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

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine, Department of Gastroenterology, Ameos Klinikum Halberstadt, Germany, UEES Guayaquil, Ecuador, Universidad de la República, Uruguay and Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 72-year-old man presented with recurrent meat boluses. On endoscopy a tight, fibrotic Schatzki ring was found. (Figure 1, panels A, B). Thus, the patient had a classic “steak house syndrome”. Destruction of Schatzki rings can be accomplished with dilation using Savary or Maloney dilators or bougies, balloon dilation, star-like incisions, cxircumferential excision using IT-knife, cold biopsy mini-excisions or with the novel “BougieCap ®” (Ovesco Endoscopy AG, Tübingen, Germany. In this case we elected the Bougie cap 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, selecting the cheapest and equally or most effective device is essential.

Figure 1. 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.

Figure 2. Technical aspects of the bougie cap (or dilator cap). When the coned cap is attached to the scope it transforms the scope into a “bougie” (dilation) device, similary to a Savary dilator (or bougie). The word “bougie” is used a lot in Europe, where the original dilators were made of wax (i.e. candle like dilators). The best wax came from Bugaya (Algeria), hence “bougie”. However, the more fitting word is “dilator”, which is indeed what we do with Savary dilator, or expansion balloons (balloon dilation).

This distally transparent, conically shaped cap is attached to the distal scope, making the scope a “bougie dilator” (Figure 3). The Bougie cap enables effective and safe dilation of strictures with direct visual feedback, offering significant advantages compared to conventional techniques (1-4) (Figure 1).

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 (3) (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 (1, 4) (Figure 3). Direct visual control during endoscopy is enabled by the transparent plastic material of the BougieCap (Figures 1-3). 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 (2).

Figure 3. Close-up image of the BougieCap (A, B, C) and the tape for attaching distally of the endoscope (D, E).

Overall, the treatment of benign stenoses in the upper gastrointestinal tract with the BougieCap can successfully and effectively dilate the primary stricture and additionally contribute to the improvement of dysphagia, as well as reducing the incidence of other complications. The BougieCap is available in various sizes, each with two different dilation diameters, allowing gentle stricture dilation and minimizing the risk of complications (3, 4) (Table 1).

Table 1. Available sizes of the BougieCap (4).

References:

1. Walter B, Meining A. Die Bougiekappe – eine neue Methode zur Behandlung von Stenosen im Gastro-intestinaltrakt. Endoscopy Campus. [accessed 2024 Jul 20]. Available from:
   https://www.endoscopy-campus.com/lehrvideo/die-bougiekappe-eine-neue-methode-zur-behandlung-von-stenosen-im-gastro-intestinaltrakt/

2. Lafeuille P, Yzet C, Bonniaud P, et al. Use of a bougie-shaped cap for dilation with direct visual control for an esophageal stricture induced by radiation therapy. Endoscopy. 2023 Dec;55(S 01):E18-E19. doi: 10.1055/a-1929-9317. Epub 2022 Sep 16. PMID: 36113487; PMCID: PMC9812673.

3. Duarte P, Walter B, Patel P, et al. Bougiecap dilatation device: Novel endoscopic method for treatment of oesophageal strictures-results from a multicentre study. Gut. 2021 Jan. 70 (Suppl 1): A1-A262.

4. BougieCap - Produkt und Verfahren für die Bougierung von Stenosen und Strikturen des oberen Gastrointestinaltraktes. Ovesco Endoscopy AG. [accessed 2024 Jul 20]
   Available from:
   https://ovesco.com/de/scopecaps/bougiecap/#/eluidde05b763_1_0

KM has been a consultant for Ovesco, Germany (2012 and 2016)

LKS does not have any COI to declare.

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