Prophylaxis of esophageal stricture after endoscopic submucosal dissection with autologous adipose-derived stromal cells.
Emergingsuggested applicable standard· British Society of Gastroenterology, 'UK guidelines on oesophageal dilatation in clinical practice' (Sami SS et al., Gut 2018;67(6):1000-1023). DOI 10.1136/gutjnl-2017-315414, PMID 29478034. Achalasia-specific dilation is governed by ASGE, 'ASGE guideline on the management of achalasia' (Khashab MA et al., Gastrointest Endosc 2020;91(2):213-227.e6, DOI 10.1016/j.gie.2019.04.231, PMID 31839408).
Decision at stakeprophylactic strategies to prevent esophageal stricture formation after endoscopic submucosal dissection
… Balloon (TTS/hydrostatic) dilation is governed instead by matching the balloon to the stricture and dilating to a pre-selected target diameter under direct endoscopic vision, with fluoroscopy added for tortuous, long or high-risk strictures; limit the first session to 10-12 mm when the stricture will not admit an adult gastroscope (9 mm or less if filiform) and repeat sessions weekly to fortnightly until easy passage of a 15 mm or larger dilator is achieved along with symptomatic improvement. …
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text.
Our full summary of this standard
Widen symptomatic GI luminal strictures with mechanical bougie (Savary-Gilliard) or through-the-scope hydrostatic balloon dilation. For achalasia, use a pneumatic balloon (Rigiflex, starting at 30 mm) with graded dilation over multiple sessions to minimize perforation risk, and always biopsy to rule out malignancy at the index procedure. For non-achalasia strictures, keep the two techniques distinct rather than applying one rule to both. The 'rule of 3' is a BOUGIE (wire-guided push-dilator) rule and its trigger is tactile: once moderate resistance is felt, pass no more than 3 progressively larger dilators in roughly 1 mm (3-Fr) steps in that session. A balloon transmits no such resistance, so the rule does not transfer to it. Balloon (TTS/hydrostatic) dilation is governed instead by matching the balloon to the stricture and dilating to a pre-selected target diameter under direct endoscopic vision, with fluoroscopy added for tortuous, long or high-risk strictures; limit the first session to 10-12 mm when the stricture will not admit an adult gastroscope (9 mm or less if filiform) and repeat sessions weekly to fortnightly until easy passage of a 15 mm or larger dilator is achieved along with symptomatic improvement. BSG 2018 does advise using no more than three successively larger diameter increments in a single session for BOTH bougie and balloon dilators, but grades that advice low quality / low strength and states explicitly that the precise 3x1 mm restriction is not evidence based, 2x1 mm may be safer in very tight or long strictures and 4x1 mm or 3x2 mm may be used safely in looser strictures or ones that have completely recurred. Treat it as a ceiling to be justified, not as a technique-independent law, and do not carry the bougie resistance trigger over to balloon dilation. Treat the underlying condition first, topical steroid optimization for EoE strictures and biologic optimization for inflammatory Crohn's strictures, before or alongside dilation. For refractory benign strictures, inject intralesional triamcinolone (40 mg in 4 quadrants) and escalate to POEM/surgery or SEMS for malignant strictures as indicated.