Safety and efficacy of combined antegrade and retrograde endoscopic dilation for complete esophageal obstruction: a systematic review and meta-analysis

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.

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

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.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.