Benign esophageal stricture dilation can be achieved by different methods, yet their environmental impact has not been compared and the clinical efficacy of the bougie cap (BC) device is not well known. This study evaluated the BC dilatation technic in terms of feasibility, effectiveness and safety, and compared its waste generation and carbon footprint  to reusable bougie and single-use hydrostatic balloon dilatation, using life cycle assessment (LCA).

We conducted a multicenter study on a prospectively maintained cohort of patients.  Consecutive adult patients with dysphagia secondary to an esophageal benign stricture, requiring endoscopic management in a French tertiary center, were screened for inclusion. 

The primary endpoint was the technical success of the BC dilatation. This was defined as the successful passing of the stricture using the BC technic only. Technical failure was defined as the need for a rescue technic (reusable bougie or balloon) and/or the inability to pass the stricture at the end of the procedure. The secondary endpoints were the number of dilatations per patient, adverse events and symptoms 3 months after the last endoscopy. The cradle-to-grave LCA was conducted according to ISO 14040/44 by and independant expert company (Apesa). 

Between January 2022 and September 2025, 125 patients with BC dilatation for benign esophageal stricture were included. Amongst the study population, 51 patients were men (40.8%) and the mean age was 61.6 years (+/- 17.3). Regarding the clinical presentation, 98 patients (78.4%) had dysphagia to solids, 8 (6.4%) had dysphagia to liquids, 6 had aphagia (4.8%) and 4 (3.2%) were asymptomatic. The mean follow-up was 7.8 months (+/- 9.7). Eight patients (6.4%) died during follow up. 

The type of stricture was iatrogenic in 54 patients (43.2%), inflammatory in 47 patients (37.6%), thermal in 11 patients (8.8%) and caustic in 6 patients (4.8%). The underlying cause was endoscopic treatment (mucosectomy, endoscopic submucosal dissection) in 27 patients (21.6%), peptic in 23 patients (18.4%), anastomotic in 17 patients (13.6%). 

A total of 299 dilatations were performed (26 of which for a 2^nd stricture in a same patient). Successful initial dilatation was achieved in 264 cases (88.3%). Rescue dilatation with a balloon was required in 28 cases (9.4%). All rescue dilatations succeeded. Final dilatation was achieved successfully in 292 cases (97.7%). Data was missing in 7 cases. The mean number of BC dilatation per patient was 2.1. Adverse events occurred in 11 cases (3.7%), amongst which 3 perforations (1%) were noted. Three months after the last endoscopic dilatation, 101 patients (80.8%) experienced no symptoms.

Single-use balloon dilation generated 427 grams (g) of equipment and approximatively 20 ml of contrast agent and water. Bougie dilation generated 50 g of waste for the packaging of peracetic acid bottle and use 170 ml of peracetic acid and 5 l of controlled tap water. BC generated 1 to 4 g of plastic (depending of the size) and 1 g of packaging waste. The respective carbon footprint for the different strategies were 0.06 and 0.63 kg CO2e for the BC without and with guidewire, 1.35 kg CO2e for the reusable bougie (with guidewire) and 3.49 kg CO2e for the single use balloon dilation (with guidewire).

In this multicenter study including 125 patients (299 dilatations) with benign esophageal stricture, the technical success of bougiecap dilatation was achieved in 88.3% of cases with an adverse events rate of 3.7%. Life cycle assessment revealed stark differences in the environmental impact between dilatation techniques, with the bougie cap strategy being the less impacting.