Retrograde approach to pharyngo-esophageal obstruction

Swallowing improvement surgeries

PURPOSE

To discuss the different swallowing improvement surgeries that address one or more dysfunctional pharyngolaryngeal structures causing dysphagia. These surgeries reduce the risk of aspiration without sacrificing vocal function.

METHODS

We searched the PubMed database and used Google Scholar search engine to find studies discussing the different swallowing improvement surgeries. A manual search of references in selected articles and reviews was done as well. No chronologic limitation was set for the studies; however, only articles written in English and Japanese were considered. Due to the nature of this article, no particular inclusion or exclusion criteria were set when searching for studies to be used as references; however, all relevant studies were reviewed and agreed upon by the authors for inclusion in this review article.

RESULTS/DISCUSSION

Surgeries to improve swallowing function can be categorized into those that reinforce nasopharyngeal closure or pharyngeal contraction, improve laryngeal elevation or pharyngoesophageal segment opening, and those that improve vocal fold closure to protect the airway during swallowing. They are an effective alternative treatment that may significantly improve these patients' quality of life. Swallowing rehabilitation with the altered pharyngolaryngeal structures is required post-operatively to significantly improve patients' dysphagia.

CONCLUSIONS

Surgeries to improve swallowing function address specific dysfunctional sites involved in the swallowing mechanism. Choosing the most appropriate surgery for each patient requires knowledge of the pathophysiology for their dysphagia and detailed pre-operative work-up.

Endoscopic Reconstruction of an Oral Feeding Route Using a Rendezvous Approach

Background

The approach to esophageal obstruction or discontinuity remains challenging and often involves complex reconstructive surgeries. The rendezvous endoscopic technique might be interesting in cases of complete esophageal obstruction.

Case Presentation

Herein we describe a successful case of endoscopic recanalization of the esophageal lumen in a patient with a long-standing esophageal discontinuity resulting from several surgeries and chemoradiation for a squamous cell carcinoma of the hypopharynx, ending in a major cervical amputation, construction of a neopharynx, and definitive surgical closure of the superior esophagus with a PEG placement. With a rendezvous technique (peroral and through the gastrostomy) and under radiographic guidance, puncture from the neopharynx into the distal esophagus was performed, followed by balloon dilation and covered metal stent placement in order to reconstruct a neoesophagus. Five weeks later, the stent was removed (using a stent-in-stent technique). No complications occurred. The patient has been able to eat soft food and is being kept under regular endoscopic surveillance to control/treat a luminal stenosis of the neoesophagus.

Conclusions

This case report illustrates a successful endoscopic treatment of post-surgical complete esophageal obstruction. This approach should be considered in the therapeutic armamentarium of these difficult clinical settings.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

Endoscopic recanalization of complete esophageal obstruction

BACKGROUND AND AIMS

Complete esophageal obstruction (CEO) is a rare complication after radiochemotherapy that dramatically impairs quality of life. Within this study, we assessed the outcome of two different endoscopic techniques for lumen restoration in patients with CEO.

METHODS

17 patients were included. Esophageal recanalization was performed in an antegrade approach (Group A) or through combined antegrade and retrograde recanalization and dilatation (CARD, Group B). Technical success, complications, and dysphagia development during follow-up (FU) were compared between the groups.

RESULTS

In Group A (n = 6), esophageal recanalization was performed by a single endoscopist with a median duration of 47 min. In two patients, antegrade recanalization led to formation of a false lumen (i.e., submucosal tunneling) followed by mediastinitis. In Group B, 21 CARD procedures were performed in 11 patients with a technical success rate of 100%. Procedure time was longer compared to Group A; however, no intra- or postprocedural complications were observed in Group B.

CONCLUSIONS

In our experience and cohort, CARD was a successful procedure for recanalization of CEO, which exhibits a more favorable safety profile over antegrade recanalization. Further randomized studies to evaluate the treatment of CEO with CARD are needed.

Safety and efficacy of combined antegrade and retrograde endoscopic dilation for complete esophageal obstruction: a systematic review and meta-analysis

Background

Complete esophageal obstruction (CEO) due to occlusive proximal stricture occurs after chemoradiation for head and neck cancers. A combined antegrade and retrograde endoscopic technique with controlled recanalization and dilation (CARD) has been shown to be an effective and safe method for regaining and maintaining esophageal luminal patency in the short term.

Methods

We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception through November 2018), to identify studies that reported the outcomes of CARD. The primary outcomes were the pooled rates of technical and clinical success, specifically improvement in dysphagia and independence from percutaneous endoscopic gastrostomy (PEG)-tube feeds. The secondary outcomes were the need for repeat dilations and the risks of complications, such as pneumomediastinum, perforation, and death.

Results

From a total of 19 studies (229 cases and 251 procedures) the calculated technical success rate was 88.9% (95% confidence interval [CI] 83.9-92.5, I²=0). The rates of improvement in dysphagia and being PEG-tube free were 58.4% (95%CI 50-66.3, I²=12.6) and 43.5% (95%CI 34.1-53.4, I²=30.6), respectively. The pooled rate of repeat dilatations was 78.9% (95%CI 69.7-85.8, I²=15.2). The risks of pneumomediastinum, perforation and death were 9.9% (95%CI 6.2-15.6, I²=0), 8% (95%CI 4.8-13, I²=0), and 6.8% (95%CI 3.4-13.1, I²=0), respectively. Minimal heterogeneity was noted in the analysis.

Conclusions

The CARD procedure for CEO has a high technical success rate, but also a high rate of repeat dilations. Given its complexity and associated adverse events, this procedure should be restricted to centers with a high level of expertise.

Total Pharyngo-esophageal Stenosis: A New Surgical Procedure Using Modified Retrograde Transillumination Approach

We performed a modified combined anterograde-retrograde dilatation in a 60-year-old woman with complete pharyngo-esophageal stricture (PES). With a large endoscopic view from the upper (laryngoscope) and lower (pediatric gastroscope introduced via gastrostomy tube) parts of the PES, the approach consisted of a retrograde puncture of the complete PES by transillumination to take the guide coming from the pediatric endoscope. The guide was pulled through the mouth and the PES dilatation was made using successive boogies of various diameters through the guide. Finally, a salivary bypass was placed to maintain the diameter of the pharyngo-esophageal way. The surgical approach was performed in 25 minutes without short, medium, and long-term complications. The patient started oral alimentation the day after the surgery, and the salivary bypass was removed after 6 months. The subject had no recurrence of the PES at 5 years.

Per-oral endoscopic tunneling for restoration of the esophagus: a novel endoscopic submucosal dissection technique for therapy of complete esophageal obstruction

BACKGROUND AND AIMS

Total aphagia from complete esophageal obstruction (CEO) can be seen in patients with head-neck or thoracic malignancies undergoing chemoradiation or surgery. Combined antegrade and retrograde endoscopy (via gastrostomy tube [G-tube] tract) is often performed for esophageal reconstruction but is limited by the length of the obstructed esophagus. We describe per-oral endoscopic tunneling for restoration of the esophagus (POETRE) for patients with longer segments of esophageal obstruction. The aim of this study was to assess the efficacy and safety of POETRE for CEO.

METHODS

All patients with CEO undergoing endoscopy with POETRE from October 2013 to September 2015 were enrolled in this single-center prospective study. Clinical, endoscopic, and radiologic records were maintained as required for clinical care and for the study. Dysphagia score was recorded before and after POETRE. Adverse events were assessed based on the American Society for Gastrointestinal Endoscopy criteria.

RESULTS

Four patients (3 men; mean age, 72.3 years) underwent POETRE for CEO ≥3 cm in length. Esophageal reconstruction was technically successful in all patients (100%). Antegrade submucosal tunneling was performed in 2 of 4 patients (50%), and retrograde tunneling was performed in the other 2 patients, all with simultaneous dual endoscope and fluoroscopic guidance. The mean dysphagia score of 4 before the procedure improved to 2.5 after POETRE during follow-up (mean, 27.8 weeks). All patients required subsequent serial endoscopic dilations as needed after POETRE. One adverse event (pneumonia) was seen (25%).

CONCLUSIONS

We present a novel ESD technique, POETRE, for therapy of complete esophageal obstruction. This approach is specifically useful for lumen restoration in patients with longer segments of esophageal obstruction. (Clinical trial registration number: NCT00968552.).

Surgical treatment of a rare complication after endoscopic stent placement for anastomotic leakage after esophageal resection

The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.

Recurrent Complete Pharyngo-Oesophageal Stricture Treated by Multidisciplinary Anterograde-Retrograde Endoscopic Dilation

Complete pharyngo-oesophageal stricture (PES) after radiotherapy for head and neck cancer is a relatively rare and difficult complication to manage. Historically this condition has been treated surgically, but endoscopic approaches are now available. We present a 61-year-old man with an epidermoid carcinoma of the supraglottic stage and a micro-invasive epidermoid carcinoma of the oropharynx treated surgically and subsequently by adjuvant radiotherapy. Eight months after the end of the radiotherapy, a complete PES was diagnosed and treated with a combined anterograde-retrograde endoscopic dilation (CARD). The procedure was performed using a transoral anterograde progression with a rigid pharyngoscope and a retrograde progression with an extra-slim nasal endoscope using the percutaneous gastrostomy already in place. Using both transillumination and direct visualisation from both sides of the complete stenosis patency was restored between the neopharynx and the oesophagus. Despite the use of an endoprosthesis, the complete PES recurred and the technique had to be performed a second time. Illustrating the complexity of the case different types of endoprosthesis and several dilations had to be performed for our patient to achieve and maintain a normal oral intake. This case report illustrates that even in complicated recurrent radiation-induced complete PES a CARD can be performed safely and successfully using different types of endoprosthesis.

Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique

AIM: To investigate the combined antegrade-retrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.

METHODS: This single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation (CARD) within the last 10 years. The patients’ demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy (PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale (FOIS) (≥ level 3).

RESULTS: The cohort consisted of six patients [five males; mean age 71 years (range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up (median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing (two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.

CONCLUSION: The CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.

Emerging techniques and efficacy of endoscopic esophageal reconstruction and lumen restoration for complete esophageal obstruction

BACKGROUND AND STUDY AIMS

Complete esophageal obstruction (CEO) is a rare occurrence characterized by progressive esophageal stricture, which eventually causes lumen obliteration. With recent advances in flexible endoscopy, various innovative techniques exist for restoring luminal continuity. The primary aim of this study was to assess the efficacy and safety of patients undergoing combined antegrade-retrograde endoscopic dilation for CEO at our institution. The secondary aim was to review and highlight emerging techniques, outcomes, and adverse events after endoscopic treatment of CEO.

PATIENTS AND METHODS

Our electronic endoscopy database was retrospectively reviewed to identify patients who underwent combined antegrade and retrograde endoscopy for CEO. Patient and procedural data collected included gender, age, technical success, pre- and post-dysphagia scores, and adverse events.

RESULTS

Six patients (67 % male, mean age 71.6 years [range 63 - 80]) underwent technically successful esophageal reconstruction with combined antegrade-retrograde endoscopy. All patients noted improvement in dysphagia with mean pre-procedure dysphagia score of 4 reduced to 1.33 (range 0 - 3) post-procedure. There were no adverse events and mean follow-up time was 17.3 months (range 3 - 48).

CONCLUSIONS

Combined antegrade and retrograde endoscopic therapy for CEO is feasible and safe. We present our experience with endoscopic management of complete esophageal obstruction, and highlight emerging techniques, outcomes and adverse events related to this minimally invasive modality.

Multi-disciplinary approach for management of refractory benign occlusive esophageal strictures

BACKGROUND

Benign occlusive esophageal strictures create substantial morbidity and have poor surgical outcomes. Various endoscopic techniques have been described to manage these strictures. The challenge remains to maintain adequate long-term esophageal patency and to limit the need for serial endoscopic dilations. Little has been reported regarding the management of these benign occlusive strictures.

METHODS

We report a case series describing the management of technically challenging benign occlusive esophageal strictures. Three patients with occlusive esophageal strictures of differing etiologies were treated using a variety of endoscopic methodologies.

RESULTS

The first patient sustained a caustic oropharyngeal injury resulting in a proximal esophageal stricture which was treated by using a combined antegrade retrograde dilation (CARD) with argon plasma coagulation (APC) and needle knife dissection resulting in the successful recanalization and patency of his stricture. A second patient developed an esophageal stricture following radiotherapy, and was treated with a CARD procedure and serial balloon dilations in combination with APC to successfully achieve esophageal luminal patency. The final patient acquired an occlusive esophageal stricture after treatment for thyroid cancer which was treated with endoscopic needle knife dissection followed by serial balloon dilations to successfully manage this stricture.

CONCLUSIONS

Occlusive esophageal strictures pose a difficult challenge to gastroenterologists and little has been reported with regards to their endoscopic management. Using the CARD technique, needle knife dissection and APC, individually or in combination, luminal patency of occlusive esophageal strictures can be accomplished safely with good results.

Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience

BACKGROUND

After chemoradiation therapy for head/neck cancer, some patients develop strictures that progress to complete pharyngoesophageal occlusion. Total lumen occlusion is less often due to other conditions. Enteral access (enterostomy tube) and good nutritional status tend to minimize the significance of dysphagia and therefore may mask recognition of impending complete lumen occlusion.

OBJECTIVE

Review outcomes of a 25-year experience with endoscopic lumen restoration (ELR) in 30 patients.

DESIGN

Retrospective, case review study.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 30 consecutive patients referred for obstructive aphagia due to complete lumen occlusion, primarily after chemoradiation therapy for head/neck cancer.

INTERVENTION

Antegrade and retrograde endoscopy with tri-plane fluoroscopy for penetrating the occluded segment, serial retrograde and antegrade dilations, plus swallowing rehabilitation therapy.

MAIN OUTCOME MEASUREMENTS

Restoration of lumen patency, swallowing function, and removal of enteral feeding tube.

RESULTS

ELR was successful in 30 patients in 31 of 33 attempts (93%). Return to soft to regular diet was achieved in 15 of 30 patients (50%), and fluids to pureed food with partial percutaneous endoscopic gastrostomy nutrition was achieved in 5 of 30 patients (17%). Ten of 30 patients (33%) were considered unsafe for oral feeding because of oropharyngeal neuromotor deficits. Complications occurred in 5 of 30 patients (17%), with no prolonged sequelae, deaths, or surgery, but two stents were placed for anastomotic fistulas. The median duration of follow-up was 22.75 months.

LIMITATIONS

Retrospective, case review study.

CONCLUSION

ELR by using tri-plane fluoroscopic guidance with antegrade and retrograde endoscopy and serial dilations allows lumen restoration and swallowing to some degree in a majority of patients. Engagement of a core team of specialists can provide optimal restoration of swallowing function.

Successful closure of pharyngo-cutaneous and phayryngo-tracheal fistulas using removable hypopharyngeal stent after laryngectomy for laryngeal carcinoma

Placement of removable stents to close pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy has not been reported before. This case presents the feasibility of removable esophageal stent in closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Consecutive patients who underwent placement of removable esophageal stent for closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Three patients underwent successful stent placement in the hypopharynx. The stents were well tolerated. Patient one had the stent for 14 months, leading to complete healing of the fistula. Removal was successful. The second patient was palliated but died 8 weeks after stent placement. The third patient has successful palliation of his tracheo-esophageal fistula and the stent is being exchanged every 3-4 months to palliate his fistula. Closure of pharyngo-cutaneous and tracheo-esophageal fistulas is feasible with esophageal removable stents. These stents provide alternative options when dealing with these challenging problems.

Total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy with gastric interposition: Successful recanalisation using a transcervical radiologically guided technique

INTRODUCTION

Pharyngo-oesophageal stricturing is common following treatment of head and neck cancers. Absolute dysphagia secondary to total stenosis, although rare, is particularly debilitating and presents a significant therapeutic challenge. We present a strategy for managing total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy (PLOG).

PRESENTATION OF CASE

A 71-year-old female developed total neopharyngeal stenosis following PLOG with gastric interposition for squamous cell carcinoma of the proximal cervical oesophagus/post-cricoid. A transcervical, percutaneous, radiologically guided procedure was performed to restore lumenal patency, which enabled resumption of oral feeding.

DISCUSSION

Established treatments for pharyngo-oesophageal strictures are frequently limited by complications in patients with complex strictures or total stenoses. Whilst several interventions have been described, recent interest has focussed on combined antegrade/retrograde endoscopic procedures dilating a pre-existing gastrostomy site for access. This was not possible in our patient due to the surgically altered anatomy which posed a unique therapeutic challenge.

CONCLUSION

This is the first reported percutaneous, transcervical, radiologically guided technique to treat neopharyngeal stenosis following PLOG. It demonstrates a novel and efficacious approach which may be considered in the management of this rare but significant complication.

Anterograde-retrograde rendezvous approach for radiation-induced complete upper oesophageal sphincter stenosis: case report and literature review

BACKGROUND

Strictures of the hypopharynx and oesophagus are frequently observed following (chemo)radiation. Anterograde dilatation of a complete stenosis carries a high risk of perforation. An alternative is described: a combined anterograde-retrograde approach.

CASE REPORT

A 75-year-old man developed complete stenosis of the oesophageal inlet after primary radiotherapy for laryngeal carcinoma and full percutaneous endoscopic gastrostomy feeding. To prevent creation of a false route into the mediastinum, a dilatation wire was introduced in a retrograde fashion into the oesophagus, through the gastrostomy opening. The wire was endoscopically identified from the proximal side and then passed through a perforation created by CO2 laser. Anterograde dilatation was safely performed, and the patient returned to a normal diet. There is consensus in the literature that blind anterograde dilatation carries a high risk of perforation; therefore, an anterograde-retrograde rendezvous technique is advisable.

CONCLUSION

In cases of complete obstruction of the oesophageal inlet, anterograde-retrograde dilatation represents a safe technique with which to restore enteric continuity.

Management of complete esophageal stricture after treatment of head and neck cancer using combined anterograde retrograde esophageal dilation

BACKGROUND

Complete esophageal stricture is a difficult problem to manage. There is limited literature to support clinical decision-making. To evaluate outcomes and efficacy, we performed a retrospective medical chart review of patients who received combined anterograde retrograde esophageal dilation (CARD) between 2002 and 2009 at our institution.

METHODS

Fifteen patients were identified who developed a stricture requiring CARD after treatment for head and neck cancers. Outcomes were pretreatment and posttreatment diet, gastrostomy tube status, and operative complications.

RESULTS

Six of 15 patients were gastrostomy tube-free at last follow-up and 11 of 15 patients were taking oral nutrition. There were 4 complications. One patient died. Two gastrostomy tube site complications occurred. One patient sustained a dental injury.

CONCLUSION

CARD offers benefit to most patients. Despite risks associated with the procedure, CARD should be considered by the clinician and patient in management of complete esophageal stricture.

Fluoroscopically guided balloon dilation for pharyngoesophageal stricture after radiation therapy in patients with head and neck cancer

OBJECTIVE

The purpose of this article is to assess the safety and long-term efficacy of fluoroscopically guided balloon dilation for pharyngoesophageal strictures after radiation therapy in patients with head and neck cancers.

MATERIALS AND METHODS

From April 1997 to February 2009, fluoroscopically guided balloon dilation was performed in 17 patients with pharyngoesophageal strictures caused by radiation therapy. Technical success, clinical success (decrease of at least one grade in dysphagia score and good contrast passage on 1-month follow-up esophagogram), recurrence of dysphagia, and complications related to the procedure were retrospectively evaluated.

RESULTS

All 17 patients underwent 41 balloon dilation procedures, with each patient undergoing one to seven procedures (mean, 2.4 procedures). The technical success rate was 100%, and clinical success was achieved in 64.7% (11/17) of the patients. Five patients (29.4%) showed no recurrence of dysphagia after one session of balloon dilation. Of 12 patients (70.6%) with recurrence of dysphagia, 10 underwent repeat balloon dilation and two underwent gastrostomy after the first session of balloon dilation. The maximum balloon diameters were 15 mm (n = 22), 20 mm (n = 16), and 25 mm (n = 3). As minor complications, three cases of type 1 esophageal rupture occurred in two patients (11.8%). There were no major complications.

CONCLUSION

Although the recurrence rate was high with repeat balloon dilation, fluoroscopically guided balloon dilation seems to be a simple and safe primary treatment technique for pharyngoesophageal stricture due to radiation therapy in patients with head and neck cancer.

Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis

OBJECTIVES/HYPOTHESIS

Assess the safety and efficacy of combined antegrade and retrograde esophageal dilation (CARD) for complete esophageal stenosis following head and neck cancer (HNC) treatment. Review HNC dysphagia management.

STUDY DESIGN

Retrospective review of all patients undergoing CARD following HNC treatment between May 2001 and September 2008.

METHODS

Forty-five patients were identified for review. Parameters assessed included: ability to obtain intraoperative esophageal patency, complications, number of dilations required, diet, and gastric tube (GT) status. Factors associated with dilation failure were analyzed.

RESULTS

Intraoperative esophageal patency was obtained in 91% of patients. Median number of all dilations per patient was three. Median number of CARDs per patient was one. Resumption of oral intake occurred in 36/45 (80%). Diet results included: regular or soft diet 32/45 (71%), GT removal 27/45 (60%), and GT dependence with nothing by mouth 9/45 (20%). Laryngeal and pharyngeal stenosis, radionecrosis, tracheotomy dependence, and elongated stenosis were associated with dilation failure. Complications occurred in 18/63 (29%) CARD procedures: eight pneumomediastinum, seven GT site problems, two esophageal perforations, and one pharyngeal infection. All complications resolved spontaneously or with minimal interventions.

CONCLUSIONS

CARD was safe and effective. Intraoperative patency was achieved in 91% of patients. Eighty percent resumed oral intake. The majority of patients had their GTs removed and resumed a soft or regular diet. Dilation failure was associated with laryngeal, pharyngeal, and excessively long esophageal stenosis, often resulting from radionecrosis. Complications were minor. CARD should be considered before relegating patients with complete esophageal stenosis to chronic GT dependence or subjecting them to laryngopharyngo esophagectomy.

Antegrade and Retrograde Endoscopy for Treatment of Esophageal Stricture

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.

Endoscopic management of upper esophageal strictures after treatment of head and neck malignancy

BACKGROUND

Dysphagia, usually due to proximal esophageal strictures, is a debilitating complication of therapy (surgery, radiotherapy, or chemotherapy) for head and neck malignancy. Scant attention has been given in the literature to the endoscopic management of these proximal esophageal strictures.

OBJECTIVE

Our purpose was to assess the technical and functional outcomes of endoscopic management of proximal esophageal strictures after therapy for head and neck cancers.

DESIGN

Retrospective case series.

SETTING

Academic medical center.

PATIENTS

Consecutive patients undergoing endoscopy and dilation of proximal esophageal strictures caused by chemoradiation or surgery for head and neck malignancy.

MAIN OUTCOME MEASUREMENT

Technical and functional success after endoscopic dilation.

RESULTS

Twenty-four patients were included. The mean age of patients was 70.4 years (range 42 to 82 years). The primary tumor site was larynx in 10 patients, oropharynx or hypopharynx in 4 patients, upper esophagus in 4 patients, and other sites in the remainder. Technical success (a luminal diameter of 42F or greater) was achieved in 80% of patients. Adequate dysphagia relief was achieved in 84% of patients whose esophageal stricture was dilated at least up to 42F. The average follow-up was 22 months (range 1-96 months). Repeat dilation was needed in 58% of patients. No complications or death occurred during the study period.

LIMITATIONS

Retrospective design and highly selected patient population. Dysphagia assessment in conjuction with a speech pathologist was not performed in all patients. Results may not be applicable to other settings.

CONCLUSION

In this case series, proximal esophageal strictures after treatment of head and neck malignancy were amenable to antegrade endoscopic dilation; however, no patient in our study had complete lumen obstruction. Repeat dilations are often needed and are effective in achieving and maintaining adequate dysphagia relief.

Successful use of biliary accessories in antegrade dilation of complex upper esophageal stricture due to chemoradiation and surgery

Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.

Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula

Background

Malignant esophageal stenosis with complete obstruction and esophagorespiratory fistula (ERF) is difficult to treat with standard endoscopic techniques.

Case presentation

We report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.

Conclusion

Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.

Role of retrograde dilatation in the management of pharyngo-esophageal corrosive strictures

Pharyngo-esophageal corrosive stricture is a complex clinical scenario. If an esophageal opening cannot be found orally through endoscopy, a retrograde approach with a mini-laparotomy and gastrostomy should be attempted. This study primarily aimed at defining the role of preoperative retrograde dilatation of pharyngo-esophageal corrosive strictures. A retrospective analysis of 51 cases of pharyngo-esophageal corrosive strictures identified between 1997-2005 was performed. The demographic details were analyzed. The details of the injury to the pharynx either in isolation or in combination were noted and the management details were recorded. In 21 patients preoperative retrograde dilatation was considered and the technique was successful in 14 (Group I). In seven the technique failed (Group II) and these patients underwent transhiatal resection and gastric pull-through and/or retrosternal pharyngocoloplasty. In Group I patients the postoperative stay was significantly less than in Group II (12 +/- 2.03 days vs. 18 +/- 4.32 days; p = 0.001) Recurrent aspiration, respiratory tract infections, choking sensation and the need for tracheostomy were less frequent in Group I. The overall functional assessment was good in Group I. For treatment of pharyngo-esophageal obstruction, if antegrade dilatation is not possible due to technical reasons, retrograde dilatation is a viable option before opting for organ replacement/bypass procedures. There is no best replacement of the native organ to maintain quality of life.

A modified self-expanding Niti-S stent for the management of benign hypopharyngeal strictures

BACKGROUND

The management of patients with refractory hypopharyngeal strictures after surgery in combination with radiation therapy is disappointing, and nutrition through feeding tubes is often required.

OBJECTIVE

To evaluate the efficacy and safety of a modified self-expanding Niti-S metal stent in the treatment of hypopharyngeal strictures after combined therapy for laryngeal cancer.

DESIGN

Case series.

SETTING

A general hospital and a university hospital.

PATIENTS

Seven consecutive patients were included. One of them did not have laryngectomy.

INTERVENTIONS

All patients received a modified Niti-S stent.

MAIN OUTCOME MEASUREMENTS

Improvement of dysphagia, avoiding periodic bougienage, and enteral nutrition through feeding tubes.

RESULTS

After placement of the first stent, dysphagia improved in all patients. Six of 7 patients developed stent migration and/or granulomatous tissue ingrowth or overgrowth. Additional stents were placed in all patients after a median of 3 months after the previous stent placement. One patient developed an esophagorespiratory fistula caused by a Polyflex stent. Two patients died of causes unrelated to the stent. The remaining 5 patients remained alive and asymptomatic after a median follow-up of 10 months.

LIMITATIONS

Periodic stent exchange. Stent placement did not resolve the stricture definitively. We had a limited number of patients and have no long-term outcome data yet.

CONCLUSIONS

The use of this modified Niti-S stent avoids both enteral nutrition through feeding tubes and the need for periodic bougienage in patients with difficult-to-treat benign hypopharyngeal strictures.

Antegrade and retrograde endoscopic approach in the establishment of a neo-esophagus: a novel technique

BACKGROUND

Although total obstruction or secondary atresia of the esophagus is extremely rare, high-grade strictures are not uncommon. The retrograde approach was previously described to achieve dilation when the conventional antegrade method fails.

SETTING

Gastroenterology laboratory in a tertiary referral center.

PATIENT

A 30-year-old man with congenital T-cell immunodeficiency had complete esophageal obstruction after a severe episode of cryptococcal meningitis that required prolonged nasogastric intubation. For the next 3 years, he had daily episodes of regurgitations and several hospitalizations for aspiration pneumonia. A barium study revealed a dilated megaesophagus, with no contrast reaching to the stomach.

INTERVENTION

Initially, a new track was created by using access from above and below the obstruction. This was followed by placement of a self-expandable silicone stent after allowing sufficient time for the new track to mature.

MAIN OUTCOME MEASUREMENTS

Restoration of esophageal continuity, which allowed resolution of the patient's aspiration pneumonia and resumption of oral feeding.

CONCLUSIONS

Complete esophageal obstruction after prolonged nasogastric intubation is a rare but serious complication. A novel endoscopic approach can be used to restore esophageal continuity, minimize complications, and avoid major reconstructive surgeries.

Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique

BACKGROUND

Esophageal strictures occur in 3% to 4% of patients with head and neck cancer who undergo radiation therapy. Some patients develop complete obstruction of the upper esophagus. Antegrade dilatation is often unsuccessful and many of these patients require surgery.

OBJECTIVE

To describe the outcomes and complications of an endoscopic antegrade-retrograde rendezvous procedure to restore esophageal patency.

DESIGN

Retrospective review of 8 cases treated with an endoscopic rendezvous procedure between August 2001 and April 2005. Medical records of consenting patients were abstracted for clinical history, procedural success, complications, and follow-up.

SETTING

A large tertiary referral center.

PATIENTS

Eight patients with head and neck or upper esophageal cancer and complete upper esophageal obstruction from radiation stricturing who underwent an attempted rendezvous procedure.

MAIN OUTCOME MEASUREMENTS

Clinical procedural success, reported adverse events.

RESULTS

Seven patients were men, and median age was 65 years. The median interval between radiation and the rendezvous procedure was 11 months. In 7 of 8 cases esophageal patency was restored and no major complications occurred. Two esophageal microperforations resolved without intervention. Most patients responded well to subsequent serial dilations and many discontinued gastrostomy tube use.

LIMITATIONS

Retrospective, selection bias.

CONCLUSIONS

An antegrade-retrograde rendezvous technique with subsequent dilation appears to be safe and effective for endoscopic management of complete upper esophageal obstruction induced by radiotherapy and can obviate the need for esophageal resection.

Endoscopic management of hypopharyngeal stenosis after organ sparing therapy for head and neck cancer

OBJECTIVES

The objective of this study was to describe and evaluate the efficacy of an endoscopic technique for the management of postchemoradiation hypopharyngeal stenosis in head and neck cancer patients.

STUDY DESIGN

Retrospective review.

METHODS

Patients with postchemoradiation hypopharyngeal stenoses were identified from the Dana Farber Cancer Institute head and neck database. Patients who had undergone extirpative surgery and reconstruction were excluded. All patients underwent either anterograde dilatation (AD) by the lead author (C.A.S.) or transgastric retrograde esophagoscopy with anterograde dilatation (TREAD) (C.A.S., M.T.J.). Chemoradiation records, clinic notes, operative reports, and swallowing test data were reviewed. Removal of the gastric feeding tube was considered the endpoint of rehabilitation.

RESULTS

Seventeen patients had postcricoid stenoses identified by modified barium swallow. Endoscopy confirmed 15 postcricoid stenoses and 2 proximal esophageal stenoses. Nine (53%) patients had partial stenoses, and eight (47%) had complete stenoses. Eight partial stenosis patients underwent 10 AD procedures and 3 TREAD procedures. Eight complete stenosis patients underwent 9 TREAD procedures and 26 subsequent AD procedures. Fifteen of 16 (93%) patients resumed swallowing after dilatation. Thirteen (81%) patients maintained their weight on an oral diet and had their gastric feeding tubes removed. Complications included hypopharyngeal perforation (13%), abdominal wall infection (6%), stomach wall dehiscence (6%), and chondroradionecrosis of the cricoid cartilage (6%).

CONCLUSIONS

Postcricoid hypopharyngeal stenosis may be partial or complete after organ sparing chemoradiation for head and neck cancer. Using the TREAD technique, successful rehabilitation of swallowing can be achieved with a low incidence of complications.

Technique of endoscopic retrograde puncture and dilatation of total esophageal stenosis in patients with radiation-induced strictures

BACKGROUND

Complete esophageal stenosis can occur after external beam radiation therapy for malignancies. Treatment for this complication has traditionally involved surgery.

METHODS

A new technique to reestablish luminal patency is described. This minimally invasive technique involves retrograde endoscopy by means of gastrostomy tube tract and puncture of the stenotic occlusion followed by stricture dilatation. The procedure is performed under combined endoscopic and laryngoscopic guidance.

RESULTS

Five consecutive patients who had complete esophageal stenoses develop after radiation therapy for malignant disease underwent retrograde endoscopy by way of gastrostomy tube tracts. Stenoses were punctured under endoscopic and laryngoscopic guidance with guide wires. Strictures were dilated with wire-guided balloons or polyvinyl dilators. Luminal patency was established in all patients using this technique without procedural complications.

CONCLUSIONS

Endoscopic retrograde puncture and dilatation of total esophageal stenoses is safe, effective, and useful to reestablish luminal patency for radiation-induced strictures. This technique should be attempted before more invasive treatments.

Carbon dioxide laser diverticulostomy: a new treatment for Zenker diverticulum

In the United States, the traditional treatment for hypopharyngeal (Zenker) diverticulum has been single-stage transcutaneous diverticulectomy. Complications following this procedure include mediastinitis, vocal cord paralysis, esophageal stenosis, fistula, and recurrent or persistent diverticula. The development of endoscopic equipment has led to a new era of surgery for this condition. Magnification of anatomic landmarks allows for better precision during surgery and reduces both surgical procedure time and postoperative complications. Additional techniques, such as diathermy, bipolar coagulation, stapler, and laser surgery, all of which decrease intraoperative bleeding, lend further support to the procedure. In several randomized controlled clinical trials, endoscopic laser treatment of diverticulum has demonstrated the best results in terms of decreased morbidity and fewer complications. Thus, laser approaches for treating Zenker diverticulum deserve consideration.

Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction

BACKGROUND

Esophageal strictures that cause complete obstruction are often difficult to dilate with standard bougienage techniques.

METHODS

A new technique was developed and applied, combined antegrade and retrograde dilation, for dilatation of complex esophageal strictures. The stomach is accessed and an endoscope (9.8 mm diameter) is directed under fluoroscopy in a retrograde fashion into the distal esophagus. A guidewire with a hydrophilic coating is advanced through the stricture and then pulled through the mouth with a simultaneously placed proximal endoscope. The guidewire is then used as a guide for antegrade esophageal dilatation.

RESULTS

Ten patients with complex esophageal strictures (with and without fistulas) were treated with this technique. Three required a second combined antegrade and retrograde dilation procedure. All strictures were dilated and no perforations occurred.

CONCLUSIONS

Combined antegrade and retrograde dilation is a safe and effective technique for dilation of complex obstructing esophageal lesions.

Tracheo-oesophageal puncture by retrograde passage of a gastroscope via mini-laparotomy and gastrotomy

Secondary tracheo-oesophageal puncture is frequently used for voice restoration after laryngectomy. A method utilizing a flexible gastroscope passed via a mini-laparotomy and gastrotomy in a retrograde manner is described in a patient where extensive pharyngeal resection made it impossible to cannulate the upper aerodigestive tract. The patient suffered minimal morbidity and produced reasonable speech.