GI Endoscopy · 2 min read
Malignant Esophageal Stricture Dilation and Passage Using the Novel Bougie Cap
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An elderly man presented with dysphagia and inability to swallow any more food. Computed tomography of the thorax showed a massively dilated esophagus filled up with food and a distal esophageal tumor (Figure 1).
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An elderly man presented with dysphagia and inability to swallow any more food. Computed tomography of the thorax showed a massively dilated esophagus filled up with food and a distal esophageal tumor (Figure 1).
Figure 1. Massive food piled up inside the esophagus. A. Arrow shows esophageal mass. B. Lateral view. Notice that the entire esophagus is filled up with food. C. Distal esophageal mass (yellow arrow).
EGD showed massive food amounts in the esophagus (Figure 2, Panel A).
Figure 2. Passage through the neoplastic stenosis using Bougie cap. A. Massive amount food. B. Esophageal cancer resulting in tight stenosis. C. Bougie cap. D. Advancing the Bougie cap through the esophageal lumen. Notice the great visibility. E. Bougie Cap inside the stomach. F. Biliary wire advanced through the Bouge cap. C. Cap remove, scope advanced alongside the wire, which served as “pathfinder”. H. Now it was possible to obtain biopsies and make a diagnosis of squamous cell esophageal cancer.
The malignant stricture was too tight to be traversed with scope (Fig. 2B). In this case we elected the BougieCap for several reasons: a) the cap is transparent (Figure 3) and has three-dilating sizes (which are marked on the cap), c) the entire dilation (bougienage) procedure can be observed through the cap (in contrast to Savary or Maloney dilations), d) it is possible to advance a wire through the cap (Figure 2B). Once the wire was inside the stomach and the stricture had been safely dilated, the wire was left in place, the scope removed, the cap removed. Then the scope was advanced alongside the wire, which served as “pathfinder”, the dilated stricture could now be traversed with the scope. And biopsies were obtained (Figure 2H).
This distally transparent, conically shaped cap is attached to the distal scope, making the scope a “bougie dilator” (Figure 2, 3). The BougieCap is available in various sizes, each with two different dilation diameters, allowing gentle stricture dilation and potentially minimizing the risk of complications.
Figure 3. Bougie cap.
The Bougie cap enables effective and safe dilation of strictures with direct visual feedback, offering significant advantages compared to conventional techniques (Figure 2).
Take home messages:
- Never push a scope through a tight malignant stricture, as this can result in perforation.
- Traditional dilation methods of tight strictures where the distal part of stricture is not visible require fluoroscopy.
- In this case the Bougie cap, due to its transparent design allowed for controlled and safe dilation.
- Placing a wire as pathfinder allows for direct endoscopic passage of the freshly dilated stricture, especially in the setting of complex stricture and debris (food).
- This case shows how using a Bougie cap allowed safe dilation and subsequent obtention of biopsies, reaching a diagnosis. Of course, the dilation was temporary and aimed mainly at obtaining tissue. The patient placement of a self-expanding metal stent and is scheduled to undergo chemotherapy and radiation.
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