Yuan HF, Liu P, Guo CQ, Bi YH. Comparative study of self-expandable stent placement, bougie dilation, and balloon dilation for post-inflammatory oesophageal strictures. World J Gastrointest Endosc 2026; 18(3): 117303 [DOI: 10.4253/wjge.v18.i3.117303]
Corresponding Author of This Article
Yong-Hua Bi, MD, PhD, Professor, Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Dong Road, Zhengzhou 450052, Henan Province, China. 274233911@qq.com
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Gastroenterology & Hepatology
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Retrospective Study
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Mar 16, 2026 (publication date) through Mar 17, 2026
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World Journal of Gastrointestinal Endoscopy
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Yuan HF, Liu P, Guo CQ, Bi YH. Comparative study of self-expandable stent placement, bougie dilation, and balloon dilation for post-inflammatory oesophageal strictures. World J Gastrointest Endosc 2026; 18(3): 117303 [DOI: 10.4253/wjge.v18.i3.117303]
Hui-Feng Yuan, Yong-Hua Bi, Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Ping Liu, Chang-Qing Guo, Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Author contributions: Yuan HF, Liu P and Bi YH participated in the conception and design of the study and were involved in the acquisition, analysis, or interpretation of data; Guo CQ wrote the manuscript; Bi YH and Guo CQ accessed and verified the study data; all authors critically reviewed and provided final approval of the manuscript; all authors were responsible for the decision to submit the manuscript for publication.
Institutional review board statement: This investigation was approved by the Institutional Review Board of the First Affiliated Hospital of Zhengzhou University (No. 2023-KY-1378).
Informed consent statement: The need for patient consent was waived due to the retrospective nature of the study.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Data sharing statement: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Corresponding author: Yong-Hua Bi, MD, PhD, Professor, Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Dong Road, Zhengzhou 450052, Henan Province, China. 274233911@qq.com
Received: December 4, 2025 Revised: December 21, 2025 Accepted: January 21, 2026 Published online: March 16, 2026 Processing time: 99 Days and 15 Hours
Abstract
BACKGROUND
The outcomes of self-expandable metal stent (SEMS) placement, bougie dilation and balloon dilation for the management of post-inflammatory oesophageal strictures (PIESs) have not been compared previously.
AIM
To compare the safety, effectiveness and cost-effectiveness of SEMS placement, bougie dilation and balloon dilation in patients with PIESs.
METHODS
The medical records of 58 patients with PIESs who underwent SEMS placement with or without dilation (stent group), bougie dilation (bougie group) or balloon dilation (balloon group) between September 2014 and February 2025 at the Gastrointestinal and Interventional Centre of our hospital were retrospectively reviewed. Clinical outcomes, including safety, effectiveness and cost-effectiveness, were compared among the three groups.
RESULTS
The technical success rates were 81.5%, 81.1% and 77.4%, and the clinical success rates were 62.5% (10/16), 70.0% (14/20) and 81.0% (17/21) in the stent, bougie and balloon groups, respectively. After the procedures, the stricture diameter increased significantly and symptom scores decreased significantly in all three groups. The cumulative costs were 2.5 × 104 ¥, 2.6 × 104 ¥ and 11.5 × 104 ¥ in the bougie, balloon and stent groups, respectively. Perforation was the only major complication. Longer hospital stays and more frequent hospitalisations were observed in the stent group. Mild bleeding and chest pain were the most common minor complications. Stent-related complications occurred in eight patients during 17 procedures.
CONCLUSION
Bougie and balloon dilation are safe, effective and cost-efficient treatments for PIESs. Treatment of PIESs with SEMSs should be undertaken with caution because of the high cumulative costs, prolonged hospital stays, frequent hospitalisations and stent-related complications.
Core Tip: This is a retrospective single-center observational study to investigate the safety, effectiveness and cost-effectiveness of self-expandable metal stent (SEMS) placement, bougie dilation, and balloon dilation for patients with post-inflammatory oesophageal strictures (PIESs). Bougie and balloon dilation are safe, effective and cost-efficient treatments for PIESs. However, treatment of PIESs with SEMSs should be undertaken with caution because of the high cumulative costs, prolonged hospital stays, frequent hospitalisations and stent-related complications.
Citation: Yuan HF, Liu P, Guo CQ, Bi YH. Comparative study of self-expandable stent placement, bougie dilation, and balloon dilation for post-inflammatory oesophageal strictures. World J Gastrointest Endosc 2026; 18(3): 117303
Peptic strictures are common benign oesophageal strictures (BESs), accounting for 70%-80% of all BESs[1,2]. Post-inflammatory strictures, which are characterized by peptic strictures, form during the healing process following ulceration and are caused by chronic inflammation resulting from uncontrolled gastro-oesophageal reflux[3,4]. Bougie and balloon dilation are the standard treatments for BESs[5-7] and are the primary treatment options for post-inflammatory oesophageal strictures (PIESs). Self-expandable metal stents (SEMSs) are widely used for the treatment of malignant oesophageal strictures[8-10]. However, fully covered SEMSs are recommended only for refractory strictures cases in patients with BESs[3,11,12]. Unfortunately, the success rate of fully covered SEMSs for refractory peptic strictures is only 35%-45%, and adverse events, including stent migration, occur in approximately 20%-25% of patients[11].
The outcomes of oesophageal stenting compared with bougie or balloon dilation have not been evaluated in prospective controlled clinical trials. The present study aimed to compare the safety, effectiveness and cost-efficiency of SEMS placement, bougie dilation and balloon dilation in patients with PIESs.
MATERIALS AND METHODS
Patients
The medical records of 58 patients with PIES treated at the Gastrointestinal and Interventional Centre between September 2014 and February 2025 were retrospectively reviewed. PIESs were associated with peptic ulcer disease (n = 15), reflux oesophagitis (n = 20) or other causes (fungal oesophagitis, syphilitic oesophagitis, and chronic oesophageal mucosal inflammation, etc., n = 23). All patients underwent endoscopically or fluoroscopically guided SEMS placement, bougie dilation or balloon dilation at least once, and their oesophagogram images and medical records were reviewed retrospectively (Figures 1 and 2). This study was approved by the Institutional Review Board of the First Affiliated Hospital of Zhengzhou University (No. 2023-KY-1378). The requirement for informed consent was waived by the Institutional Review Board of the First Affiliated Hospital of Zhengzhou University owing to the retrospective study design, and all clinical data were anonymised.
Figure 1 Preoperative tests prior to balloon dilation of post-inflammatory oesophageal strictures in a 31-year-old man.
A: The oesophagogram revealed a 2 cm stenosis in the lower esophagus; B: The endoscopic examination revealed an oesophageal stricture located 35 cm from the incisors, with an internal diameter of approximately 0.2 cm, making it impossible for the endoscope to pass through; C: Pathological examination confirmed the stenosis as post-inflammatory oesophageal stricture caused by oesophageal reflux.
Figure 2 Preoperative tests prior to stent placement for post-inflammatory oesophageal strictures in a 68-year-old man.
A: The endoscopic examination revealed an oesophageal stricture 35 cm from the incisors, with food obstructing the esophagus and preventing endoscopic passage; B: The oesophagogram revealed a 4.7 cm severe stricture in the lower esophagus; C: The pathology showed chronic inflammation of oesophageal mucosa with ulcer and inflammatory granulation tissue hyperplasia.
Endoscopically guided dilation
Patients fasted for 6-8 hours to empty the stomach, and midazolam was administered intravenously for conscious sedation. An endoscope (GIF-Q260J or GIF-H260; Olympus Optical Co., Ltd., Tokyo, Japan) was inserted orally, and a guidewire was advanced through the working channel and passed across the stricture. An appropriate balloon catheter or Savary-Gilliard bougie (5-17 mm) was selected according to the luminal diameter. A non-compliant balloon (Bard Peripheral Vascular, Inc.; Cook Corporation, Bloomington, United States) or CRETM balloon (Boston Scientific, Marlborough, MA, United States) was introduced along the guidewire. The balloon was gradually inflated either manually with water or under controlled pressure when using the CRETM balloon. Endoscopy was performed immediately after balloon withdrawal to assess for oesophageal perforation or bleeding at the dilation site (Figure 3). Repeated dilations were performed at varying intervals in patients with recurrent strictures. The choice of endoscopic or fluoroscopic dilation was determined jointly by patients and clinicians, and some patients alternated between the two methods during multiple sessions.
Figure 3 Endoscopically guided balloon dilation of maleost-inflammatory oesophageal strictures.
A: A guidewire was passing through the stricture; B: An 8 mm balloon was inserted for dilation, maintaining dilation for 2 minutes after the waist disappeared; C: The fluoroscopic view of balloon dilation procedure; D: The endoscopic view of the dilated lumen immediately after dilation, mild mucosal bleeding was observed around the stricture.
Fluoroscopically-guided balloon dilation or stenting
All patients provided written informed consent before the procedure. Balloon dilation, SEMS placement and stent removal were performed by experienced operators under fluoroscopic guidance according to an established protocol (Figure 4). Patients fasted for approximately 6 hours before the procedure to reduce the risk of aspiration. Topical lidocaine was applied to the pharynx.
Figure 4 Fluoroscopically guided stenting procedure for the senile patient.
A: A 20 mm × 120 mm oesophageal stent was introduced and inserted in the lower esophagus; B: The oesophagogram immediately after the procedure shows improved passage through the widened lumen of the lower esophagus; C: Restenosis was observed at the proximal end of the stent 2.5 months after stent placement; D: A second 20 mm × 100 mm oesophageal stent was implanted at the stricture site; E: The second stent migrated distally about 2 months after placement, leading to symptom recurrence; F: The two stents were successfully removed under fluoroscopy.
A 0.035-inch guidewire and a 5F multifunctional catheter were advanced across the stricture. Approximately 5-10 mL of water-soluble contrast medium was administered orally to delineate the stricture segment. After exchanging the guidewire for a stiff wire, a balloon catheter (Bard Peripheral Vascular, Inc.; Cook Corporation, Bloomington, United States) was advanced to the stricture site. Water-soluble contrast medium was injected until the balloon “waist” disappeared. Immediately after dilation, an oesophagogram was performed to assess stricture resolution and detect oesophageal perforation.
For stent placement, a fully covered SEMS (diameter 16-22 mm; length 80-140 mm; Taewoong Medical, Seoul, South Korea; Cook Corporation, Bloomington, United States) was deployed across the stricture[9,10]. Stent removal was recommended 1-3 months after placement to minimise long-term complications.
Follow-up and study endpoints
Gastroscopy was routinely performed during follow-up. Barium studies (e.g. upper gastrointestinal series or oesophagogram) were reserved for patients with suspected stricture recurrence, to avoid unnecessary radiation exposure. Dysphagia was graded according to Ogilvie’s dysphagia classification: Grade 1, inability to eat some solid foods; grade 2, inability to eat semi-solid foods; grade 3, inability to swallow liquids; and grade 4, complete dysphagia[6,10,11]. Technical success was defined as a successful dilation, with a reduction in stricture rate of at least 20% without serious complications such as massive bleeding or perforation[13]. Using a previously described stricture index[14], the stricture rate was calculated as follows: 100%-stricture diameter/normal oesophagus diameter × 100%. Clinical success was defined as an improvement of at least one grade in the dysphagia score sustained for 6-12 months[13,15]. Oesophageal rupture was classified into three types as previously described[16]. Changes in stricture severity, technical success, clinical success, dysphagia scores and complications were compared among the three groups. Hospital stay duration, costs, number of balloon dilations and number of stenting sessions were also evaluated.
Statistical analysis
Data are presented as means ± SD or medians with interquartile ranges (IQR). Group comparisons were performed using one-way analysis of variance or Student’s t-test for continuous variables and Fisher’s exact test for categorical variables. A P value < 0.05 was considered statistically significant.
RESULTS
Baseline characteristics
Fifty-eight patients with PIES were enrolled between September 2014 and February 2025. Baseline characteristics are summarised in Table 1. No significant differences were observed among the three groups with respect to sex, age, symptom duration, underling disease or stricture type or length. The causes of PIES included peptic ulcer disease (n = 15), gastro-oesophageal reflux disease (n = 20) and other causes (n = 23).
Table 1 Clinical characteristics of enrolled patients, n (%)/mean ± SD.
Technical outcomes, hospitalisation data and changes in stricture characteristics are presented in Table 2. Technical success were 81.5%, 81.1% and 77.4% (P = 0.9451) and clinical success rates were 62.5% (10/16), 70.0% (14/20) and 81.0% (17/21) (P = 0.4095) in the stent, bougie and balloon groups, respectively. No significant differences were observed in technical success or treatment duration. Median follow-up periods were 43.7, 30.6 and 40.7 months, respectively (P = 0.1818). In total, 194 dilations and 56 stenting sessions were performed. The median number of dilations were 5.0, 2.0 and 2.0 in the stent, bougie and balloon groups, respectively (P = 0.0818). The dilation size of bougie or balloon was significantly larger in the stent group, while the other two groups showed no significant difference in dilation size.
Table 2 Technical outcomes, hospitalisation and stricture change, n (%)/median (25th-75th percentiles)/mean ± SD.
Stricture diameter increased significantly and dysphagia scores decreased significantly after treatment in all three groups. Cumulative costs were significantly lower in the bougie and balloon groups (2.5 × 104 ¥ and 2.6 × 104 ¥, respectively) than in the stent group (11.5 × 104 ¥, P < 0.0001). Hospital stays were longer (median: 52.2 days, IQR: 25.3-75.7) and hospitalisations were more frequent (median: 7.0; IQR: 5.5-11.0) in the stent group. Although no significant differences were observed in the median number of dilations or average costs per session, these values tended to be higher in the stent group.
Stenting procedure and complications
Twenty-nine SEMSs were inserted, with 1-7 stents per patient. All but one stent were successfully removed; the remaining stent was retained in a patient who continued to undergo treatment. The median stent indwelling duration was 3.8 months (IQR: 1.7-6.3). Indications for stent removal included scheduled removal after completion of treatment for 14 stents in eight patients (50.0%) and stent-related complications for 14 stents in ten patients (62.5%), including stent migration in five cases, stent intolerance in three cases and stent restenosis in six cases. Overall, stent-related complications were observed in eight patients (50.0%) during 17 procedures (30.4%), including stent migration in six cases (eight procedures), stent restenosis in four cases (six procedures), and stent intolerance in four cases (four procedures).
Dilation-related complications
As shown in Table 3, mild bleeding and chest pain were the most common minor complications. Stent-related complications occurred in eight patients during 17 procedures. Perforation occurred in two patient (12.5%) in the stent group and two patients (9.1%) in the balloon group; no perforations were observed in the bougie group (Table 2). Mild bleeding occurred in 12 patients (75.0%) in the stent group (28 procedures), 14 patients (70.0%) in the bougie group (31 procedures) and 20 patients (90.0%) in the balloon group (44 procedures). Mild chest pain was observed in five (31.3%) in the stent group (nine procedures), one patient (5.0%) in the bougie group, and four patients (18.2%) in the balloon group (eight procedures). None of the 58 patients experienced massive bleeding or procedure-related mortality.
Table 3 Complications, clinical outcomes and follow-up, n (%)/median (25th-75th percentiles).
Common types of BES include peptic strictures, anastomotic strictures and corrosive esophagitis. Bougie or balloon dilation is the first-line treatment for symptomatic BESs, including peptic strictures[3]. However, approximately half of patients require repeated dilations[1,17], resulting in increased hospital stays and higher costs. Alternative treatment strategies include SEMS placement[18-20] and large-diameter balloon dilation[21]. To our knowledge, the success rates, cost-effectiveness, hospitalisation rates and symptom improvement associated with stent placement, bougie dilation and balloon dilation have not been directly compared, although dilation is commonly used for peptic oesophageal strictures[22,23]. In the present study, technical success rates were 81.5%, 81.1% and 77.4% in the stent, bougie and balloon groups, respectively, while clinical success rates were 62.5%, 70.0% and 81.0%, respectively. In contrast, higher technical and clinical success rates have been reported for balloon dilation after endoscopic submucosal dissection (ESD), with success rates of up to 92.9% at 1 month after dilation, compared with balloon dilation for strictures[24]. In previous studies, clinical success was defined as symptom improvement 1 month after dilation and this definition has been used to assess the efficacy of balloon dilation for benign strictures[13,15]. In our clinical experience, a 1-month follow-up period may be insufficient to accurately represent treatment efficacy, as some patients develop recurrent dysphagia and require repeated interventions after this time. Therefore, we defined clinical success as symptom improvement sustained for at least 6-12 months.
Although the clinical success rate observed in this study was lower than that reported for post-ESD strictures, the results remain encouraging and demonstrate the clinical effectiveness of bougie and balloon dilation for PIESs. In addition to differences in the definition of clinical success, variations in ulcer formation and healing between PIESs and post-ESD strictures may contribute to differing outcomes. Peptic ulceration typically persists long enough to result in stricture formation, inducing fibrosis and granulation hyperplasia in the submucosal layer, which may reduce tissue contractibility[24]. In contrast, ulcers induced by ESD tend to heal more rapidly, with initial mucosal shrinkage followed by rapid regeneration. In peptic ulcers, regenerative mucosa forms along the ulcer margin and extends towards the ulcer center[24]. Despite these differences, balloon dilation resulted in comparable outcomes in both conditions.
Previous studies have shown no significant differences in efficacy or complication rates between bougie and balloon dilation for the treatment of BESs[5,25]. Patients with BESs typically develop solid-food dysphagia when the stricture diameter is less than 14 mm[26,27]. In a study of 121 patients with BESs, 46.1% achieved clinical success after bougie dilation to a diameter greater than 13 mm, whereas only 17.8% achieved clinical success when the dilation diameter was less than 13 mm[27]. Accordingly, the target dilation diameter for BESs is generally set at 13-15 mm and occasionally extended to 16-18 mm[23,27,28]. Previous studies have also demonstrated that balloon diameter is a key determinant of dilation efficacy, with larger balloon dilations often yielding better outcomes than bougie or small-balloon dilations[6,7,21]. In the present study, the efficacy of balloon dilation was not superior to that of bougie dilation, likely because balloon diameters were not significantly increased.
For refractory strictures that do not respond to dilation, stent placement allows prolonged and sustained stricture expansion, promoting tissue remodelling and theoretically reducing stricture recurrence after stent removal[3,11]. However, reported success rates for stent placement in refractory cases are only 35%-45%, with adverse events occurring in 20%-25% of patients, including stent migration rates of 25%-35%[11]. In this study, patients in the stent group tended to require more dilations than those in the bougie and balloon groups, although this difference was not statistically significant. This trend may reflect a higher proportion of refractory strictures in the stent group. However, only one refractory stricture was identified in our cohort, with most patients undergoing stent placement at the initial treatment stage. These unexpected findings appear to contradict current guidelines recommending stent placement primarily for refractory oesophageal strictures. Moreover, stent placement did not improve prognosis and may contribute to the development of refractory strictures[29,30].
With respect to safety, perforations occurred during balloon dilation in two patients in the stent group (12.5% or 2/16 patients; 2.5% or 2/79 procedures) and in two patients in the balloon group (9.1% or 2/22 patients; 3.2% or 2/62 procedures). These rates are markedly lower than the 50% perforation rate reported by Tsunada et al[31], in which two of four patients with strictures following ESD for gastric neoplasms experienced rupture after balloon dilation. Na et al[24] reported a perforation rate of 7.1% (1/14 patients; 2.9% or 1/35 procedures), while Takahashi et al[32] reported a perforation rate of 9.0% (7/78 patients; 1.1% or 7/648 procedures), findings that are consistent with our results. In contrast, Fujishiro et al[33] reported no perforations following balloon dilation. Overall, reported perforation rates following balloon dilation range from 0% to 50%[24].
Cumulative costs, hospital stay duration and the numbers of hospitalisations were all higher in the stent group than in the bougie and balloon groups. In addition, stent-related complications occurred in eight patients during 17 procedures in the stent group. Ten patients (62.5%) required stent removal because of complications, including stent migration, intolerance, and restenosis. All stents used in this study were covered SEMSs, which are known to be prone to stent migration[34]. Several techniques, such as endoscopic clipping and the Endostitch device, have been developed to reduce stent migration[35,36]. Covered SEMSs were used exclusively in this study to minimise restenosis by preventing tissue ingrowth. Nevertheless, stent restenosis remains unavoidable, particularly at the stent ends and in cases of prolonged indwelling time. Timely stent removal may reduce the incidence of restenosis. Furthermore, stent intolerance is more likely in patients with cervical oesophageal stenosis or hypersensitivity, and factors such as stent size and duration of placement are associated with intolerance.
This study has several limitations. As a retrospective, single-center study, inherent selection bias may have occurred, including treatment allocation based on patient and clinician preference. A standardised dilation protocol was not implemented, with variability in initial dilation size, dilation intervals and the number of dilations per session, which may have influenced treatment efficacy. Additionally, the relatively small sample size limited statistical power and generalisability and may have introduced confounding factors. To date, no prospective controlled clinical trials have compared the outcomes of oesophageal stenting with bougie or balloon dilation. Well-designed, randomised, prospective studies are required to address these limitations.
CONCLUSION
In conclusion, bougie and balloon dilation are safe, effective and cost-efficient treatments for PIESs. However, treatment of PIESs with SEMSs should be undertaken with caution because of the high cumulative costs, prolonged hospital stays, frequent hospitalisations and stent-related complications.
Henskens N, Wauters L, Vanuytsel T. Intralesional steroid injections in addition to endoscopic dilation in benign refractory esophageal strictures: a systematic review.Acta Gastroenterol Belg. 2020;83:432-440.
[PubMed] [DOI]
Jue TL, Storm AC, Naveed M, Fishman DS, Qumseya BJ, McRee AJ, Truty MJ, Khashab MA, Agrawal D, Al-Haddad M, Amateau SK, Buxbaum JL, Calderwood AH, DeWitt J, DiMaio CJ, Fujii-Lau LL, Gurudu SR, Jamil LH, Kwon RS, Law JK, Lee JK, Pawa S, Sawhney MS, Thosani NC, Yang J, Wani SB; ASGE Standards of Practice Committee; (ASGE Standards of Practice Committee Chair, 2017-2020). ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.Gastrointest Endosc. 2021;93:309-322.e4.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 67][Cited by in RCA: 70][Article Influence: 14.0][Reference Citation Analysis (0)]
Spaander MC, Baron TH, Siersema PD, Fuccio L, Schumacher B, Escorsell À, Garcia-Pagán JC, Dumonceau JM, Conio M, de Ceglie A, Skowronek J, Nordsmark M, Seufferlein T, Van Gossum A, Hassan C, Repici A, Bruno MJ. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.Endoscopy. 2016;48:939-948.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 191][Cited by in RCA: 219][Article Influence: 21.9][Reference Citation Analysis (1)]
Tsunada S, Ogata S, Mannen K, Arima S, Sakata Y, Shiraishi R, Shimoda R, Ootani H, Yamaguchi K, Fujise T, Sakata H, Iwakiri R, Fujimoto K. Case series of endoscopic balloon dilation to treat a stricture caused by circumferential resection of the gastric antrum by endoscopic submucosal dissection.Gastrointest Endosc. 2008;67:979-983.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 40][Cited by in RCA: 40][Article Influence: 2.2][Reference Citation Analysis (0)]
