Esophageal Stricture Dilation Using the Novel Bougie Cap

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Contributors: Luka K. Schöpf , MS, Josip Juraj Strossmayer Universität Osjiek, Croatia, Ameos Klinikum Halberstadt, Germany

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Contributors:
 
Luka K. Schöpf, MS, Josip Juraj Strossmayer Universität Osjiek, Croatia, Ameos Klinikum Halberstadt, Germany

Maren Haslach-Häfner, BA

Berufsfachschule für Pflege, Helios Frankenwaldklinik, Kronach, Germany

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA

An elderly man presented with recurrent meat boluses due to a tight, fibrotic Schatzki ring was found (Figure 1, panels A, B). Destruction of Schatzki rings can be accomplished with dilation using Savary or Maloney dilators or bougies, balloon dilation, star-like incisions, circumferential excision using IT-knife, cold biopsy mini-excisions or with the novel single-use, disposable “BougieCap” (Ovesco USA). In this case we elected the BougieCap for several reasons: a) the cap is transparent (C-G) and has three-dilating sizes (which are marked on the cap) (C, D, E, F), c) the entire dilation (bougienage) procedure can be observed through the cap (in contrast to Savary or Maloney dilations) (D,E,F, G), d) in this era, where many countries have embraced a throw-away approach of utensils (one-time use, “disposable” devices, including Savary dilators), selecting the cheapest and equally or most effective device makes sense. This distally transparent, conically shaped cap is attached to the distal scope, making the scope a “bougie dilator” (Figure 2). The BougieCap is available in various sizes, each with two different dilation diameters, allowing gentle stricture dilation and potentially minimizing the risk of complications.

The Bougie cap enables effective and safe dilation of strictures with direct visual feedback, offering significant advantages compared to conventional techniques (Figure 2).

Figure 2. Dilation of a Schatzki Ring with Bougie Cap. A. Tight fibrotic distal stenosis. B. After removing the food bolus with a cylindrical cap inspection of the distal esophagus revealed a Schatzki ring with remaining lumen of about 9 mm.  C. Bougie Cap view of tongue. D. The distal tip of the cap is reaching the distal esophagus. E. The stretching or dilation of the stricture is easily seen. F. Two mucosal lacerations are seen, reflecting excellent dilation. G. Cap crossing the gastroesophageal junction (notice the Z-line). H. Cap entered the stomach.

Steps for dilation: The conical BougieCap is attached distally to the endoscope with special tape and advanced to the stenosis. By pushing forward and gently rotating the endoscope, the mucosal stricture can be dilated (Figure 1). The BougieCap includes a front aperture for advancing a (0,021-to-0,035-inch (biliary) guide wire (max. 1 mm) when required and two lateral apertures that permit air insufflation, water irrigation, and suction (Figure 2). Direct visual control during endoscopy is enabled by the transparent plastic material of the BougieCap (Figures 1, 2). Additionally, vessel compression by the BougieCap enhances mucosal examination, which improves the visibility of mucosal tears and reducing the risk of mucosal bleeding as a complication. Especially in the context of 'Green Endoscopy', employing the single-use BougieCap is advantageous as it reduces plastic waste by up to 99% compared to traditional dilation techniques. Moreover, costs are much less compared to disposable balloons and Savary dilators. Nonetheless, Savary “bougies” and dilation balloons are safe and efficient techniques that have been available for more than five decades. Thus, prospective studies evaluating this novel BougieCap with other dilation methods are warranted.

Images from EndoCollab. See endocollab.com for more information, including videos, quick tips and lectures on these and many other practical endoscopy tricks and techniques.

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