Negotiating Dire Straits with a BougieCap
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STANFORD MULTIDISCIPLINARY SEMINARS
Negotiating Dire Straits with a BougieCap Hannah Ramrakhiani1 · George Triadafilopoulos2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Case Presentation and Evolution
Discussion
A 62-year old male was initially evaluated for a progressively worsening sensation of food getting lodged below his throat associated with a decrease in caloric intake and a 16 lb weight loss. His past history was significant for hospitalization 15 months prior to chest pain, nausea, vomiting, and odynophagia. CT scan showed circumferential mural thickening of the esophagus. An upper endoscopy revealed necrotic-appearing mucosa with biopsies showing evidence of acute ischemic injury. Four weeks later, he developed dysphagia to both liquids and solids. A follow-up upper endoscopy identified a 10-cm-long stricture, extending from mid- to distal esophagus with a lumen diameter as narrow as 4 mm. Balloon dilation with a through-the-scope (TTS) balloon was complicated by an esophageal perforation that was treated with an emergent thoracotomy, distal esophagectomy, and gastric pull-up and placement of a feeding jejunostomy (Fig. 1). Over the next year, he noted increasing difficulty swallowing, prompting a gastroenterology consultation. Barium swallow examination revealed a tight stricture at the anastomosis that narrowed the lumen diameter to 5 mm. An upper endoscopy performed using an ultrathin endoscope confirmed a tight stricture located 18 cm from the incisors. The stricture was located just distal to the upper esophageal sphincter making it difficult to use a TTS balloon for dilation. Using an endoscopic BougieCap®, the stricture was dilated initially to 7 mm. Over the course of the next few weeks, the patient underwent two more upper endoscopies with dilation of the stricture to 12 mm in size with good results. At a follow-up office visit 6 months later, he reported being able to eat a fairly normal diet and had gained 10 lb (Fig. 2).
Benign esophageal strictures are due to gastroesophageal reflux disease, Schatzki’s rings, eosinophilic esophagitis (EoE), surgical anastomosis, radiation therapy, and complications of endoscopic ablative therapies [1]. Esophageal dilation as the first-line therapy is very effective in managing dysphagia with response rates exceeding 90% [2–4]. There are two types of esophageal dilators available—mechanical (bougie) dilators and balloon dilators. Each of these can be used with or without a guidewire (Fig. 3). Mechanical (bougie) dilators can be used for the treatment of simple strictures. They exert a combined radial and longitudinal force, which may increase the risk of perforation. The Maloney dilator is the most common mechanical dilator that does not require a guidewire to be passed. Although Maloney dilators have been traditionally filled with mercury, recent versions are filled with tungsten in order to provide flexibility and weight without potential toxicity in the event of bougie rupture. Of the several wire-guided dilators available,
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