/or intubation of malignant strictures (6.4% with a mortality of 2.3%).10 The risk of perforation was greater with less experienced endoscopists (performed <500 previous diagnostic endoscopies).10 Hernandez et al reported a perforation rate of 4 out of 348 procedures (1.1%); however, all these four perforations occurred when Maloney dilators (non-wire guided) were passed blindly into complex strictures. No perforations occurred with Savary-Gilliard (wire-guided) and balloon dilators.12 Hagel et al reported the most recent large retrospective case series of 1497 procedures on 368 patients over a 10-year period. Operators used Savary-Gilliard bougies (Cook Medical, Bloomington, Indiana, USA) or through the scope (TTS) balloons (Controlled Radial Expansion, CRE, Boston Scientific Ltd, Cork, Ireland and Eclipse Wire Guided Balloon Dilators, Cook Ireland Ltd, Limerick Ireland). Eight perforations (0.53%) occurred in malignant, post-radiation or caustic strictures. No perforations were reported in other types of strictures, such as peptic, postoperative and eosinophilic oesophagitis.18

The reported risk of perforation in achalasia has varied widely across studies from 0% to 8% (2–4% in most studies) with a mortality of 0–1%.19 20 Katzka et al 19 pooled data from all 25 studies in the literature and reported a perforation rate of 2%; however, the balloon size, pressure, dilatation times and single or multiple dilatations varied in almost every study. The perforation rate is lower with a graded approach to balloon dilatation and in experienced hands.20

(c) What are the contraindications/cautions for stricture dilatation?

• Do not perform oesophageal dilatation in patients with active or incompletely healed oesophageal perforation as it may extend the oesophageal defect and promote mediastinal soiling3 4 (GRADE of evidence: low; strength of recommendation: strong).

• Perform dilatation in patients with a recent, healed perforation; recent upper gastrointestinal surgery; pharyngeal or cervical deformity; or bleeding disorders after careful consideration of the benefits, risks and alternatives of the procedure3 4 (GRADE of evidence: low; strength of recommendation: strong).

Dilatation may be performed in patients who are having concurrent radiotherapy.3 4

Fasting

• Advise patients to fast for at least 6 hours before the procedure in order to ensure emptying of the oesophagus and stomach. Patients with achalasia are likely to have oesophageal stasis and are therefore required to fast for a longer time based on the clinician’s judgement3 4 (GRADE of evidence: low; strength of recommendation: strong).

Patient premedication

• Inform patients that dilatation is likely to be uncomfortable, in particular, when push dilators are used rather than dilatation balloons (GRADE of evidence: low; strength of recommendation: strong).

• Offer patients intravenous sedation with a benzodiazepine and an opioid analgesic as a minimum. Propofol sedation (delivered by a suitably qualified person), or a general anaesthetic are valid alternatives based on the clinician’s and patient’s preference, procedure complexity, as well as local availability and expertise (GRADE of evidence: low; strength of recommendation: strong).

Patients taking anticoagulants or antiplatelet agents and those at risk of endocarditis

UK-based clinicians must adhere to the BSG and NICE guidelines on management of anticoagulation and antibiotic prophylaxis during endoscopy.21 22 Clinicians in other countries should follow the corresponding guidelines in their country or region of practice.22–24

Personnel, training and equipment

(a) Who should perform dilatation?

• Oesophageal dilatation should only be undertaken only by (or under direct supervision of) an experienced operator who performs sufficient numbers to maintain their skills. The operator should be supported by at least two assistants (one of whom must be a trained nurse) in the endoscopy/radiology room4 25 26 (GRADE of evidence: moderate; strength of recommendation: strong).

The specific number of dilatation procedures required each year to maintain the operator’s skills remains unknown. It is good practice for independent operators to audit their outcomes and be regularly involved in the care of patients with upper GI disorder. Professional bodies such as Joint Advisory Group on Gastrointestinal Endoscopy (JAG) may define the suitable number of procedures for training and maintenance of practice standards.

• Ensure that trainees performing dilatation have adequate knowledge and understanding of the indications for, contraindications to, and complications of, this therapeutic procedure. An understanding of the steps for recognition and management of complications is required. Trainees should be familiar with different dilatation techniques as well as alternative and complementary treatment options27 (GRADE of evidence: moderate; strength of recommendation: strong).

It is estimated that less experienced endoscopists (who have performed fewer than 500 diagnostic upper endoscopy procedures) are four times more likely to cause a perforation than their more experienced colleagues.10 In the UK, the JAG stipulates that training on therapeutic endoscopy should be undertaken only after competency in diagnostic procedures is achieved (minimum of 300 procedures) and the former should take place under direct supervision.27 No formal guidelines exist for interventional radiologists, but a similar level of experience in diagnostic and interventional procedures is recommended. Close collaboration of the radiologists with interventional endoscopists and upper GI surgeons is essential for the appropriate management of complications.

Appropriate staffing and equipment are important for the provision of safe and successful therapeutic endoscopy procedures. Poor staffing levels are associated with worse outcomes from dilatation.10 Procedural assistants should be familiar with the dilatation equipment and capable of helping the operator in cases of an emergency. Qualified radiographers must be present when the procedure is performed under X-ray screening.4 10 25

(b) Where should the procedure be performed?

• Perform the procedure in a dedicated, fully equipped endoscopy room with access to x-ray screening and surgical support,10 25 or a similarly equipped radiological suite (GRADE of evidence: moderate; strength of recommendation: strong).

• Units must have an agreed protocol to follow in case of a perforation with clear identification of a qualified surgeon (on or off site) to manage this complication in cases where luminal treatment, such as a covered stent, is not feasible or appropriate6 10 (GRADE of evidence: low; strength of recommendation: strong).

Access to radiographic screening must be available to assist dilatation if there are difficulties in passing a guidewire or balloon catheter through the stricture.25 When a perforation occurs, prompt treatment should be started and the relevant surgical team must be informed immediately.25

Oesophageal dilators

There are two types of oesophageal dilators: the push (bougie) dilator and the balloon dilator.

The dilatation technique

This section describes the general technique of benign stricture dilatation. Achalasia dilatation and disease-specific considerations will be discussed in subsequent sections.

Strictures can be simple or complex.33 34 Simple strictures are short (<2 cm), concentric, straight, and allow the passage of a normal diameter endoscope.33 34 Examples include Schatzki’s rings, oesophageal webs and peptic strictures.33 34 Overall, one to three dilatation sessions are sufficient to relieve dysphagia in simple strictures. Only 25–35% of patients require additional sessions, with a maximum of five dilatations in >95% of patients.35 Complex strictures are usually longer (≥2 cm), angulated, irregular or have a severely narrowed diameter.33 34 These are more difficult to treat and have a tendency to be refractory or to recur despite dilatation.

(a) What size dilator should be initially chosen?

The initial dilator choice should be based on the known or estimated stricture diameter, length and the underlying pathology.

• Consider limiting the initial dilatation to 10–12 mm in diameter (corresponding to 30–36F) in cases of very narrow strictures not passable by the adult gastroscope. The target for filiform strictures should be even lower (≤9 mm) (GRADE of evidence: very low; strength of recommendation: weak).

(b) What is the recommended number of dilatations or size increments per session?

• Consider using no more than three successively larger diameter increments in a single session for both bougie and balloon dilators. The precise restriction of 3×1 mm diameter increments is not evidence based3 4 36 (GRADE of evidence: low; strength of recommendation: low).

Although a ‘rule of three’ is recommended by many practice guidelines and authorities,3 4 no studies have demonstrated improvement in safety or efficacy with this approach. On the other hand, a recent retrospective study showed that non-adherence to the rule of three did not appear to increase the risk of adverse events, particularly perforation, after oesophageal dilatation using bougie dilators, except for malignant strictures.36 For very tight or long strictures, it may be safer to limit the initial dilatation to one or two size increments (2×1 mm) only. Conversely, larger increments may be safely used (4×1 mm or 3×2 mm) in less tight strictures or in those which have completely recurred after the first dilatation session.37 Patients usually need several sessions to achieve resolution of dysphagia and they should be informed of this possibility before the first procedure.

(c) The need for wire guidance or endoscopic control?

• Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients to enhance safety18 38–40 (GRADE of evidence: moderate; strength of recommendation: strong).

• Do not use weighted (Maloney) bougies with blind insertion, because safer dilators are available41 (GRADE of evidence: high; strength of recommendation: strong).

(d) What is the role of fluoroscopy in stricture dilatation?

• Perform dilatation without fluoroscopy for simple strictures as efficacy and safety have been shown in several studies18 38–40 (GRADE of evidence: moderate; strength of recommendation: strong).

• Use fluoroscopic guidance to enhance safety during dilatation of strictures that are either high risk (such as post-radiation and caustic); cannot be passed endoscopically and are long; angulated; or multiple18 38–40 (GRADE of evidence: moderate; strength of recommendation: strong).

The use of radiographic screening in non-simple strictures gives additional assurance and control of the dilatation process. During wire-guided dilatation, it demonstrates that the wire has passed the stricture, and kinking of the wire has not occurred within or distal to the stricture. Fluoroscopy also shows that the dilator is following the line of the oesophageal lumen. During balloon dilatation, it indicates whether the balloon has slipped during inflation and whether obliteration of the stricture waist has occurred.3 4

Radiographic screening is particularly helpful when the stricture is tortuous or complex or associated with a large hiatus hernia or a diverticulum. It may also be of value when the guidewire meets resistance during passage through the stricture or when an adequate length of wire cannot be passed distal to the stricture. Although comparative trials are not available, the selective use of radiological screening appears safe and effective and is supported by extensive clinical experience.42 43 The use of small calibre gastroscopes should also be considered in narrow strictures.

• Perform repeat endoscopy or injection of contrast after dilatation in cases where perforation is suspected, to consider immediate treatment with a fully covered self-expandable metal stent6 (GRADE of evidence: low; strength of recommendation: strong).

• Use carbon dioxide insufflation instead of air during endoscopy whenever possible, in complex strictures to minimise luminal distension and postprocedural pain44 (GRADE of evidence: high; strength of recommendation: strong).

Upper oesophageal sphincter disturbances, including motor disorders and mechanical disorders, can result in symptoms of dysphagia.45 Pathologies associated with disordered neurally mediated opening of the upper oesophageal sphincter, including oculopharyngeal muscular dystrophies, may be amenable to dilatation to relieve symptoms.46 Furthermore, while a cricopharyngeal bar is often an incidental radiological finding in cricopharyngeal fibrosis, treatment of associated dysphagia by both balloon and bougie dilatation methods can be successful.47

• Consider upper oesophageal sphincter dilatation in the treatment of dysphagia with disordered upper oesophageal sphincter opening, post-cricoid web, cricopharyngeal bar with or without the presence of a Zenker’s diverticulum, or to permit passage of radiofrequency ablation (RFA) catheters45–53 (GRADE of evidence: moderate; strength of recommendation: strong).

Aftercare and follow-up

(a) Postprocedure and discharge instructions

• Monitor patients for at least 2 hours in the recovery room and provide clear written instructions with advice on fluids, diet and medications after the procedure10 25 (GRADE of evidence: moderate; strength of recommendation: strong).

• Do not perform imaging and contrast studies routinely after the procedure, unless patients— during recovery—develop persistent chest pain, fever, breathlessness or tachycardia (GRADE of evidence: very low; strength of recommendation: weak).

• Ensure that patients are well and tolerating water on leaving the hospital4 (GRADE of evidence: low; strength of recommendation: strong).

• Suspect perforation when patients develop pain, breathlessness, fever or tachycardia.15 Transient chest pain is not uncommon following dilatation but persistent pain should prompt a CT scan with oral contrast to look for perforation54 (GRADE of evidence: low; strength of recommendation: strong).

A chest X-ray examination may show pneumothorax, pneumomediastinum, air under the diaphragm or a pleural effusion but normal appearances do not exclude perforation. If clinical suspicion is high or if endoscopy examination raises the possibility of a deeper laceration than just mucosal, then ideally a CT scan with oral contrast should be performed. Conventional contrast studies are less sensitive and may miss small perforations.54–56 Moreover, CT can detect other complications, such as pleural effusions, pneumopericardium and pneumoperitoneum.57

• Perform endoscopic re-inspection if the patient becomes symptomatic while in the procedure room, in order to assess for the presence of perforation and to undertake treatment which may include immediate endoscopic stent placement6 (GRADE of evidence: low; strength of recommendation: strong).

Iatrogenic perforation is a medical emergency. The patient should be assessed by an experienced physician and experienced surgeon in order to formulate an appropriate plan, which may include surgical, endoscopic or conservative management.4

• Provide patients with contact information for the on-call team should they experience chest pain, breathlessness or become unwell4 (GRADE of evidence: low; strength of recommendation: strong).

(b)Timing of next follow-up and procedure end points

The timing of subsequent dilatation sessions may depend on the degree of success of initial dilatation and the patient’s response to the procedure. Patients often require multiple sessions, especially if the stricture has a narrow diameter or any complex features.58 In the majority of studies, a repeat procedure was performed after 1 week and a subsequent follow-up at 2–4 weeks.31 59 In some patients, however, symptoms tend to recur rapidly following dilatation, hence they may require more frequent weekly or biweekly dilatations based on symptoms and stricture resolution.3 4

As a general rule, the last dilator size used in the previous session must be passed first. However, the degree of fibrosis and stricture healing is unpredictable and not all patients are expected to tolerate passage of the largest diameter dilator used during the previous session. Reassessment of stricture diameter is required and a smaller size dilator may be used if deemed appropriate.

Most patients respond well to oesophageal dilatation but outcomes are influenced significantly by the underlying pathology, with better clinical response rates achieved in peptic and post-surgical strictures than in caustic and post-radiation pathology.43

There is no consensus on the definition of end point for dilatation. In one case series of 321 patients, 98% of those in whom a 15 mm (45F) dilator was inserted, achieved clinical response over a mean follow-up period of 18.8 months.43 In one prospective study, all patients underwent dilatation to 15 mm then were randomised to either a subjective (end point is alleviation of dysphagia, n=19) or objective (end point is passage of 12 mm barium pill, n=15) group. Patients in the objective group had less recurrent dysphagia (P=0.02) and required fewer redilatation sessions (P<0.05) than the subjective group.59 The size of the oesophageal lumen will vary depending on the height and weight of the patient, and a 15 mm lumen end point is for someone of average size.

• Perform weekly or two-weekly dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement31 43 59 (GRADE of evidence: moderate; strength of recommendation: strong).

A brief checklist is shown in figure 1. This may be used as a guide.

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Figure 1

Stricture dilatation procedure checklist.

Achalasia dilatation

Pneumatic balloon dilatation (PD) is one of a number of effective treatments for achalasia, which include surgical or endoscopic myotomy. However, the latter are outside the remit of this guideline.60 Bougie dilators are not used for achalasia dilatation.

• Perform dilatation with pneumatic balloons 30–40 mm in diameter starting at 30 mm in the first session to reduce the risk of complications5 19 61 (GRADE of evidence: high; strength of recommendation: strong).

The dilatation technique varies across different studies and there is no consensus in the literature on the optimal method of performing pneumatic dilatation for achalasia. The balloon is usually positioned at the oesophagogastric junction and inflated according to the manufacturers’ instructions for 1–3 min.

• Perform a second dilatation session 2–28 days later with a larger size balloon of 35 mm⁵ (GRADE of evidence: high; strength of recommendation: strong).

Most authors advocate a third session either routinely or in cases where symptoms remain (Eckardt score >3) with the cautious use of 40 mm balloon if possible. If the Eckardt score remains >3 after the third session, the treatment is usually considered to have failed.5 Patients with a recurrence of symptoms during follow-up may require further dilatation.5

• Consider repeat dilatation (after the initial series) during  follow-up  to maintain symptom response5   (GRADE of evidence: high; strength of recommendation: strong).

The procedure is effective in 90% of patients in the first year and this reduces to 86% in the second year.5 Up to one-third of patients may have recurrence of symptoms during 4–6 years of follow up.62 63 The vast majority can be successfully treated by repeat dilatation, achieving remission rates of up to 97% and 93% at 5 and 10 years, respectively.62

• Perform dilatation under endoscopic or fluoroscopic control based on clinician’s preference and local expertise64–66 (GRADE of evidence: moderate; strength of recommendation: strong).

Fluoroscopic control is used in the majority of studies reporting safety and efficacy of balloon dilatation in achalasia; however, the safety of endoscopic control alone has been shown in a few studies.64–66 Comparative studies between the latter two approaches are lacking. Routine oesophagograms obtained after PD for achalasia did not reveal any clinically unsuspected perforations and no perforations were missed in cases that were not followed by oesophagograms.67 Impedance planimetry may be a tool that improves decision-making in dilating achalasia.68

• Consider proton pump inhibitor (PPI) therapy after dilatation as the technique has 10–40% rate of symptomatic gastro-oesophageal reflux disease (GORD) or ulcerative oesophagitis after treatment69–72 (GRADE of evidence: high; strength of recommendation: strong).

PD does not preclude a subsequent myotomy. Similarly, PD may be performed for recurrence of dysphagia following myotomy.73–79

• Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, but it is not essential67 80 (GRADE of evidence: moderate; strength of recommendation: weak).

PD is contraindicated in patients with poor cardiopulmonary function, frailty or other comorbid illnesses preventing surgery, should an oesophageal perforation occur.81 Patients with hiatal hernia or oesophageal diverticulum have undergone PD safely by experienced operators.82

Peptic strictures

Peptic strictures requiring dilatation have been reported to occur in about 1–2% of patients with reflux oesophagitis, the proportion remaining relatively constant over the past three decades despite a rising incidence of reflux oesophagitis.83 This has been attributed to the widespread adoption of PPI therapy.84 Between 40% and 60% of peptic strictures require only one dilatation,30 83 85 86 with the need for redilatation being highest in the subsequent 1–2 years.86 A recent snapshot of practice in the USA suggests that more than 80% of patients with peptic strictures require only one dilatation.87 This may be because peptic strictures tend to be short and straight, and with the widespread use of PPIs for GORD this more recent survey of practice may reflect the fact that peptic strictures are becoming less severe. Patients with smaller stricture diameter and longer strictures are less likely to respond to dilatation and vice versa.32 58 85

It is clear that dysphagia in patients with reflux oesophagitis may result from oesophagitis rather than stricture, and symptoms may improve with healing of oesophagitis using PPI therapy without the need for dilatation.88 In addition, oesophagitis as well as stricture diameter contribute to the severity of dysphagia,89–91 and healing of oesophagitis in patients with strictures is associated with a reduced need for redilatation.92 Finally, PPI therapy, but not H2 receptor antagonist treatment, reduces the need for, and frequency of, dilatation of peptic strictures after the initial dilatation.92–95

• Offer PPI therapy to patients with GORD and dysphagia, as this treatment has been shown to reduce the need for oesophageal dilatation83 84 89 92 (GRADE of evidence: high; strength of recommendation: strong).

• Offer PPI therapy after endoscopic dilatation for peptic strictures in order to reduce recurrence rate89 92–94 (GRADE of evidence: high; strength of recommendation: strong).

• Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation (stricture recurrence), less effective in healing of oesophagitis and in providing symptom relief from GORD and dysphagia89 92–95 (GRADE of evidence: high; strength of recommendation: strong).

The management of refractory peptic strictures will be discussed in the relevant section.

Schatzki’s ring

Schatzki’s ring is an annular constriction at the gastro-oesophageal mucosal junction, covered on its proximal side by squamous epithelium and distally by gastric mucosa.96 It was first appreciated on barium swallow radiology, provided the oesophagus was adequately distended,97 occurring in 6–14% of barium swallow examinations and often asymptomatic.98 99 The natural history of asymptomatic Schatzki’s ring is unknown so it is not established whether treatment (for instance, with a PPI) is indicated. Schatzki’s ring is less often seen at endoscopy100 unless the gastro-oesophageal junction is adequately distended by air insufflation. It is a common cause of intermittent dysphagia for solids and of food bolus obstruction: ‘Schatzki’s rule’ states that dysphagia is usual with ring diameters of ≤ 13 mm, and rarely occurs if the diameter exceeds 20 mm,101 with a ‘grey’ area in between where symptoms are less consistently observed.

Schatzki’s ring is associated with gastro-oesophageal reflux39 102 103 and with eosinophilic oesophagitis, even in the absence of other endoscopic oesophageal mucosal abnormalities.100 102 This may explain why patients with rings and acid reflux (demonstrated by pH monitoring), and also unselected patients with Schatzki’s rings appear to have fewer recurrences after dilatation when receiving PPI therapy.39 104 Dysphagia due to Schatzki’s ring was relieved by PPI therapy without the need for dilatation in a small retrospective case series.105

Dilatation therapy for symptomatic Schatzki’s ring is directed toward achieving rupture of the ring; therefore, larger calibre dilators may be needed.101 There is robust evidence for the efficacy of a single dilatation to 16–20 mm.106 Electrosurgical incision of the ring has been reported to be at least as effective in relieving dysphagia due to Schatzki’s ring as a single large calibre dilatation in randomised trials.107 Two studies suggest that incision may lead to longer remission of dysphagia than bougienage, proposing this treatment for patients with recurrence after a course of bougienage.108 109 Relapses still occur, but long-term PPI therapy (omeprazole 20 mg/day) significantly reduces the risk of relapse compared with placebo at up to 48 months of follow-up.39 104

Biopsy excision was shown to be effective and safe in a small feasibility study of 10 patients with dysphagia due to a Schatzki’s ring (six of whom had previously undergone bougie or balloon dilatation). Complete endoscopic obliteration of the ring and improvement of dysphagia was achieved (using jumbo biopsy forceps) in all 10 patients during 379 days (range 63–496 days) of follow-up with no serious complications.110

• Do not offer dilatation for asymptomatic Schatzki’s rings incidentally discovered on diagnostic endoscopy or contrast studies (performed for unrelated indication)97–99 (GRADE of evidence: low; strength of recommendation: strong).

• Consider exclusion of eosinophilic oesophagitis by distal, mid and proximal oesophageal biopsies in symptomatic Schatzki’s ring100 102 (GRADE of evidence: moderate; strength of recommendation: strong).

• Offer a single dilatation session using graded dilatation to a relatively large diameter (16–20 mm) to treat dysphagia related to Schatzki’s ring39 106 111 (GRADE of evidence: moderate; strength of recommendation: strong).

• Offer PPI therapy after dilatation, as this reduces the risk of relapse of Schatzki’s ring39 104 (GRADE of evidence: moderate; strength of recommendation: strong).

• Consider electrosurgical incision as an effective alternative treatment to oesophageal dilatation for relieving dysphagia related to Schatzki’s ring108 109 112 (GRADE of evidence: high; strength of recommendation: strong).

In studies reporting this technique, the incision was performed using a standard needle-knife papillotome with a 5 mm cutting wire passed through the accessory channel of the endoscope. Three to four longitudinal incisions were performed radially to the junction of the base of the ring and the oesophageal wall.109 Other experts recommend the use of standard endoscopic submucosal dissection (ESD) needle knife, IT knife or argon plasma coagulation.113 This procedure must be performed by a skilled operator who is familiar with the technique and uses it regularly (such as for ESD procedures).

Post-endoscopic therapy strictures

Oesophageal stenosis can occur after Endoscopic Resection or after Endoscopic Mucosal Ablation for oesophageal neoplasia.

Eosinophilic oesophagitis (EoE)

EoE is a common immune/antigen-mediated oesophageal disease characterised clinically by symptoms of oesophageal dysfunction and histologically, by eosinophil predominant inflammation.154 First described by Attwood and Straumann in 1993–94,155 156 EoE usually presents with dysphagia and is now the the most common cause of food bolus obstruction in patients under the age of 50 years.157 EoE is the the most common cause of spontaneous perforation of the oesophagus. It is the second most common benign disease of the oesophagus.158 It is often underdiagnosed and yet 50 times more common than achalasia.158

Postoperative strictures

Post-radiation strictures

Radiotherapy treatment has revolutionised the management of most solid organ malignancies, but may induce stricturing of the oesophagus. The risk of stricturing can be anticipated before radiotherapy in patients with greater tumour invasion (T-score) and greater circumferential involvement.209–211 Radiotherapy induces tissue ischaemia, fibrosis and subsequent oesophageal stenosis. In contrast to other oesophageal strictures, the fibrosis often affects the tissues surrounding the oesophagus, creating a non-compliant mediastinum. As a consequence, radiation strictures are frequently refractory to dilatation and progressive. The risk is increased with higher radiation doses.212–217 Furthermore, radiotherapy with concurrent chemotherapy increases the likelihood of stricture217 218 and is a cause of completely obstructed oesophagus,.212 219–221 Prior insertion of a gastrostomy should be considered to aid nutrition in already malnourished individuals and this offers an additional conduit through which dilatation attempts of subsequent oesophageal strictures can be made. Where antegrade passage of a guidewire is unsuccessful, a retrograde attempt through the gastrostoma can be made using catheter and guidewire under fluoroscopic control.

The endoscopic CARD approach can be considered in patients with a completely occluded oesophagus. In most circumstances, this requires a general anaesthetic, although conscious sedation has also been used.218 222 A CT scan is also recommended to exclude nearby vessels.223

Visualisation of the proximal aspect of the stricture is undertaken by insertion of an antegrade endoscope. A second endoscope is inserted through the gastrostomy site and the stricture is trans-illuminated in order to identify the now obstructed lumen. Typically, a guidewire is passed from the distal oesophagus proximally under fluoroscopic guidance, puncturing through the stricture and then removed per-orally.209 212 219 222–224 A needle knife,225 straight catheter223 or EUS fine aspiration needle223 225 226 has also been shown to be effective at traversing the stricture by incision. Biplanar fluoroscopy or cone-beam CT may be used to facilitate an axial alignment of the endoscopes and needles and reduce the risk of perforation. Once a guidewire has been passed a bougie or balloon can dilate to 12–15 mm.219–221 223 224 226–229 In some patients, the placement of a temporary (up to 1 month) fully covered SEMS is necessary to maintain the luminal patency with or without a nasogastric tube for feedig.223

No large studies have been undertaken to evaluate the use of the CARD procedure, and it should be regarded as a last resort for use in expert hands only. Evidence from case series suggests it is safe, with no patients requiring emergency surgical intervention.223 The majority of larger series suggest good success (defined as discontinuation of percutaneous endoscopic gastrostomy feeding), although in most instances, repeated dilatation is still required every 2–3 months.212 219 223

• Consider a combined anterograde and retrograde dilatation (CARD) or rendezvous approach under general anaesthetic as an alternative to surgery in the treatment of the completely obstructed oesophagus, where local expertise is available209 212 218 219 221 222 225–228 (GRADE of evidence: moderate; strength of recommendation: weak).

• Use fluoroscopic guidance to assist with the rendezvous procedure209 212 218 219 221 222 225–227 (GRADE of evidence: moderate; strength of recommendation: strong).

• Use a guidewire to navigate through the obstruction when using the CARD approach to re-establish luminal patency209 212 219 222 225 (GRADE of evidence: low; strength of recommendation: strong).

• After gaining luminal patency using the CARD procedure, perform subsequent dilatation using either balloon224 226 229 or bougie212 219–221 228 (GRADE of evidence: moderate; strength of recommendation: strong).

Caustic strictures

Oesophageal injury can be caused by ingestion of caustic substances. Alkalis are the the most common caustic agents ingested in Western countries, while acid ingestion is more common in developing countries, such as India. Caustic oesophageal injury can lead to the lower oesophageal sphincter pressure becoming impaired, which in turn leads to gastro-oesophageal reflux that can worsen stricture formation.230 231

After initial radiological assessment, an upper gastrointestinal tract endoscopy, with gentle air insufflations or preferably with CO₂, should be considered after caustic ingestion within the first 12–48 hours to determine prognosis and management, including oesophageal stricture formation and subsequent requirement for dilatation.232 Contraindications to endoscopy include radiological suspicion of perforation or burns to the supraglottic and epiglottic areas. A CT grading system for caustic lesions has been proposed, but there is insufficient evidence to demonstrate its widespread utility.233 234

• Perform upper gastrointestinal tract endoscopy within the first 12–48 hours after caustic ingestion235–238 (GRADE of evidence: moderate; strength of recommendation: strong).

Several techniques have been used in an attempt to prevent stricture formation. These techniques include oral steroids,239 240 antibiotics, mitomycin C and intraluminal stents,241 but there is limited evidence on outcomes.

Late management makes dilatation more complex owing to fibrosis in the oesophageal wall. Dilatation can be carried out with either bougie or balloon dilators. There is no clear advantage of one technique over another.126 242–246 The Savary-Gilliard type was used in the majority of studies reporting on efficacy of bougie dilatation and is preferred by some practitioners in consolidated and fibrotic strictures.

• Ensure timely management of oesophageal strictures with dilatation as this plays a key role in affecting patient outcomes242–246 (GRADE of evidence: moderate; strength of recommendation: strong).

Dilatation is more hazardous between 1 and 3 weeks after injury and some avoid this time interval. From approximately week 3, scar retraction begins, resulting in stricture formation. The time interval between dilatations varies in published reports but should be less than 2–3 weeks. The number of sessions required to achieve the desired outcome varies; usually three or four are required but the number can be significantly higher.

The perforation rate for caustic strictures is higher than the standard benign oesophageal stricture dilatation rate with anything from 0.4% up to 32% recorded in the literature. The complication rate is lower when performed by those with more experience, and reported to be 4.5%.

• Consider avoiding dilatation within 3 weeks of initial caustic ingestion242 246 (GRADE of evidence: low; strength of recommendation: weak).

• Consider a time interval between dilatations of <2 weeks246 247 (GRADE of evidence: very low; strength of recommendation: weak).

Refractory strictures are more common in caustic ingestion. Management has been reported with intralesional steroid injection or topical mitomycin C at the time of dilatation, temporary stent placement, biodegradable stents and a suspended oesophageal silicone prosthesis. If oesophageal dilatation fails then surgical resection can be considered. There is no consensus for the optimum management of these strictures.245 248–252

Refractory strictures

A stricture should be considered refractory after an inability to maintain a luminal diameter of  ≥14 mm after five sequential dilatation sessions 1–2 weeks apart or maintain the target diameter for 4 weeks once it has been reached.253 Refractory strictures are rare and challenging. Before embarking on any particular management the clinician and patient should be aware of the poor level of data for the outcomes and risks of most techniques.

• Inform patients about the lack of good quality evidence for best approach to treatment of refractory strictures (GRADE of evidence: low; strength of recommendation: strong).

• Consider discussion with, and/or referral to, centres with expertise in treatment and follow-up of patients with refractory strictures (GRADE of evidence: low; strength of recommendation: weak).

• Ensure optimal management of ongoing inflammation with high dose PPI therapy before defining a stricture as refractory83 84 89 92 (GRADE of evidence: high; strength of recommendation: strong).

• Consider alternative neuromuscular causes in patients with ongoing dysphagia despite a seemingly adequate oesophageal diameter126 (GRADE of evidence: low; strength of recommendation: strong).

Complex strictures (>2 cm, angulated, irregular, severely narrowed) of the following aetiologies are most often implicated in refractory strictures: anastomotic, radiation induced, caustic, post-ablative therapy.33