Complications of endoscopic esophageal stricture dilation

INTRODUCTION — The treatment of benign esophageal strictures typically involves dilation combined with acid suppressive therapy. Advances in endoscopic equipment and dilators have improved the safety of esophageal dilation [1], but esophageal dilation may lead to complications even in the most experienced hands. Awareness of the complications associated with dilation permits early recognition and reduces morbidity and mortality.

This topic will review the major complications associated with esophageal stricture dilation. The techniques used for the dilation of benign esophageal strictures, the approach to patients with non-iatrogenic esophageal perforations, and the complications associated with upper endoscopy in general are discussed separately.

●(See "Endoscopic interventions for nonmalignant esophageal strictures in adults".)

●(See "Boerhaave syndrome: Effort rupture of the esophagus".)

●(See "Overview of esophageal injury due to blunt or penetrating trauma in adults".)

●(See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)

ESOPHAGEAL PERFORATION — The major complication of esophageal dilation is esophageal perforation, which is associated with a mortality rate of approximately 20 percent [2]. The incidence of perforation is influenced by the etiology of the stricture, the experience of the endoscopist, and the techniques and equipment used. In general, perforation rates associated with esophageal stricture dilation are low, unlike procedures such as pneumatic dilation for achalasia, where perforations are estimated to complicate three to five percent of procedures. (See "Pneumatic dilation and botulinum toxin injection for achalasia", section on 'Esophageal perforation'.)

Studies suggest that the perforation rate associated with the dilation of benign strictures is between 0.1 and 0.3 percent [3-8]. The perforation rate was 0.1 percent per session in a report from 1999 that looked at 1043 dilation sessions using Eder-Puestow or Savary dilators in 153 patients (over half of whom had peptic strictures) [4].

In contrast, the perforation rate associated with dilation of pharyngeal strictures may be higher. In a cohort study of 477 patients with pharyngeal stenosis after total laryngectomy who underwent a total of 968 dilatation sessions, the perforation rate was 0.6 percent [9]. (See "Management of late complications of head and neck cancer and its treatment", section on 'Dysphagia'.)

Risk factors — Several risk factors for esophageal perforation have been recognized, although the magnitude of risk is uncertain [5,10-14]. These include:

●A malignant stricture

●Severe esophagitis

●Prior radiation therapy

●A history of caustic ingestion

●Complex (tortuous) or long strictures

●Presence of esophageal diverticula

●Inexperienced operator

●A large hiatal hernia

●Use of high inflation pressures with balloon dilation

●A history of previous esophageal perforation

●A history of prior esophageal surgery (such as for trauma or a congenital abnormality)

Eosinophilic esophagitis has generally been considered a risk factor for deep mucosal tears and esophageal perforation [15-18]. However, studies examining whether patients with eosinophilic esophagitis are at increased risk have had variable results, and we believe it is prudent to continue to view patients with eosinophilic esophagitis as being at increased risk for perforation (see "Treatment of eosinophilic esophagitis (EoE)", section on 'Esophageal dilation'):

●In a meta-analysis of 37 studies including 977 patients with eosinophilic esophagitis and over 2000 dilations, perforation occurred in nine patients (0.03 percent). It was concluded that perforation from esophageal dilation in eosinophilic esophagitis is rare, and esophageal dilation should be considered a safe procedure in these patients [19].

●A systematic review found only one perforation associated with 671 esophageal dilations (0.1 percent) in patients with eosinophilic esophagitis, a rate that is similar to the expected perforation rate for patients without eosinophilic esophagitis [20].

●However, an increased perforation rate was noted in a study in which there were three perforations among 293 dilations (1 percent) [16].

Clinical manifestations — The majority of patients with an esophageal perforation present for evaluation within 24 hours of the injury, though in some cases the presentation may be delayed [21]. The clinical features of esophageal perforation depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Cervical perforations are typically less severe than intrathoracic or intra-abdominal perforations, though contamination of the mediastinum can occur [2].

The most common symptom is pain, occurring in more than 70 percent of patients with intrathoracic perforations [22]. Patients may develop tachycardia, tachypnea, and fever, which can progress rapidly to sepsis and shock. Auscultation of the chest in patients with mediastinal emphysema (pneumomediastinum) may reveal a crunching noise ("Hamman's sign").

Additional signs and symptoms may include:

●Cervical perforation may be associated with neck pain, tenderness of the sternocleidomastoid muscle, dysphonia, hoarseness, cervical dysphagia, and cervical subcutaneous emphysema.

●Intrathoracic perforation results in contamination of the mediastinum and may also extend into the pleural cavity (most often on the left). It is most commonly associated with chest, back, or epigastric pain that is exacerbated with inspiration and swallowing. Patients may also have dysphagia, odynophagia, dyspnea, hematemesis, cyanosis, and, rarely, pericardial tamponade if the perforation involves the posterior pericardium. Mediastinal inflammation may eventually result in cervical subcutaneous emphysema. Due to negative intrathoracic pressure, gastric contents and bacteria may be drawn into the pleural space. Patients may develop signs of sepsis and shock within hours.

●Intra-abdominal perforation results in contamination of the peritoneal cavity. Patients may report back pain and an inability to lie supine. In addition, patients often report epigastric pain that may radiate to the shoulder. Patients may also present with an acute (surgical) abdomen. As with intrathoracic perforation, patients may rapidly deteriorate.

The laboratory evaluation may reveal a leukocytosis. While not part of the diagnostic workup for an esophageal perforation, pleural fluid collected during thoracentesis may contain undigested food, have a pH less than 6, or have an elevated salivary amylase level [23,24].

Differential diagnosis — Not all patients with pain following esophageal dilation have a perforation. Nonspecific chest pain following esophageal dilation is not uncommon, though it is typically mild, self-limited, and lacks the associated signs and symptoms seen with a perforation, such as subcutaneous emphysema. An exception is the pain associated with esophageal dilation with stent placement, which may be severe [25-27]. In addition, some patients will complain of abdominal discomfort resulting from air insufflation. Like patients with nonspecific chest pain, the abdominal discomfort is typically mild and transient. (See 'Nonspecific chest pain' below.)

Chest or abdominal pain may also be seen with disorders such as myocardial infarction, pancreatitis, peptic ulcer perforation, aortic aneurysm dissection, spontaneous pneumothorax, or pneumonia. However, the history of a recent esophageal dilation makes these disorders less likely.

In general, an esophageal perforation should be excluded if the patient's pain is moderate to severe, if it fails to improve after one to two hours, or if there are other symptoms suggestive of a perforation. In addition, patients with post-procedure pain should be given nothing by mouth until it is clear that their pain is improving. (See 'Clinical manifestations' above.)

Diagnosis — An esophageal perforation should be suspected in patients who develop significant neck, chest, or abdominal pain following endoscopy. Generally, the evaluation starts with an examination for signs of a perforation (eg, subcutaneous emphysema), followed by plain thoracic and cervical radiographs. If needed, contrast esophagography or computed tomographic (CT) scanning may be obtained to confirm the diagnosis or to look for intrathoracic and intra-abdominal collections that require drainage. (See 'Clinical manifestations' above.)

Because delays in diagnosis are associated with higher complication and mortality rates, early diagnosis is essential [28-30]. As an example, in a summary of 390 patients from 11 series, the overall mortality rate for patients who did not receive treatment within 24 hours was 27 percent (range 0 to 46 percent), whereas it was 14 percent (range 0 to 28 percent) for patients who were treated within 24 hours [2].

Thoracic and cervical radiographs — Patients with a suspected perforation should undergo thoracic and cervical radiographs (posterior-anterior and lateral films). In addition, if an intra-abdominal perforation is suspected, upright abdominal films should be obtained. Radiographic evidence of emphysema is found subcutaneously in the neck in approximately 95 percent of patients with cervical perforations, and in the mediastinum in approximately 40 percent of patients with intrathoracic perforations [31]. Other findings suggestive of an esophageal perforation include pleural effusions, mediastinal widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. Mediastinal emphysema may not become visible radiographically for an hour, and pleural effusions and mediastinal widening may take several hours to develop [32].

Contrast esophagography (Gastrografin or barium swallow) — Contrast esophagography usually establishes the diagnosis. The sensitivity of contrast studies depends upon the size and location of the perforation, and the technique used for the study. The studies should be carried out with the patient in the right lateral decubitus position [33]. In many centers, water-soluble contrast agents (eg, Gastrografin) are used initially. Esophagography with water-soluble contrast will show extravasation on radiograph in 50 percent of patients with cervical perforations and 75 to 80 of patient with thoracic perforations (image 1) [34]. Water-soluble contrast must be used with care in patients at risk for aspiration, as it can cause severe pneumonitis. In such patients, dilute barium is preferred as the initial contrast agent. In addition, water-soluble contrast should not be used in patients with known or suspected fistulas between the esophagus and the respiratory tract or if respiratory tract perforation is suspected.

If the water-soluble contrast study is negative, a barium study should be performed. Barium studies will detect 60 percent of cervical perforations and 90 percent of intrathoracic perforations [31,35]. Although barium is superior to water-soluble contrast for demonstrating small perforations, it causes an inflammatory response in mediastinal or pleural cavities and is therefore not used as the primary diagnostic study [36].

Computed tomography — If clinical suspicion remains high despite negative findings on esophageal contrast studies, or if contrast studies cannot be obtained, CT scanning should be performed. A CT scan is highly sensitive for detecting extravasated air in soft tissues adjacent to the esophagus or in the mediastinum [37]. Other findings on CT scan may include esophageal wall thickening, pleural effusions, or periesophageal fluid [37]. We agree with the recommendation of some authors that all patients with an esophageal perforation undergo CT scanning to look for intrathoracic and intra-abdominal fluid collections that would require drainage [38].

Flexible upper endoscopy — Upper endoscopy is generally not used to diagnose a perforation following esophageal dilation (though it may be used in other settings where esophageal perforation is suspected, such as penetrating trauma). Air insufflated during endoscopy may dissect intramurally and cause cervical subcutaneous emphysema. This in turn could suggest a more serious perforation than what is actually present and may result in surgery in a patient who could have been managed medically [2]. However, upper endoscopy may be employed as part of the treatment for the perforation (see 'Endoscopic management' below).

If a perforation is clearly seen at the time of the index endoscopy, radiographic imaging should still be obtained to assess the extent of the perforation/leak, or if endoscopic therapy is performed at the time of the perforation, to assess closure of the defect.

Management — The management of patients with esophageal perforation following esophageal dilation depends upon the severity of the perforation and the elapsed time between the perforation and its diagnosis. Management options include medical management, endoscopic therapy, and surgery.

Patients whose perforations are recognized early have a good prognosis and, in many cases, can be managed nonsurgically. By contrast, a delay in diagnosis (particularly beyond 24 hours) usually leads to the need for surgical intervention and is associated with a mortality rate as high as 25 to 50 percent [35,39].

The goals of management are to prevent further contamination, treat infection, restore gastrointestinal tract continuity, and provide nutritional support.

General management — Because the mortality rate associated with esophageal perforation is high, intensive care unit admission should be considered not only for patients with evidence of hemodynamic compromise, but also for patients with multiple comorbid conditions.

Regardless of what management approach is chosen (medical, endoscopic, or surgical), all patients with an esophageal perforation require the following:

●Avoidance of all oral intake

●Nutritional support, typically parenteral

●Intravenous broad spectrum antibiotics

●Intravenous proton pump inhibitor

●Drainage of fluid collections/debridement of infected and necrotic tissue if present

In addition, surgical consultation should be obtained for all patients, since patients managed medically or endoscopically may deteriorate and require surgical intervention.

Medical management

Patient selection for medical management — Several reports have documented successful nonsurgical management of esophageal perforations in appropriately selected patients [31,35,39-43].

Characteristics that are associated with favorable outcomes in patients who are managed nonoperatively include [38]:

●Iatrogenic perforations, since patients are likely to have taken nothing by mouth prior to the procedure, which limits the amount of gastric contents [44]

●Clinically stable patients who are young and healthy

●Patients who present within 24 hours of the perforation, or patients with a delayed presentation who are hemodynamically stable without signs of sepsis

●Cervical esophageal perforations

●Small transmural thoracic perforations with local, circumscribed extravasation of contrast

●Absence of continued extravasation into the mediastinum or pleura and emptying of contrast from the perforation site into the distal esophagus and stomach during contrast esophagography

Characteristics associated with poor outcomes include [38]:

●Sepsis, respiratory failure, and shock

●Intra-abdominal perforations

●Perforations in multiple locations

●Large perforations with widespread contamination

●Perforations involving the pleural cavities

●Perforations with retained foreign bodies

●Perforations within neoplastic tissue

Therefore, it is appropriate to consider medical management if all of the following criteria are met [2,43]:

●The perforation is diagnosed early, or if diagnosed late, the leak is contained

●The leak is contained within the neck or mediastinum or between the mediastinum and visceral lung pleura

●Contrast is able to flow back into the esophagus from the cavity surrounding the perforation

●The injury is not in neoplastic tissue, is not in the abdomen, and is not proximal to an obstruction

●The patient has minimal symptoms

●Signs and symptoms of sepsis are absent

●Access to contrast studies can be obtained at any time of day

●An experienced thoracic surgeon is readily available if the patient deteriorates

Patients who do not fulfill these criteria should be considered for surgical management. However, in patients who are deemed to be at high risk for surgical intervention, the risks of surgery need to be weighed against the benefits. In some cases, nonoperative therapy (medical or endoscopic management) may be preferable in such patients. In addition, endoscopic management may be an option for perforations associated with neoplastic tissue. (See 'Endoscopic management' below and 'Surgical management' below.)

Approach to medical management — For patients who are appropriate candidates for medical management, treatment includes [38] (see 'Patient selection for medical management' above):

●Avoidance of all oral intake for at least seven days

●Parenteral nutrition support

●Intravenous broad spectrum antibiotics for 7 to 14 days

●Drainage of fluid collections

The role of a nasogastric tube, which may help minimize extravasation of oral secretions through the perforation, is less clear [39]. Some advocate placing a tube above the perforation, others suggest using a tube that crosses the perforation, and others do not use a nasogastric tube at all. However, passage of a tube into the stomach may be dangerous in the setting of a perforation and can lead to the reflux of gastric contents. Because of these risks, we do not place a nasogastric tube for management of esophageal perforation.

If the patient is improving clinically, a barium esophagram should be obtained after seven days. Management will then depend upon what is seen:

●If there is no contrast extravasation, clear liquids can be initiated. The diet can then be advanced as tolerated.

●If the barium esophagram demonstrates that the perforation is still present, but is smaller, then it is reasonable to wait another seven days to allow more time for healing and then repeat the study. At that time, if there is no perforation demonstrated, clear liquids can be initiated and the diet advanced as tolerated. If the perforation is still present after two weeks, we proceed with placement of a removable covered metal stent. (See 'Endoscopic management' below.)

●If the perforation is the same size or larger, then our approach is to place a removable covered metal stent to treat the perforation. (See 'Endoscopic management' below.)

Patients who show signs of clinical deterioration during medical management require surgical intervention. Surgery is indicated in patients who are being managed medically if any of the following develop [38] (see 'Surgical management' below):

●A perforation that initially had limited extravasation of contrast develops free diffuse extravasation

●Extension of the perforation

●Clinical deterioration, persistent fevers, or sepsis (if a collection that is amenable to percutaneous drainage is present then attempted drainage of the collection prior to proceeding with surgery is reasonable)

●Progression of pneumomediastinum or pneumothorax

●Development of an empyema

Outcomes with medical management — Studies suggest that in appropriately selected patients, medical management can be successful [45-47]:

●In a series of 26 patients with iatrogenic perforations who were managed medically, four patients (15 percent) died, and one patient required surgery because of mediastinal soilage and sepsis [47]. Of the patients who died, one had presented more than 24 hours after the perforation, two had perforations in the setting of esophageal cancer, and one was elderly with renal failure.

●In a series of 47 patients with esophageal perforations (25 iatrogenic), all 34 of the patients treated with medical management survived and had documented esophageal healing at the time of discharge [46].

Endoscopic management — Removable plastic or fully covered, self-expandable metal stents (FCSEMS) make it possible to treat some patients with esophageal perforations endoscopically, and the rate of stent use appears to be increasing. In a study of 659 patients with benign esophageal perforation, esophageal stents were placed in 100 patients (15 percent), and the rate of stent placement increased from 7 to 30 percent over the eight year duration of the study [48].

Stents may be appropriate for patients with perforations in the setting of an esophageal neoplasm [49,50] or for patients who are unlikely to tolerate more extensive surgery, provided an endoscopist who is experienced with esophageal stent placement is available. Multiple series have described the successful use of stents for esophageal perforations, though no large trials have been carried out [51-57]. In one series, 33 patients (19 of whom had an iatrogenic perforation) underwent stenting with removable stents [51]. The stent sealed the lesion in 32 patients (97 percent). Stent extractions were uncomplicated in all 23 patients who had their stents removed within six weeks. Ten patients had their stents removed between 6 and 84 weeks after placement. In that group, there were six extraction-related complications. Ultimately, four patients (12 percent) required an esophageal resection. For three patients, it was due to failed stent therapy, and in one it was due to failed stent removal.

Covered stents have been associated with risk of stent migration [58]. Most advanced endoscopists anchor FCSEMS in the esophagus to decrease the risk of migration. Anchoring methods include suturing or placing a special over-the-scope clip device that is designed specifically for use with FCSEMS [59].  

If an esophageal stent is used, a repeat esophagram should be obtained in one to two days to document that the perforation has sealed [38]. Once confirmed, the patient may resume oral intake (typically clear liquids to start, with advancement of the diet as tolerated). If stent migration occurs, an attempt to reposition or to replace the stent is reasonable [38].

The optimal amount of time to leave the stent in place has not been established. Stents are often removed six to eight weeks following insertion, but the longer the stent is left in place, the more likely that granulation tissue may develop that may make stent removal difficult. There are reports of removal in as few as 10 to 21 days with complete healing of the perforation [50,52,53]. In patients being treated with a stent, we suggest removal within six weeks of placement.

There have also been reports suggesting that endoscopic clips may be used to treat patients who have acute esophageal perforations due to therapeutic endoscopy, provided there is no evidence of significant extraesophageal contamination [60-66]. An over-the-scope-clip system (OTSC) has been used successfully to close perforations. The OTSC system appears to be a safe and effective method [67]. However, until more data become available, we suggest that endoscopic clips only be used to close perforations in the setting of clinical trials by endoscopists who are highly skilled in their use.

Surgical management — Patients who are not candidates for or who fail conservative attempts at treatment require surgical treatment. This can include primary repair of the defect, resection of the defect, diversion, drainage of collections, or in some cases, esophagectomy. The surgical approach is discussed in detail elsewhere. (See "Surgical management of esophageal perforation".)

NONSPECIFIC CHEST PAIN — Chest pain is sometimes observed following stricture dilation, even in patients without a perforation. This nonspecific chest pain is usually mild, self-limited, and requires no specific therapy. Rare patients require a period of a liquid diet and/or analgesics. Chest pain following dilation is commonly observed in patients with eosinophilic esophagitis in whom even gentle dilation can cause mucosal tearing and/or perforation. It is also relatively common when dilation is followed by placement of an expandable stent. (See "Endoscopic stenting for palliation of malignant esophageal obstruction" and "Treatment of eosinophilic esophagitis (EoE)", section on 'Esophageal dilation'.)

An esophageal perforation should be excluded if the patient's pain is moderate to severe, if it fails to improve after one to two hours, or if there are other symptoms suggestive of a perforation. In addition, patients with post-procedure pain should be given nothing by mouth until it is clear that their pain is improving. (See 'Clinical manifestations' above and 'Diagnosis' above.)

BACTEREMIA — Esophageal dilation has the highest incidence of bacteremia of all gastrointestinal endoscopic procedures, occurring in approximately 45 percent of cases [68]. In spite of this, complications of bacteremia such as endocarditis are rare [69]. A survey performed in 1976 found only two cases of endocarditis in over 23,000 dilations [3].

Guidelines for antibiotic prophylaxis have been established by the American Society for Gastrointestinal Endoscopy [70] and the American Heart Association (table 1). The guidelines do not recommend antibiotic prophylaxis for esophageal dilation. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

HEMORRHAGE — Significant hemorrhage related to esophageal dilation is uncommon. In one series, hemorrhage requiring blood transfusions occurred in 0.2 percent of esophageal dilations with mechanical dilators [3]. Another series found significant hemorrhage in 2 percent of patients who underwent balloon dilation [71]. However, subsequent series suggested that the incidence of hemorrhage is infrequent, regardless of the type of dilator used [72,73].

Endoscopic evaluation and therapy are not required in a hemodynamically stable patient with a small amount of hematemesis or coffee ground emesis. However, patients with ongoing bleeding, hemodynamic instability, or a drop in hematocrit should undergo endoscopy for evaluation and treatment. (See "Approach to acute upper gastrointestinal bleeding in adults".)

COMPLICATIONS RELATED TO ENDOSCOPY — Complications associated with procedural sedation and the endoscopy itself include aspiration pneumonia, respiratory failure, and cardiac arrhythmias [3,74]. (See "Gastrointestinal endoscopy in adults: Procedural sedation administered by endoscopists", section on 'Adverse events' and "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Complications'.)

SUMMARY AND RECOMMENDATIONS

●The major complication of esophageal dilation is esophageal perforation, which is associated with a mortality rate of approximately 20 percent. The incidence of perforation is influenced by the etiology of the stricture, the experience of the endoscopist, and the techniques and equipment used. In general, perforation rates associated with benign esophageal stricture dilation are low (one to two per thousand). (See 'Esophageal perforation' above.)

●The clinical manifestations of esophageal perforation may include neck, chest, or back pain, hoarseness, dysphagia, odynophagia, dyspnea, hematemesis, subcutaneous emphysema, and symptoms of an acute abdomen. (See 'Clinical manifestations' above.)

●The diagnosis of an esophageal perforation is based upon recognition of the clinical features and radiographic evaluation. The diagnosis should be suspected in patients who develop significant neck, chest, or abdominal pain following endoscopy. Generally, the evaluation starts with plain thoracic and cervical radiographs. If needed, contrast esophagography or computed tomographic (CT) scanning may be obtained to confirm the diagnosis or to look for intrathoracic and intra-abdominal collections that require drainage. (See 'Diagnosis' above.)

●The management of patients with esophageal perforation following esophageal dilation depends upon the severity of the perforation and the elapsed time between the perforation and its diagnosis. Management options include medical management, endoscopic therapy, and surgery. (See 'Management' above.)

Regardless of what management approach is chosen, all patients with an esophageal perforation require the following:

•Avoidance of all oral intake

•Nutritional support, typically parenteral

•Intravenous broad spectrum antibiotics

•Intravenous proton pump inhibitor

•Drainage of fluid collections/debridement of infected and necrotic tissue if present

●Chest pain is sometimes observed following stricture dilation, even in patients without a perforation. It is usually mild, self-limited, and requires no specific therapy. However, an esophageal perforation should be excluded if the patient's pain is moderate to severe, if it fails to improve after one to two hours, or if there are other symptoms suggestive of a perforation. In addition, patients with post-procedure pain should be given nothing by mouth until it is clear that their pain is improving. (See 'Nonspecific chest pain' above and 'Diagnosis' above.)

●Other uncommon complications of esophageal stricture dilation include bacteremia and hemorrhage. (See 'Bacteremia' above and 'Hemorrhage' above.)