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

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.

New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review

Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.

Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review

Background

Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported.

Materials and Methods

Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores.

Conclusions

Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

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.

Esophageal Third Space Endoscopy: Recent Advances

PURPOSE OF THE REVIEW

The novel concept of third space endoscopy was first applied to humans in 2008 for the management of achalasia through peroral endoscopic myotomy (POEM) procedure. Over the ensuing 10 years, this revolutionary procedure, which started in Japan, has been adopted and mastered by surgeons and gastroenterologists across the globe. In this article, we review the recent innovations and applications of third space endoscopy in the management of esophageal disorders.

RECENT FINDINGS

With experience and innovation, the application of third-space endoscopy has extended beyond achalasia, and currently, it is used in the management of other esophageal disorders including, spastic esophageal disorders, subepithelial tumors, complete esophageal obstruction, and esophageal diverticula. The recent advances in third space endoscopic procedures have not only permitted endoscopic access to places, previously thought impossible, but also enabled the precision of surgery along with reduced peri-operative morbidity due to its minimally invasive nature. While short- and mid-term outcome studies have shown excellent results, we eagerly await the long-term outcome studies before these procedures could be established as the procedures of choice.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

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.).

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.