Functional outcome of patients treated for radiation-induced complete esophageal obstruction after successful endoscopic recanalization (with video)

Combined antegrade and retrograde dilation (CARD) for management of complete esophageal obstruction: Multicenter case series

Background and study aims Complete esophageal obstruction (CEO) is a rare complication of radiation therapy for esophageal or head and neck cancers and can be challenging to manage endoscopically. A rendezvous approach by combined anterograde and retrograde endoscopic dilation (CARD) can be used to re-establish luminal integrity in such cases. Our study aimed to review our experience with patients with CEOs managed by CARD. Patients and methods Six patients who had CARD for CEO were reviewed. The primary outcomes were immediate technical and clinical success of CARD. Secondary outcomes were adverse events (AEs) associated with the procedure and continued dependency on the percutaneous endoscopic gastrostomy (PEG)-or jejunostomy tube. Results The mean age was 59 years (range 38-83). Five patients had CEO secondary to neoadjuvant chemoradiotherapy for esophageal cancer, and one patient had complete obstruction secondary to neck trauma. CARD was technically successful in five patients (86%). Two patients had AEs. One had pneumomediastinum requiring no intervention, while the other had bilateral pneumothorax requiring chest tube placement. The median follow-up duration of repeated dilations to maintain liminal patency was 20 months. Four patients had improvement in dysphagia, tolerating oral intake, and mouth secretions after the procedure, with a mean functional oral intake scale (FOIS) score > 3 and an overall success rate of 83%. Conclusions The CARD approach to re-establish esophageal luminal patency in CEO is a safer alternative to high-risk blind antegrade dilation or an invasive surgical approach. It is usually technically feasible with improved swallowing ability in most patients.

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 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.

Outcomes of Combined Antegrade-Retrograde Dilations for Radiation-Induced Esophageal Strictures in Head and Neck Cancer Patients

The purpose of this study is to analyze outcomes of combined antegrade-retrograde dilations (CARD). This retrospective study was conducted on 14 patients with a history of head and neck cancer, treated with radiation therapy that was complicated by either complete or near-complete esophageal stenosis. All patients had minimal oral intake and depended on a gastrostomy tube for nutrition. Swallow function before and after CARD was assessed using the Functional Oral Intake Scale, originally developed for stroke patients and applied to head and neck cancer patients. Patients undergoing CARD demonstrated a quantifiable improvement in swallow function (p = 0.007) that persisted at last known follow-up (p = 0.015) but only a minority (23.1%) achieved oral intake sufficient to obviate the need for tube feeds. Complication rates were 24% per procedure or 36% per patient, almost all complications required procedural intervention, and all complications occurred in patients with complete stenosis. Our study suggests further caution when considering CARD, careful patient selection, and close post-operative monitoring.

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.

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.

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.