A novel approach to radiation-induced post-cricoid esophageal stricture: the "Laryngeal Jack" to facilitate dilatation

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.

Fatal central venous air embolism: a rare complication of esophageal dilation by rendezvous

BACKGROUND

Esophageal dilation by rendezvous is a useful technique for the treatment of complicated esophageal strictures.

METHODS AND RESULTS

We present a case of a 74-year-old man with chronic dysphagia caused by a complete cervical esophageal stricture that developed after external beam radiotherapy for treatment of papillary thyroid carcinoma. During attempted dilation using the rendezvous technique, the patient suffered a fatal pulmonary air embolism. The technique of esophageal dilation by rendezvous, complications, and risk factors for development of venous air embolism are discussed.

CONCLUSION

To the best of our knowledge, this is the first report in the literature of fatal venous air embolism after dilation by rendezvous.

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.

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.

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.

Complete hypopharyngeal obstruction by mucosal adhesions: A complication of intensive chemoradiation for advanced head and neck cancer

BACKGROUND

Severe swallowing dysfunction is the dominant long-term complication observed in patients treated for head and neck squamous cell carcinoma (HNSCC) with treatment protocols using intensive concurrent chemotherapy with radiation therapy (chemo/XRT). We identified a subset of these patients, who were seen with complete obstruction of the hypopharynx distal to the site of the primary cancer, and in whom we postulate that the obstruction was caused by separable mucosal adhesions rather than obliteration by a mature fibrous stricture.

METHODS

Seven patients were referred to the senior author with a diagnosis of complete hypopharyngeal obstruction between 1992 and 2001. The diagnosis was confirmed by barium swallow imaging and/or endoscopy before referral in all patients. Patients underwent recanalization by passing a Jesberg esophagoscope under general anesthesia, followed by serial dilations and intensive swallowing therapy. Patient charts were reviewed retrospectively after institutional review board approval.

RESULTS

All seven patients were successfully recanalized. No patient had a perforation or other significant complication related to the recanalization procedure or subsequent dilations. Five of the seven patients showed improvement in swallowing at some point after the initial procedure, but just two patients recovered sufficiently to have their gastrostomy tube removed permanently.

CONCLUSIONS

We conclude that complete hypopharyngeal obstruction secondary to mucosal adhesions is one cause of gastrostomy tube dependence in patients who have been treated with chemo/XRT for HNSCC. It is a difficult problem to treat, but most patients can recover useful swallowing function without undergoing laryngectomy or major surgical reconstruction. The postulated pathophysiology has implications for prevention as well as treatment.

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.