Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP) (with videos)

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.

Treatment for postchemoradiotherapy hypopharyngeal stenosis: Pharyngoesophageal bypass using an anterolateral thigh flap-A case report

Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.

Endoscopic and Abdominal Management of Complete Benign Esophageal Obstruction

Benign esophageal strictures leading to complete esophageal occlusion are well known. In the pre-endoscopic era, such cases required surgery, but over the last decade, various novel endoscopic techniques have been developed to prevent morbidity and mortality. A 37-year-old man presented after 1 year of dysphagia and weight loss, and was found to have complete esophageal obstruction, not allowing even passage of guidewire. We used a combination antegrade endoscopic abdominal procedures to deploy a stent, obviating the need for surgery. His symptoms improved dramatically, and the stent was successfully removed 12 weeks later. He is now swallowing normally and has gained significant weight.

Poor functional performance following bidirectional dilatation of severe post radiation oesophageal stricture

CONCLUSION

Bidirectional oesophageal dilatation for severe chemoradiation-induced oesophageal strictures is efficacious in improving luminal patency but ineffective in relieving functional dysphagia.

OBJECTIVE

To assess the efficacy of bidirectional oesophageal dilatation in the severely strictured oesophagus induced by radiation therapy following the treatment of head and neck malignancies.

METHODS

The study design was a case series in the setting of a tertiary cancer centre. We carried out a retrospective analysis of patients who underwent bidirectional oesophageal dilatation for oesophageal stricture secondary to radiation therapy for head and neck malignancies over a 5-year period. The parameters of the primary tumour, evaluation of preoperative and postoperative oesophageal dysfunction and complications of the procedure were evaluated.

RESULTS

There were nine episodes of bidirectional oesophageal dilatation among five patients with complete or severe oesophageal obstruction. Mean age was 63 years. The procedure was uneventful in all but one patient who was found to have postoperative mediastinitis, and healed completely. Four patients had persistent dysphagic symptoms despite post dilatation video fluoroscopy failing to reveal any significant narrowing of the oesophageal lumen.

Outcomes of serial dilation for high-grade radiation-related esophageal strictures in head and neck cancer patients

OBJECTIVES/HYPOTHESIS

Dysphagia and esophageal stricture are frequent consequences of treatment for head and neck cancer. This study examines the effectiveness of the anterograde-retrograde rendezvous procedure and serial dilations in reestablishing esophageal patency to allow return to oral diet and gastrostomy tube removal in a cohort of patients with complete or near-complete esophageal stricture following nonsurgical cancer treatment.

STUDY DESIGN

Retrospective review of patients treated with radiation therapy with or without concurrent chemotherapy presented with complete or near-complete esophageal stricture. Patients underwent serial dilations using combined anterograde-retrograde dilation (rendezvous) techniques.

METHODS

Medical records of patients having undergone treatment between 2006 and 2012 were reviewed, and semistructured interviews were also conducted to determine current swallowing function and actual patient experience. The primary outcome was swallowing improvement that allowed for return to oral diet and/or gastrostomy tube removal. Outcomes were compared between patients with complete and near-complete (<5 mm in diameter) strictures and univariate analysis performed to identify associations between patient, cancer, and treatment characteristics on odds of gastrostomy tube removal.

RESULTS

Twenty-four patients (median age 59.5 years, 63% male, 91% Caucasian) underwent treatment. Fifty percent of patients had complete occlusion of the esophageal lumen. The majority of patients (92%) underwent either anterograde (54%) or combined antero-retrograde (38%) approach. Following a median (interquartile range) of 9 (6-20) dilation sessions, 42% of patients were able to return to an oral diet and/or had their gastrostomy tube removed. This outcome was independent of whether the stricture was complete or near complete (P = .67). Of patients who had their gastrostomy tubes removed, only 33.3% had ever smoked, compared to 92.3% of those whose tubes were not discharged (P = .007).

CONCLUSIONS

Recannulation is possible even in cases of complete or near-complete stricture. Several factors appear to impact the likelihood of successful outcome, but in this study, only patients with a history of smoking had a significantly lower likelihood of return to full oral diet.

Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy

Severely stenosed radiation-induced benign strictures around the level of cricopharyngeus post-radical chemoradiation for head and neck or upper esophageal cancers pose significant management problems. We report our technique of bidirectional assessment and dilatation of pharyngoesophageal strictures in patients with an in situ percutaneous endoscopic gastrostomy (PEG) tube. The upper gastrointestinal surgeon approached the area of stenosis in a retrograde manner through the PEG tube to guide the otolaryngeal surgeon who performed anterograde dilatation via a rigid laryngoscope. Between 2005 and 2009, bidirectional esophageal dilatation was performed on 5 patients at our institution. Video fluoroscopy confirmed improved patency of stenosed esophagus in all cases and good improvement in swallowing ability in 4 patients. The ability to accurately assess pharyngoesophageal strictures using bidirectional visualization and transillumination is the key modification of our technique. We suggest using bidirectional esophageal dilatation on difficult cases with severe pharyngoesophageal stenoses although extreme care is required.