Self-dilatation is an effective and cost-saving strategy for refractory benign oesophageal strictures: Case series and a proposed management algorithm

Introduction

Refractory benign oesophageal strictures (RBES) can be extremely challenging to treat, with stent placement (generally considered if >5 balloon dilatations are unsuccessful) only effective in around 40% of cases. Self-dilatation with bougie dilators is advised by the European Society of Gastrointestinal Endoscopy (ESGE) but remains underused in clinical practice. We present our experiences of self-dilatation for RBES, highlighting the significant cost-benefits the technique can have.

Methods

We present two cases of RBES successfully managed with bougie self-dilatation. Cost-estimates were provided by the trust clinical coding team.

Results

A 70-year-old female with dysphagia was found to have a 6cm long peptic oesophageal stricture at 25cm. Over the next two years, in addition to high dose PPI she underwent 19 endoscopic balloon dilatations and placement of a fully covered self-expanding metal stent at an estimated cost of £17,061 (OGD + dilatation £565, OGD + stent £6310). She was subsequently taught bougie self-dilatation before meals with a 14mm dilator, which led to 7kg weight gain, the ability to tolerate an almost normal diet and only one further OGD in the next 8 months. A 74 year-old-male had a peptic oesophageal stricture at 35cm, which was highly refractory to all attempted therapy over a seven year period. In total, 67 balloon dilatations were performed, 26 under GA due to anxiety. 21 biodegradable stents and 3 fully-covered metal stents were placed with limited short-term benefit, with an estimated overall cost of endoscopic treatment of £223, 765. With stent placement increasingly difficult due to fibrosis and surgical intervention felt to high risk, the patient was taught twice daily self-dilatation with a 14mm dilator. This has allowed him to eat a solid diet, maintain weight and require only one further OGD in the subsequent six months.

Conclusions

Our experiences add to the existing literature that self-dilatation is an effective, safe and well-tolerated option for the management of RBES. In addition, we highlight the substantial cost-savings self-dilatation is likely to have in some patients. Based on a review of existing literature, we propose a management algorithm for RBES highlighting the need for earlier consideration of self-dilatation as a potential therapeutic option (figure 1) With increasing awareness and growing evidence of the benefits of this technique, we hope to see its use in clinical practice increase in the future.