The radiological management of gastrointestinal strictures and other obstructive lesions

Endoscopic balloon dilatation for pharyngo-upper esophageal stricture after treatment of head and neck cancer

BACKGROUND AND AIM

Dysphagia caused by pharyngo-upper esophageal stricture is a complication of treatment for head and neck cancer. Endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for stricture in many areas of the gastrointestinal tract. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures that developed after treatment for head and neck cancer.

METHODS

From January 2010 to December 2013, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures occurring after surgery and/or chemoradiotherapy for head and neck cancer were retrospectively examined.

RESULTS

Mean number of EBD sessions per patient was 6.6 (1-30), and mean maximum diameter of dilation was 15.8 (11-20) mm. Technical success was achieved in 16 of 19 (84.2%) patients, and only two major complications (bleeding and pha ryngeal edema) occurred in a total of 125 dilatation sessions (1.6%). Regarding the influence of chemoradiotherapy on the outcome of EBD, patients who had undergone chemoradiotherapy plus surgery experienced significantly more restenosis during the follow-up period compared to those who had undergone surgery alone (50% vs 0%, P < 0.05).

CONCLUSIONS

This retrospective analysis demonstrated the efficacy and safety of exclusive EBD for pharyngo-upper esophageal strictures occurring after treatment for head and neck cancer, indicating that the therapeutic application of EBD could be extended to such strictures. Patients who underwent chemoradiotherapy and surgery experienced more restenosis; hence, such patients should be carefully followed up after EBD treatment.

Radiologically guided balloon dilatation of neopharyngeal strictures following total laryngectomy and pharyngolaryngectomy: 21 years’ experience

Objective:

To assess the efficacy of radiologically guided balloon dilatation for the treatment of dysphagia secondary to neopharyngeal strictures in patients who have undergone laryngectomy.

Study design:

Retrospective case series.

Subjects and methods:

Twenty consecutive patients with pharyngeal stricture and dysphagia following total laryngectomy or pharyngolaryngectomy. Patients underwent balloon dilatation of the stricture under radiological guidance. The main outcome measure was maintenance of swallowing.

Results:

Five patients gained relief of their dysphagia with one balloon dilatation only. Nine patients required more than one dilatation to maintain swallowing. Two patients had balloon dilatation procedures and stent insertion for palliative relief of dysphagia from known recurrent malignant disease. Three patients failed to maintain swallowing with repeat dilatations. No patients suffered any significant complications such as perforation.

Conclusions:

Radiologically guided balloon dilatation is minimally invasive and safe. It is well tolerated. It may be repeated frequently, and can successfully relieve pharyngeal strictures in patients who have undergone total laryngectomy or pharyngolaryngectomy.

Malignant obstruction of the left colon

The management of malignant obstruction of the colon distal to the splenic flexure is controversial. The 'traditional' three-stage procedure is marred by frequent failure to complete the planned sequence of operations and a resulting high permanent stoma rate. At each stage the mortality rate (7 per cent) and morbidity rate (30 per cent) are significant. The mortality rate following primary resection with delayed anastomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed. Primary anastomosis may be performed after subtotal or segmental colonic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4-6 per cent, but cases are often carefully selected. It is difficult to suggest clear guidelines based on existing data. Although there are strong arguments in favour of a single-stage procedure, surgeons must decide whether available resources and local circumstances permit this. The alternative is Hartmann's procedure or referral to a surgeon with an interest in emergency colorectal surgery.

Balloon dilatation of the pharynx

Balloon dilatation has become a widely accepted technique in the management of oesophageal and other gastrointestinal strictures. The use of this procedure in the pharynx has rarely been reported. We have performed 55 balloon dilatations on 13 patients with pharyngeal strictures. In three patients all symptoms were permanently abolished after one dilatation. Seven patients were successfully managed with repeated, regular dilatations. Two patients had a good initial response but this was not maintained and one patient had no relief of symptoms. Balloon dilatation is minimally invasive, less traumatic than rigid pharyngoscopy with dilatation, and well tolerated. It may be frequently repeated, and has successfully relieved dysphagia caused by benign and malignant strictures of the pharynx, including instances where previous rigid bouginage had failed.