Treatment of a radiation-induced esophageal web with retrograde esophagoscopy and puncture

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.

Management of a postradiation esophageal web in the setting of a coexisting Zenker's diverticulum

We present a case of postradiation obstructive esophageal web, seen in the setting of a coexisting Zenker's diverticulum, that was treated with combined anterograde and retrograde esophagoscopy puncture and dilation. We also review the relevant literature. Obstructing esophageal webs and stenoses are well-documented complications seen in patients with head and neck cancer treated with radiation therapy. For thin webs, combined anterograde and retrograde esophagoscopy along with puncture and dilation can be a relatively safe treatment option for selected patients. The presence of a coexisting Zenker's diverticulum may predispose the patient to the development of postradiation esophageal complications and make subsequent assessment more difficult to perform.

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.

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.

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.

Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer

BACKGROUND

Chronic esophageal toxicity after radiotherapy alone for cancer of the head and neck (HNCa) is rare: 2.6% for strictures and 0.8% for stenosis after a 60-Gy dose. With combined modality therapy, stricture rates of 22% to 37% have been reported. We report the frequency of esophageal toxicity after simultaneous modulated accelerated radiation therapy (SMART) with chemotherapy for HNCa.

METHODS

The records of the otolaryngology/head and neck surgery department of Emory University, Atlanta, GA, were screened for patients undergoing combined modality therapy using SMART for HNCa. Radiation Oncology records were reviewed for target and critical normal structure dosimetry, with detailed analysis of esophageal and supraglottic laryngeal dosimetry. Hospital and clinic records were reviewed for evidence of esophageal toxicity.

RESULTS

From January 2003 to August 2005, 99 patients underwent definitive therapy for squamous cell HNCa using SMART and chemotherapy. Follow-up was documented in all cases. Median dose to sites of gross primary or nodal disease was 70.29 Gy, at 2.13 Gy per fraction. Median dose to the ipsilateral neck was 63.03 Gy at 1.91 Gy per fraction. Median dose to the contralateral neck in 97 patients treated was 57.75 Gy at 1.75 Gy per fraction. Thirteen (13%) patients developed esophageal strictures. Five (5%) patients had complete esophageal stenosis. Four (14%) of the 29 patients with either a hypopharyngeal primary or a N2c nodal disease developed complete stenosis. A statistically larger esophageal volume of esophagus reactivity > or = 60 Gy (V(60)) was found in patients who developed stenosis/stricture when compared with a randomly selected population of N2a/b patients who did not develop those toxicities. Esophageal stenosis/stricture was also numerically more common in patients receiving taxane-based chemotherapy, developing in 23%, as opposed to 9% in patients treated with platinum-based chemotherapy.

CONCLUSION

The risk of esophageal stenosis may increase with SMART and chemotherapy for HNCa. Potential mechanisms to reduce this include (a) contouring the esophagus as a dose-limiting structure; (b) early flexible examination posttreatment, with early intervention with dilation; (c) improved therapy for mucositis.