Serial Through-the-Scope Balloon Dilatation of Benign Peptic Oesophageal Strictures: From Controlled Tissue Disruption to Biological Remodelling
Written by Prof Ashraf Rasheed MB BCh BAO FRCSI FRCS Eng FACS FRCS Gen Surg Lead Consultant Gastrointestinal & Biliary Surgeon/ Professor of Gastrointestinal Surgery/ Medico-legal Expert Witness/ Global Surgical Educator
July 13, 2026
Principles, Technique and Biological Basis
Introduction
Benign peptic oesophageal strictures remain one of the commonest causes of progressive dysphagia encountered in upper gastrointestinal practice. Despite significant advances in acid suppression therapy, they continue to represent the final stage of chronic gastro-oesophageal reflux disease (GORD), in which repeated mucosal injury, ulceration and healing culminate in irreversible collagen deposition, fibrosis and luminal narrowing. Although endoscopic balloon dilatation has been performed for decades, it is frequently regarded as a simple mechanical procedure. This perception fails to appreciate the biological processes that determine both immediate technical success and long-term clinical outcome.
Modern balloon dilatation should not be viewed as merely stretching scar tissue. Rather, it is a process of controlled radial micro-disruption of mature collagen, initiating a cascade of mechanotransduction, extracellular matrix remodelling and collagen reorganisation. When repeated at appropriate intervals and combined with effective suppression of gastric acid exposure, these controlled interventions progressively remodel the fibrotic oesophageal segment into a compliant lumen capable of restoring normal swallowing. The procedure therefore represents a form of planned biological reconstruction, rather than forceful mechanical expansion.
Understanding this principle fundamentally changes the philosophy of treatment. Success is not achieved by maximising the diameter during a single endoscopic session, but by respecting tissue biology, avoiding excessive trauma, and exploiting the predictable phases of wound healing through carefully timed serial interventions.
This chapter describes a practical, evidence-based approach to through-the-scope (TTS) balloon dilatation of benign peptic oesophageal strictures, integrating current evidence with biological principles and practical experience accumulated over many years of specialist foregut practice.
Biological Basis of Serial Balloon Dilatation
Fibrosis is not a static process. The mature scar that forms within a benign peptic stricture is composed predominantly of densely cross-linked type I collagen arranged in circumferential bundles. These collagen fibres resist expansion and account for the progressive dysphagia experienced by affected patients.
During balloon inflation, radial forces are transmitted uniformly around the circumference of the oesophageal wall. Rather than stretching intact collagen fibres, the balloon creates numerous microscopic disruptions within the fibrotic matrix. These controlled micro-failures initiate a complex healing response characterised by activation of fibroblasts, release of matrix metalloproteinases, degradation of abnormal collagen, and synthesis of new extracellular matrix.
Over the following days, collagen undergoes progressive remodelling before maturing and developing new intermolecular cross-links. During this relatively brief period, the scar remains biologically responsive to further controlled expansion. Repeat dilatation performed during this window promotes progressive lengthening and reorganisation of the fibrotic segment before mature scar contraction becomes established.
Conversely, delaying subsequent dilatation for many weeks allows collagen maturation and recontraction, effectively reversing much of the previous gain.
This biological phenomenon explains why serial dilatation performed at one- to two-week intervals consistently produces superior long-term results compared with widely spaced procedures.
The objective of treatment is therefore not simply enlargement of the lumen but gradual restoration of oesophageal compliance through progressive tissue remodelling.
Indications
Endoscopic balloon dilatation is indicated in patients with symptomatic benign peptic oesophageal strictures causing dysphagia and impaired swallowing despite appropriate medical therapy.
Typical indications include:
Progressive dysphagia secondary to chronic gastro-oesophageal reflux disease.
Benign peptic strictures associated with a large hiatus hernia.
Recurrent peptic strictures following previous successful dilatation.
Symptomatic luminal narrowing preventing adequate nutrition or quality of life.
The diagnosis of benign disease should always be established before embarking upon repeated dilatation. Any atypical appearance should prompt repeat biopsy to exclude malignancy.
Contraindications
Absolute contraindications include:
Suspected or established oesophageal perforation.
Uncorrected coagulopathy.
Haemodynamic instability.
Inability to tolerate upper gastrointestinal endoscopy.
Relative contraindications include:
Active severe oesophagitis with impending perforation.
Deep circumferential ulceration.
Recent oesophageal surgery.
Severe cervical deformity preventing safe endoscopy.
1. Pre-procedure Assessment
Careful pre-procedure evaluation is fundamental to successful treatment.
The assessment begins by confirming that the lesion is truly benign.
The evaluation should include:
Detailed clinical history.
Duration and progression of dysphagia.
Previous endoscopic reports.
Previous histology.
Previous cross-sectional imaging where available.
Previous dilatation procedures.
Current acid suppression therapy.
Previous oesophageal perforation.
Previous thoracic or upper gastrointestinal surgery.
Anticoagulant or antiplatelet therapy.
Nutritional assessment.
Weight loss.
Performance status.
Any doubt regarding the diagnosis mandates repeat biopsy before dilatation.
The endoscopist should also determine whether persistent reflux remains active. Ongoing acid injury continues to stimulate collagen deposition and substantially increases the likelihood of recurrent fibrosis. Mechanical dilatation without effective control of reflux addresses only the consequence of disease rather than its underlying cause.
Assessing Stricture Complexity
Not all benign strictures behave similarly. Before selecting a balloon, the endoscopist should evaluate the complexity of the lesion.
Important factors include:
Length of the stricture.
Estimated luminal diameter.
Degree of fibrosis.
Presence of ulceration.
Associated oesophagitis.
Hiatus hernia.
Barrett's oesophagus.
Previous dilatation history.
Long, narrow strictures containing dense fibrosis generally require more treatment sessions than short focal peptic strictures. Stricture length and calibre are recognised predictors of treatment complexity and the likelihood of refractory disease.
Patients should therefore be counselled before treatment that restoration of swallowing usually requires a planned programme of serial dilatation rather than a single procedure.
2. Equipment
The following equipment should be available:
High-definition therapeutic gastroscope.
Through-the-scope balloon dilators.
Balloon inflation device with pressure gauge.
Sterile water or dilute contrast for balloon inflation.
Guidewire where appropriate.
Suction apparatus.
Carbon dioxide insufflation.
Fluoroscopy for selected complex strictures.
Routine fluoroscopy is unnecessary for straightforward benign peptic strictures but remains valuable in long, tortuous or non-traversable lesions.
3. Initial Endoscopic Assessment
Following intubation of the oesophagus, the stricture should be examined systematically.
The following characteristics should be recorded:
Distance from the incisors.
Length.
Morphology.
Luminal diameter.
Degree of fibrosis.
Active inflammation.
Ulceration.
Mucosal friability.
Presence of Barrett's oesophagus.
Associated hiatus hernia.
One of the most important decisions at this stage is determining whether the gastroscope can traverse the narrowing.
A benign stricture through which a standard adult gastroscope (approximately 9–10 mm outer diameter) cannot pass represents a clinically significant narrowing and provides a practical guide when selecting the initial balloon diameter.
Traversable Versus Non-Traversable Strictures
Traversable Strictures
If the gastroscope passes safely:
inspect the distal oesophagus;
examine the gastro-oesophageal junction;
identify the presence and size of any hiatus hernia;
assess the stomach;
evaluate ongoing reflux injury.
The balloon is then introduced directly through the working channel under continuous endoscopic vision.
Non-Traversable Strictures
Failure to traverse the narrowing should never prompt forceful advancement of the endoscope, instead:
carefully identify the true lumen;
maintain direct visualisation throughout;
gently advance the balloon catheter into the lumen;
use a guidewire where necessary;
employ fluoroscopy selectively in difficult or tortuous strictures.
Most oesophageal perforations occur because excessive longitudinal force has been applied to the endoscope rather than because of controlled radial balloon expansion.
4. Choosing the Initial Balloon
Perhaps the single most important decision during balloon dilatation is selection of the initial balloon diameter. Contrary to common belief, this decision is based less on the patient's dysphagia than on careful visual estimation of luminal calibre. The first balloon should approximate—but not substantially exceed—the estimated diameter of the stricture.
Typical starting sizes are:
Estimated lumen Initial balloon
2–4 mm 6 mm
4–5 mm 6 mm
5–7 mm 8 mm
7–9 mm 10 mm
9–11 mm 12 mm
10–12 mm 12–15 mm
Beginning with an excessively large balloon offers no long-term advantage and significantly increases wall stress and perforation risk. The goal is controlled biological remodelling—not maximal expansion during the first procedure.
Visual Estimation of Luminal Diameter
Accurate visual estimation of luminal calibre is one of the most valuable skills acquired by experienced therapeutic endoscopists, yet surprisingly little practical guidance exists in the literature.
Before selecting the balloon, the endoscopist should mentally compare the stricture lumen with the known external diameter of the adult gastroscope (approximately 9–10 mm). This simple comparison provides a remarkably reliable estimate of luminal calibre and greatly assists appropriate balloon selection.
The following practical calibration system may be used during routine endoscopy:
Endoscopic appearance Estimated lumen diameter Scope traversal
Suggested first TTS balloon
Pin-hole lumen 2–3 mm Impossible 6 mm
Pencil-tip lumen 4–5 mm Impossible 6–8 mm
Small central lumen 6–7 mm Usually, impossible 8 mm
Narrow but clearly visible lumen 8–9 mm May traverse with an 10 mm ultrathin gastroscope
Adult gastroscope almost passes 10–11 mm Occasionally traversable 12 mm
Adult gastroscope passes with 11–12 mm Traversable 12–15 mm resistance
Visual estimation should never rely solely upon the apparent size of the lumen. The overall morphology of the stricture, its length, degree of fibrosis, associated ulceration and eccentricity must all be considered before selecting the initial balloon.
Whenever uncertainty exists, the safer strategy is always to begin with the smaller balloon and continue treatment through planned serial dilatation rather than aggressive expansion during a single session.
Part II – Balloon Dilatation Technique, End Points and Serial Tissue Remodelling
5. Balloon Positioning
Once the appropriate balloon has been selected, accurate positioning becomes the next critical step. Even the most appropriate balloon diameter will fail to achieve optimal results if it is not centred correctly across the fibrotic segment.
The balloon should be advanced gently under continuous endoscopic vision until its midpoint lies at the narrowest part of the stricture. Equal lengths of the balloon should remain proximal and distal to the fibrotic ring. Modern TTS balloons contain radiopaque markers that can be helpful during fluoroscopic guidance in complex cases, although fluoroscopy is unnecessary for most straightforward benign peptic strictures.
The balloon should never be advanced forcefully. If resistance is encountered before the balloon reaches the stricture, the catheter should be withdrawn and the true lumen re-identified. Excessive longitudinal force contributes more to perforation than controlled radial balloon expansion.
Once satisfactory positioning has been confirmed, the endoscope should remain sufficiently close to permit continuous observation throughout inflation while avoiding excessive contact with the balloon itself.
6. Principles of Balloon Inflation
Balloon inflation is the defining stage of the procedure. Contrary to popular belief, the objective is not to inflate the balloon to its maximum rated diameter, nor is success determined by the pressure achieved within the balloon.
Instead, balloon inflation represents a carefully controlled process of gradually loading the fibrotic ring until controlled collagen disruption occurs.
Inflation should therefore always be:
Slow
Progressive
Continuous
Under direct vision
Rapid inflation produces abrupt increases in mural tension, reducing the opportunity to observe tissue behaviour and increasing uncontrolled stress within the oesophageal wall.
Slow inflation, by contrast, allows gradual redistribution of radial forces while providing continuous feedback regarding tissue compliance.
The endoscopist should resist the temptation to "push through" resistant fibrosis.
Instead, the tissue should be allowed to respond gradually to controlled radial loading.
7. Understanding the Balloon Waist
Perhaps the single most important visual sign during balloon dilatation is the appearance of the balloon waist.
As inflation begins, the balloon expands freely above and below the stricture while remaining constricted at the level of maximal fibrosis. This creates the characteristic "hourglass" appearance.
The waist represents the point of greatest circumferential collagen resistance. As inflation continues, controlled microscopic disruption occurs within the fibrotic collagen bundles. Gradually, the waist begins to disappear. This process represents successful tissue disruption.
For this reason, the balloon waist—not balloon pressure—is the most reliable indicator of adequate dilatation. Many inexperienced operators focus excessively on inflation pressure. Experienced endoscopists focus almost entirely upon the behaviour of the waist.
8. The Biological Meaning of Waist Disappearance
Disappearance of the waist should not simply be regarded as a mechanical event. Rather, it signifies that sufficient radial stress has been generated to overcome the tensile strength of mature collagen fibres.
Microscopic failure of collagen bundles initiates a healing response characterised by:
fibroblast activation
collagen degradation
extracellular matrix remodelling
reorientation of collagen fibres
restoration of tissue compliance
This biological response forms the scientific basis of serial balloon dilatation. The objective is therefore controlled collagen disruption, not maximal luminal expansion.
9. Determining the Safe End Point
One of the commonest technical errors during oesophageal dilatation is continuing inflation after adequate tissue disruption has already occurred.
The appropriate endpoint is: complete or near-complete disappearance of the balloon waist without excessive resistance. Once this has occurred, further inflation offers little therapeutic benefit while progressively increasing the risk of mural injury.
If the waist persists despite increasing pressure:
stop inflating
accept the degree of expansion achieved
inspect the mucosa
schedule further serial dilatation
Dense mature fibrosis cannot safely be overcome by force. It must instead be remodelled progressively over several treatment sessions.
10. How Long Should the Balloon Remain Inflated?
Although practice varies slightly between centres, current evidence and clinical experience suggest that inflation should generally be maintained for: 30–60 seconds
This duration allows redistribution of radial forces and completion of collagen micro-disruption. Prolonging inflation beyond one minute has not been shown to improve clinical outcomes.
Repeated prolonged inflations simply expose tissue to unnecessary mechanical stress. Some operators prefer a second inflation after complete deflation. This is reasonable provided tissue injury remains minimal.
11. Sequential Balloon Dilatation
Following successful inflation of the initial balloon:
completely deflate the balloon
withdraw slightly
inspect the treated segment carefully. This inspection is essential.
Progression to a larger balloon should never be automatic. Instead, the decision should depend upon tissue behaviour, if:
the waist has disappeared,
satisfactory mucosal disruption is present,
tissue compliance has clearly improved,
Then, progression to the next balloon size is appropriate.
Conversely, if substantial mucosal splitting has already occurred, further balloon expansion during the same session is rarely necessary.
Typical progression might be:
6 mm
↓
8 mm
↓
10 mm
or
10 mm
↓
12 mm
↓
13.5 mm
↓
15 mm
The endoscopist should remember that biology, not protocol, determines progression.
12. The Rule of Three—Does It Still Apply?
For many years, oesophageal dilatation has been taught according to the traditional "rule of three." Originally described for bougie dilators, this recommended that no more than three progressively larger dilators should be passed during a single procedure.
This principle was developed largely because blind bougie dilatation generated significant longitudinal shearing forces. Modern through-the-scope balloon dilatation differs fundamentally. The balloon produces controlled radial expansion while the entire procedure is performed under direct endoscopic vision.
Consequently, strict adherence to the historical "rule of three" is probably unnecessary. Nevertheless, from a practical perspective, limiting treatment to two or three sequential balloon diameters remains sensible.
Beyond this point:
additional biological benefit becomes limited,
tissue trauma increases,
procedure time lengthens,
perforation risk may increase.
Quality of tissue response is considerably more important than the number of balloon sizes used.
13. Recognising Acceptable Mucosal Injury
The objective of balloon dilatation is controlled disruption. Consequently, a degree of mucosal injury should be expected. Indeed, absence of any mucosal disruption may indicate inadequate treatment.
Expected findings include:
superficial longitudinal splits
linear mucosal tears
minor oozing
limited submucosal exposure
These changes represent successful collagen disruption. Most heal rapidly without clinical consequence.
14. Recognising Excessive Injury
The endoscopist must distinguish expected therapeutic injury from impending perforation.
The following findings should immediately terminate further dilatation:
deep muscular disruption
circumferential tearing
visible mediastinal fat
false passage formation
uncontrolled bleeding
rapidly enlarging mural defect
These findings indicate excessive wall injury. No additional balloon inflation should be attempted.
15. Patient Pain During Balloon Inflation
Mild retrosternal discomfort is common. Unexpected severe pain, however, deserves immediate attention.
Pain out of proportion to balloon expansion may indicate:
deep mural injury
occult perforation
eccentric balloon positioning
The safest response is always:
stop inflation
deflate the balloon
reassess endoscopically
Pain should never be ignored simply because the balloon has not yet reached its intended diameter.
16. Final Endoscopic Inspection
Following completion of dilatation, the treated segment should be inspected meticulously.
Assessment should include:
adequacy of luminal expansion
depth of mucosal injury
bleeding
muscular exposure
evidence of perforation
Repeated passage of the gastroscope through the freshly treated segment should be avoided unless clinically necessary.
Repeated instrumentation may convert an otherwise satisfactory result into significant tissue trauma.
17. Target Diameter
One of the commonest misconceptions is that every patient requires an oesophageal diameter of 20 mm. This is incorrect. Most benign peptic strictures become functionally satisfactory between 15–18 mm.
Many patients regain completely normal swallowing at: 14–15 mm.
Only selected individuals require expansion beyond 18 mm.
Functional swallowing depends not simply upon luminal diameter but also upon:
oesophageal compliance
motility
residual inflammation
associated hiatus hernia
oesophageal shortening
The objective should therefore be restoration of normal swallowing rather than achievement of an arbitrary numerical diameter.
18. Repeat Dilatation Strategy
Perhaps the greatest determinant of long-term success is not the technical performance of balloon dilatation but the interval between treatment sessions.
After each procedure, collagen enters an active phase of remodelling.
During the following one to two weeks:
fibroblasts reorganise collagen,
immature collagen remains extensible,
extracellular matrix turnover continues.
This represents the ideal biological window for further controlled expansion.
Accordingly, repeat dilatation should generally be scheduled at: 1–2 week intervals
Waiting substantially longer allows:
collagen maturation,
scar contraction,
recurrent luminal narrowing.
Many apparent "recurrent strictures" are simply the consequence of allowing biological remodelling to complete before the next intervention.
The concept of serial dilatation therefore reflects tissue biology rather than convenience of scheduling.
Patients should understand from the outset that treatment is a structured programme rather than a series of isolated procedures.
Furthermore, failure to achieve or maintain satisfactory swallowing despite approximately five serial dilatations performed at one- to two-week intervals should prompt consideration of refractory stricture disease and reassessment of the treatment strategy.
Part III – Medical Optimisation, Refractory Strictures and Expert Practice
19. How Many Dilatation Sessions Are Usually Required?
One of the commonest misconceptions among both clinicians and patients is that balloon dilatation represents a single definitive treatment. In reality, benign peptic oesophageal strictures should be regarded as a chronic fibroproliferative disorder that requires planned serial intervention rather than isolated mechanical expansion.
Patients should therefore be counselled before treatment that restoration of swallowing is a gradual biological process. Appropriate counselling not only sets realistic expectations but also improves compliance with repeat procedures and reduces anxiety when dysphagia has not completely resolved after the first treatment.
Although the exact number of procedures varies according to the severity of fibrosis, stricture length, chronicity and adequacy of reflux control, the following represents a useful guide.
Stricture Type Typical Number of Sessions
Simple peptic stricture 3–5
Moderately fibrotic stricture 4–6
Long-standing dense fibrosis 6–10 or more
Refractory stricture Individualised
The endoscopist should avoid promising a fixed number of procedures, as the biological response differs considerably between patients.
Why Approximately Five Sessions Often Produce Durable Remodelling
Although no universally accepted number of dilatations exists, my own experience has consistently demonstrated that stable tissue remodelling is most frequently achieved after approximately five serial balloon dilatations, provided that treatment is performed every one to two weeks and combined with optimal suppression of gastro-oesophageal reflux.
This observation reflects the biology of collagen turnover rather than any arbitrary procedural target. Each balloon dilatation produces controlled collagen disruption. Each subsequent procedure builds upon the previous biological response.
Repeated controlled expansion gradually converts a rigid fibrotic segment into a compliant oesophageal wall capable of maintaining luminal patency.
Patients who undergo irregular treatment schedules seldom achieve comparable results because mature collagen contracts between sessions, effectively reversing much of the previous gain.
This biological model formed the basis of a Master Class on benign peptic oesophageal strictures that I had the privilege of delivering, emphasising that successful treatment depends upon understanding wound healing as much as technical expertise.
20. Medical Therapy After Balloon Dilatation
Balloon dilatation treats the consequence of reflux disease. It does not treat the underlying disease itself. Without adequate suppression of acid exposure, ongoing inflammation continues to stimulate fibroblast activation and collagen deposition, leading inevitably to recurrent fibrosis.
Consequently, every patient undergoing balloon dilatation should receive aggressive medical management of reflux disease.
Treatment should include:
High-dose proton pump inhibitor therapy (30-60 minutes before meal)
Lifestyle modification where appropriate.
Weight optimisation.
Smoking cessation.
Management of nocturnal reflux.
Treatment of associated oesophagitis.
Long-term surveillance where Barrett's oesophagus is present.
The objective is complete healing of oesophagitis and elimination of ongoing mucosal injury.
Mechanical success without biological control of reflux invariably results in recurrent disease.
The Emerging Role of Potassium-Competitive Acid Blockers (P-CABs)
The introduction of potassium-competitive acid blockers (P-CABs), particularly vonoprazan, represents one of the most promising developments in reflux disease over the past decade.
Unlike conventional proton pump inhibitors, P-CABs produce rapid, potent and sustained inhibition of gastric acid secretion without requiring acid activation.
Although long-term evidence specifically relating to benign peptic strictures remains limited, the biological rationale is compelling.
Superior acid suppression may:
accelerate healing of oesophagitis;
reduce ongoing collagen deposition;
decrease recurrent fibrosis;
prolong the interval between dilatations;
reduce progression to refractory disease.
Where available, P-CAB therapy may therefore become an important adjunct to serial balloon dilatation. Unfortunately, despite its potential advantages, it is not yet universally available in routine clinical practice within the United Kingdom.
The Importance of Treating the Underlying Reflux Mechanism
A benign peptic stricture should never be regarded as an isolated oesophageal abnormality.
Rather, it represents the end-stage manifestation of uncontrolled gastro-oesophageal reflux.
Many patients have a large sliding hiatus hernia, severe disruption of the anti-reflux barrier or significant anatomical abnormalities that continue to expose the distal oesophagus to gastric contents.
Failure to correct these abnormalities permits continued inflammation despite technically successful balloon dilatation.
Consequently, once satisfactory luminal remodelling has been achieved, patients should be reassessed for definitive correction of the underlying reflux mechanism.
Selected patients may benefit from anti-reflux surgery, particularly when:
reflux remains poorly controlled despite optimal medical therapy;
a large hiatus hernia is present;
repeated peptic strictures continue to recur.
Restoration of the anti-reflux barrier addresses the underlying disease process and offers the best opportunity for durable long-term success.
21. Refractory Benign Peptic Strictures
Fortunately, the majority of benign peptic strictures respond to carefully performed serial balloon dilatation.
A small proportion, however, remain refractory despite repeated treatment.
Although definitions vary, failure to achieve or maintain satisfactory swallowing despite approximately five well-conducted serial dilatations at appropriate intervals should prompt reconsideration of management.
The endoscopist should first determine whether the apparent treatment failure reflects:
inadequate acid suppression;
excessively long intervals between procedures;
persistent reflux due to a large hiatus hernia;
unrecognised malignancy;
radiation injury;
eosinophilic oesophagitis;
poor patient compliance.
Only after these 7 factors have been excluded should the stricture be regarded as truly refractory.
Intralesional Steroid Injection
Intralesional triamcinolone has become an important adjunct for selected refractory benign strictures.
Following successful balloon dilatation, triamcinolone is injected into the disrupted fibrotic tissue, typically targeting the longitudinal mucosal lacerations produced during expansion.
The biological rationale is straightforward. Steroids inhibit fibroblast proliferation, reduce collagen synthesis and limit excessive scar formation.
Randomised studies have demonstrated reduced recurrence and fewer subsequent dilatation procedures in carefully selected benign strictures.
Steroid injection should not replace adequate balloon dilatation but rather complement it.
Radial Incision Therapy
Short, dense fibrotic strictures may occasionally prove resistant to repeated balloon expansion.
In these patients, radial incision therapy provides an alternative approach.
Using an endoscopic knife, controlled longitudinal incisions are made through the fibrotic ring before or after balloon dilatation.
This technique disrupts circumferential scar tissue mechanically rather than relying solely upon radial balloon expansion.
Radial incision therapy should generally be reserved for experienced therapeutic endoscopists and selected short refractory strictures.
Temporary Fully Covered Self-Expanding Metal Stents
Temporary placement of a fully covered self-expanding metal stent represents another option for carefully selected refractory strictures.
The stent exerts continuous radial force over several weeks, encouraging prolonged remodelling.
However, this approach should not be considered first-line therapy. Migration remains the principal limitation, and current guidance recommends removal within approximately three months when used for benign disease.
In my practice, temporary stenting is reserved for highly selected patients who have failed conventional serial balloon dilatation and in whom surgery is either inappropriate or undesirable.
When Should Surgery Be Considered?
Repeated balloon dilatation should never become an end in itself.
If recurrent fibrosis persists despite optimal medical therapy and well-conducted serial endoscopic treatment, the underlying reflux mechanism should be addressed definitively.
For many patients, this involves repair of a significant hiatus hernia with reconstruction of the anti-reflux barrier.
Correction of the underlying anatomical abnormality removes the stimulus responsible for repeated collagen deposition.
Only exceptionally will oesophageal replacement become necessary for benign peptic disease.
Complications
Although balloon dilatation is generally safe, every endoscopist must remain vigilant for complications.
Potential adverse events include:
Perforation
Bleeding
Chest pain
Transient bacteraemia
Aspiration
Sedation-related complications
Perforation remains the most feared complication but is uncommon when careful technique, gradual expansion and appropriate balloon selection are employed. The overwhelming majority of perforations result from excessive force rather than appropriately staged serial dilatation.
Technical Tips and Pitfalls
Tips
Study the morphology before selecting the balloon.
Estimate luminal diameter before introducing the balloon.
Use the adult gastroscope as an internal measuring reference.
Inflate slowly.
Watch the waist—not the pressure gauge.
Reassess after every balloon.
Respect tissue behaviour.
Treat biology rather than numbers.
Schedule the next procedure before the patient leaves the endoscopy unit.
Pitfalls
Starting with an excessively large balloon.
Waiting several months between procedures.
Chasing an arbitrary target diameter.
Ignoring persistent reflux.
Continuing despite deep mural injury.
Repeatedly traversing the treated segment unnecessarily.
Treating recurrent fibrosis without addressing a large hiatus hernia.
Practical Pearls
Balloon dilatation is controlled biological remodelling, not forceful stretching.
The balloon waist is the most reliable indicator of adequate collagen disruption.
Balloon pressure is far less important than tissue behaviour.
The initial balloon should reflect the estimated luminal diameter rather than the severity of dysphagia.
Visual estimation of luminal calibre is a fundamental endoscopic skill.
The adult gastroscope provides a reliable internal reference for estimating stricture diameter.
Most benign peptic strictures respond to serial dilatation every one to two weeks.
Stable remodelling is commonly achieved after approximately five treatment sessions.
Aggressive acid suppression is essential for durable success.
P-CABs may represent an important future advance in reducing recurrent fibrosis.
Definitive correction of the underlying reflux mechanism should always be considered once adequate luminal remodelling has been achieved.
Failure to improve after multiple well-performed procedures should prompt consideration of steroid injection, radial incision therapy, temporary stenting or anti-reflux surgery.
Key Messages
Through-the-scope balloon dilatation is far more than a technical procedure. It is a carefully orchestrated process of controlled collagen disruption followed by progressive biological remodelling. Appreciating this distinction transforms the management of benign peptic oesophageal strictures from a series of isolated endoscopic interventions into a structured programme of tissue reconstruction.
Successful treatment depends not upon force, but upon judgement: selecting the appropriate balloon, respecting tissue behaviour, recognising the significance of the balloon waist, repeating dilatation within the optimal biological window, and combining mechanical intervention with meticulous control of the underlying reflux disease. When these principles are consistently applied, the vast majority of patients achieve durable restoration of swallowing with a low risk of complications.
Disclaimer: This article was originally published by Prof. Rasheed on LinkedIn and is republished on this website with the author's permission. It is shared to improve accessibility for readers and does not alter the original opinions or clinical perspectives expressed in the publication. For the original version, please visit the LinkedIn article. Serial Through-the-Scope Balloon Dilatation of Benign Peptic Oesophageal Strictures: From Controlled Tissue Disruption to Biological Remodelling | LinkedIn
