Endoscopic balloon dilatation for pharyngo-upper esophageal stricture after treatment of head and neck cancer

Prospective Assessment of Safety, Tolerance, and Perceptions of Awake Airway and Esophageal Dilation

OBJECTIVE

An increasing number of laryngeal and esophageal procedures are being performed as "awake" procedures (non-general anesthesia), with some under local anesthesia, including in clinic. While high tolerance and safety profiles have been reported for various laryngeal procedures, few studies directly assess tolerability of awake dilation procedures of the upper esophagus (UE) and laryngotracheal airway (LTA).

STUDY DESIGN

Prospective, open-label.

METHODS

Prospectively collected patient and physician surveys from a tertiary laryngology center recorded patient tolerance, safety, and perceptions of awake UE and LTA balloon dilation.

RESULTS

Fifty-six awake procedures were performed on 41 patients, including 46 UE and 20 LTA dilations. All procedures were successfully completed. Overall pain was mild (3.5 ± 2.4/10, ranging 0 = no pain to10 = worst pain) and the dilation itself was reportedly the most painful portion (4.1 ± 2.9/10). Patient satisfaction with the procedure was high (7.0 ± 2.2/10, ranging 0 = worst to 10 = best experience). Most patients would undergo the procedure again (73.6%) and would recommend the procedure to others (89.3%). Patient-reported tolerance was similar immediately postoperatively and at follow-up. LTA and UE dilation patients reported similar levels of tolerance.

CONCLUSIONS

Awake upper esophageal balloon dilation is a safe, well-tolerated procedure with high completion and patient satisfaction rates. Similarly, early experience with awake laryngotracheal airway balloon dilation suggests comparable favorability, although careful consideration of patient selection and procedural implementation is strongly recommended to optimize and protect patient safety.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1343-1351, 2025.

Safety of a Novel Upper Esophageal Sphincter Balloon Dilator

OBJECTIVE

The shape of esophageal dilators has not changed in over 350 years. Clinical and animal research suggests that the upper esophageal sphincter (UES) is not round but approximates a kidney shape and that cylindrical dilators may be suboptimal. The Infinity UES Dilation System has been developed specifically for the anatomic configuration of the UES. This study evaluates the safety of the UES-specific Infinity Dilation System.

METHODS

All patients undergoing dilation of the UES between January 1, 2022 and September 1, 2023 were included. Demographics, procedure indication, dilator type, minor adverse events, and major complications were abstracted. Minor adverse events, complications, and maximum dilation dimension (mm) were compared between groups.

RESULTS

A total of 477 patients were included. Eight hundred and seventy-three total UES dilations were performed. The primary indications for UES dilation were cricopharyngeus muscle dysfunction (43%) and stenosis from radiation toxicity (40%). Twenty-three percent (202/873) of dilations were performed with an Infinity balloon, 31% (270/873) were performed using two conventional balloons placed side by side, and 46% (401/873) were performed with one singleton conventional balloon. The average maximum dilation dimension was 33 (±4.7) mm for Infinity balloons, 32 (±3.8) mm for two side-by-side balloons, and 18 (±3.4) mm for singleton balloons. There were three major complications with conventional balloons and none with Infinity balloons. There were no significant differences in minor adverse events between groups.

CONCLUSIONS

A UES-specific esophageal dilator provides a greater maximum dilation dimension and appears to be at least as safe as dilation with a single cylindrical balloon designed to dilate the esophagus.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:66-72, 2025.

Neopharyngeal Stricture following Laryngectomy

Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.

Balloon dilatation complications during esophagogastric anastomotic stricture treatment under fluoroscopy: Risk factors, prevention, and management

BACKGROUND

Balloon dilatation (BD) is a common treatment for esophagogastric anastomotic stricture (EAS), but with complications. This study investigates the risk factors, prevention, and management of BD complications to provide clinical guidance.

METHODS

We retrospectively analyzed the clinical data of 378 patients with EAS treated by BD from March 2011 to June 2021. The association between esophagogastric anastomotic rupture outcome and patient and stricture characteristics and treatment were analyzed by logistic regression.

RESULTS

BD was performed 552 times and technical success, 98.0%; overall clinical success, 97.8%; major adverse events, 1.3%; minor adverse events, 9.4%; mortality, 0.3%. Logistic regression showed that age (p = 0.080), sex (p = 0.256), interval from surgery to stricture development (p = 0.817), number of dilatations (p = 0.054), cause of stricture (p ≥ 0.168), and preoperative chemotherapy (p = 0.679) were not associated with anastomotic rupture. Balloon diameter (p < 0.001), preoperative radiotherapy (p = 0.003), and chemoradiotherapy (p = 0.021) were correlated with anastomotic rupture. All patients with type I and II ruptures resumed oral feeding without developing into type III rupture. Type III rupture occurred in six cases, who resumed oral feeding after 7-21 days of nasal feeding and liquid feeding. One patient died of massive bleeding after BD.

CONCLUSIONS

Symptomatic treatment for type I and II ruptures and transnasal decompression and jejunal nutrition tubes for type III rupture, are suggested pending rupture healing. Tumor recurrence, preoperative radiotherapy, and balloon diameter affected the anastomotic rupture outcome.

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.

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.

Office-Based Cricopharyngeus Balloon Dilation for Post Chemoirradiation Dysphagia in Nasopharyngeal Carcinoma Patients: A Pilot Study

Dysphagia is a common sequela post chemo/radiotherapy for nasopharyngeal carcinoma (NPC), with cricopharyngeal dysfunction often a contributing factor. This study examined the impact of balloon dilation of the cricopharyngeus and cervical oesophagus on swallow competence for dysphagic patients with cricopharyngeal dysfunction post NPC. Patients with NPC were screened for dysphagia and cricopharyngeal dysfunction using fiberoptic endoscopic evaluation. Thirteen symptomatic patients, median 14.1 years post chemoradiotherapy for NPC, then underwent balloon dilation under local anesthesia. Before and 1 month post dilation, swallow function was assessed with fluoroscopy, and rated using the penetration-aspiration scale, temporal swallowing measures, and MBSImP pharyngoesophageal segment opening and esophageal clearance parameter. The MD Anderson Dysphagia Inventory (MDADI; Chinese version) and the Functional Oral Intake Scale (FOIS) were collected pre-, 1 month, and approximately 3 months post dilation. Post-dilation, significant improvements were noted in mean FOIS scores (5.00 to 5.62), duration of cricopharyngeus opening (0.42 s to 0.53 s), MBSImP pharyngoesophageal opening scores (1.61 to 1.08), penetration-aspiration scale scores (4.85 to 3.92) and MDADI Composite score (46.48 to 52.43). At 3 months post dilation, the MDADI Composite Score showed sustained benefit. The procedure was well tolerated and without complication. In patients with cricopharyngeal dysfunction post NPC, balloon dilation significantly improved swallow function, reduced aspiration risk and improved quality of life. Evidence from a larger cohort with long-term follow-up is warranted to determine sustained benefit.

Patch esophagoplasty with a free proximal lateral leg flap for focal stricture of the cervical esophagus: A case report

Esophageal stricture after surgery or trauma is a major reason for poor oral nutrition, body-weight loss, and general damage to health. Patch esophagoplasty, after repeated failed dilation attempts, is recommended for focal esophageal strictures. In this report, we present a case in which a free proximal lateral leg flap was used for reconstruction of focal stricture of the cervical esophagus. A 62-year-old man developed progressive dysphagia after hypopharyngeal cancer ablation and adjuvant radiotherapy. He was referred for surgical interventions after repeated failed dilation attempts. Preoperative evaluation revealed a 3-cm segment stricture of the cervical esophagus without evidence of an additional distal stricture. Patch esophagoplasty with free tissue transfer was planned. After the stricture site had been explored, the fibrotic tissue was resected. A pathology report confirmed no evidence of malignancy. The resultant defect in an otherwise healthy posterior esophageal wall was reconstructed using a proximal lateral leg flap. Recovery was uneventful and the functional outcome was satisfactory at the 6-month follow-up. For the radiated patients with cervical esophageal focal strictures, we introduced a novel use of the proximal lateral leg flap in patch esophagoplasty because of its unnoticeable donor site morbidity and its thin and pliable nature. © 2016 Wiley Periodicals, Inc. Microsurgery 37:426-430, 2017.