Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy

Transcription

1 OPERATIVE TECHNIQUES PICTORIAL ESSAY Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy Haim Gavriel, MD,* Cuong Duong, MB, BS, PhD, FRACS, John Spillane, MB, BS, FRACS, Andrew Sizeland, MB, BS, FRACS Department of Surgical Oncology, Peter MacCallum Cancer Institute, Melbourne, Australia Accepted 25 January 2012 Published online 31 March 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI /hed ABSTRACT: Severely stenosed radiation-induced benign strictures around the level of cricopharyngeus post radical chemoradiation for head and neck or upper esophageal cancers pose significant management problems. We report our technique of bidirectional assessment and dilatation of pharyngoesophageal strictures in patients with an in situ percutaneous endoscopic gastrostomy (PEG) tube. The upper gastrointestinal surgeon approached the area of stenosis in a retrograde manner through the PEG tube to guide the otolaryngeal surgeon who performed anterograde dilatation via a rigid laryngoscope. Between 2005 and 2009, bidirectional esophageal dilatation was performed on 5 patients at our institution. Video fluoroscopy confirmed improved patency of stenosed esophagus in all cases and good improvement in swallowing ability in 4 patients. The ability to accurately assess pharyngoesophageal strictures using bidirectional visualization and transillumination is the key modification of our technique. We suggest using bidirectional esophageal dilatation on difficult cases with severe pharyngoesophageal stenoses although extreme care is required. VC 2012 Wiley Periodicals, Inc. Head Neck 35: , 2013 KEY WORDS: esophagoscopy, esophageal stricture, radiotherapy, dysphagia, hypopharyngeal cancer INTRODUCTION Pharyngoesophageal stenosis is common in patients who receive radiotherapy for laryngeal and hypopharyngeal cancers and occurs in approximately 20% of these patients. 1,2 These patients typically develop dysphagia and odynophagia mostly in the cervical esophagus within the radiation field. 3 In patients with severe or complete stenosis, complete dysphagia with an inability to swallow saliva has been reported. Diagnostic esophagoscopy and esophageal dilatations play an important role in investigating the dysphagia and in managing the underlying stenosis. In these cases, due to suboptimal visualization and assessment of the stricture, uncontrolled dilatation using rigid or flexible anterograde techniques is usually unsuccessful and can be very hazardous, with a high risk of creating a false lumen followed by imminent mediastinitis, neck abscess, or sepsis. A temporary percutaneous endoscopic gastrostomy (PEG) tube is often used to nutritionally support patients with head and neck or esophageal cancers undergoing radical chemoradiation due to significant dysphagia observed secondary to treatment effect and/or the underlying malignancy. The presence of a PEG tube in patients with severe pharyngoesophageal stenoses facilitates a novel and safe approach in assessing and dilating these strictures endoscopically. *Corresponding author: H. Gavriel, Departments of Surgical Oncology, Peter MacCallum Cancer Institute, Melbourne, Australia. haim.ga@012.net.il The novel technique of bidirectional esophageal dilatation or retrograde endoscopic assisted esophageal dilatation is scarcely reported in the English-language literature; however, the accumulating data suggest that its efficacy might be better than the standard anterograde flexible/rigid esophagoscopy. 4 7 We would like to share our experience and knowledge of using the technique of bidirectional esophageal dilatation in patients with pharyngeal and upper esophageal cancer who have had chemoradiotherapy and suffer from severe and complicated pharyngoesophageal stenosis. PROCEDURE The procedure is performed under general anesthesia in the operating room. Endotracheal intubation is performed in all cases. The patient is placed in a supine position, and the room setting is as drawn in Figure 1. A rigid laryngoscope is inserted first to the hypopharynx by the otolaryngologist in an attempt to assess the location and severity of the stenosis, even though dilatation using the anterograde approach is not expected to be a possibility in these patients due to very tight stenosis demonstrated preoperatively. At this stage the laryngoscope is kept in the hypopharynx while the upper GI surgeon starts to approach the stenosis from below. An ultraslim gastroscope (Olympus GIF-XP 160; Olympus America Inc., Center Valley, Pennsylvania, PA, USA) is used for retrograde endoscopy through the gastrostomy stoma, with an external diameter of 5.9 mm (18 French) and a 2.0-mm accessory channel (see Figure 2). During retrograde scope insertion, there is no need to dilate the gastrostomy stoma if the patient has a 20-French gastrostomy feeding tube. The stomach is insufflated with air, and the gastric HEAD & NECK DOI /HED MAY

2 GAVRIEL ET AL. FIGURE 1. Operating room setting for bidirectional esophageal dilatation. FIGURE 4. The otolaryngologist is scoping from the hypopharynx while the gastroscope is advanced superiorly toward the stenotic area. [Color figure can be viewed in the online issue, which is available at FIGURE 2. Retrograde endoscopy through the gastrostomy stoma. [Color figure can be viewed in the online issue, which is available at antrum is identified. The lesser curvature is followed superiorly toward the lower esophageal sphincter, and the esophagus is entered (see Figure 3). At this stage the otolaryngologist is scoping from the hypopharynx while the gastroscope is advanced superiorly (see Figure 4). The area of stenosis is approached and evaluated from superior and inferior aspects with each surgeon relying on the visualization and transillumination of the other. Two major clues are searched for: the first is visualization of the other surgeon's tools and the second is the other surgeon's instrumental light glowing through the existing opening (see Figure 5). After thorough evaluation of the strictured segment, the upper gastrointestinal (GI) surgeon passes a guidewire superiorly through the stenotic opening (Figures 6 and 7). From the cranial end, the guidewire is grasped and pulled FIGURE 3. Retrograde view of the lower esophageal sphincter. [Color figure can be viewed in the online issue, which is available at FIGURE 5. The otolaryngologist s instrumental light glowing through the existing opening as seen from below. [Color figure can be viewed in the online issue, which is available at 734 HEAD & NECK DOI /HED MAY 2012

3 BIDIRECTIONAL ESOPHAGEAL DILATATION FIGURE 6. The upper GI surgeon passes a guidewire superiorly through the stenotic opening. [Color figure can be viewed in the out through the mouth by the otolaryngologist (Figures 8 and 9). With the gastroscope withdrawn to the distal part of the esophagus, bougie dilators are sequentially passed over the guidewire starting from the smallest size of 8 French up to the largest possible, usually 16 French (Figures 10 and 11). By the end of the serial dilatations, the effect can be clearly appreciated, as seen from the pharyngeal end in Figure 12. After all the instrumentations are removed out from the patient, a new gastrostomy tube is inserted (see Figure 13). A prophylactic antibiotic is not prescribed on a routine basis and a clear liquid diet is started within 12 hours without a post procedural contrast study. FIGURE 8. The guidewire is grasped and pulled out through the mouth by the otolaryngologist. [Color figure can be viewed in the REPORT OF 5 CASES Between 2005 and 2009, bidirectional esophageal dilatation was performed in 5 cases. All patients received radical chemoradiotherapy to the neck for the treatment of pharyngolaryngeal carcinomas. All 5 patients had complete tumor response at the site of the primary but developed severe radiation-induced benign pharyngoesophageal stricture with an inability to even swallow their own saliva. The severity of these strictures was proven by fluoroscopy preoperatively. All patients had PEG tube insertion for nutritional supplementation during their course of treatment. Although the risk of esophageal perforation was not insignificant due to the nature and location of the pharyngoesophageal strictures, no patient wanted to be dependent on PEG-tube feeding lifelong and all were keen for and gave informed consent to endoscopic dilatation. Bidirectional assessment and subsequent endoscopic dilatation of these challenging pharyngoesophageal stenoses were feasible in all cases. The complication rate was low and acceptable in this group of high-risk patients. Only 1 patient developed mediastinitis due to esophageal FIGURE 7. The guidewire in the lower esophagus as seeing through the gastroscope. [Color figure can be viewed in the FIGURE 9. The surgeons holding both ends of the guidewire. [Color figure can be viewed in the online issue, which is available at HEAD & NECK DOI /HED MAY

4 GAVRIEL ET AL. FIGURE 12. The gastroscope observed by the otolaryngologist through the dilated esophagus. [Color figure can be viewed in the FIGURE 10. Bougie dilators are sequentially passed over the guidewire by the otolaryngologist. [Color figure can be viewed in the cell carcinoma (SCC) of the base of tongue and required repeated dilatations due to complete obstruction of the pharyngoesophageal stenosis. The initial mild improvement observed restenosed. microperforations, which settled down quickly with conservative treatment. Postoperative video fluoroscopy demonstrated improved patency of the pharyngoesophageal segment in all cases. Four patients reported of good improvement in swallowing with an ability of handling a soft diet and 3 of them required no further dilatation. A couple of patients who required further dilatation due to postoperative fibrosis and restenosis underwent the procedure within a year from the first attempt. The fifth patient underwent definitive chemoradiotherapy due to squamous DISCUSSION Upper esophageal stricture is common in patients who receive radiotherapy for head and neck cancers. We present here our experience using bidirectional esophageal dilatation for the treatment of obstructed esophagus in these patients. The use of our technique while following the suggested steps of mutual visual confirmation can offer safety and efficiency with a very high success rate. We prefer this method in treating postoperative severely obstructed esophagus since it enables detecting severely narrowed lumen in great precision because this space is approached from both sides. The ability of both surgeons to detect each other's instruments, light, and movement gives the procedure its high success rate, opposing the results obtained in surgery performed by either of the surgical specialties. FIGURE 11. The bougie dilator passed over the guidewire as seeing through the gastroscope. [Color figure can be viewed in the FIGURE 13. A new gastrostomy tube is inserted at the end of the procedure. [Color figure can be viewed in the online issue, which is available at 736 HEAD & NECK DOI /HED MAY 2012

5 BIDIRECTIONAL ESOPHAGEAL DILATATION CONCLUSIONS Bidirectional esophageal dilatation in severe pharyngoesophageal strictures is technically feasible and appeared to have a reasonably high success rate. In our study only 1 of 5 patients demonstrated with a complication that settled down quickly with conservative treatment. REFERENCES 1. Caudell JJ, Schaner PE, Meredith RF, et al. Factors associated with longterm dysphagia after definitive radiotherapy for locally advanced head-andneck cancer. Int J Radiat Oncol Biol Phys 2009;73: Lee WT, Akst LM, Adelstein DJ, et al. Risk factors for hypopharyngeal/ upper esophageal stricture formation after concurrent chemoradiation. Head Neck 2006;28: Franzmann EJ, Lundy DS, Abitbol AA, Goodwin WJ. Complete hypopharyngeal obstruction by mucosal adhesions: a complication of intensive chemoradiation for advanced head and neck cancer. Head Neck 2006;28: Langerman A, Stenson KM, Ferguson MK. Retrograde endoscopic-assisted esophageal dilation. J Gastrointest Surg 2010;14: Tang SJ, Singh S, Truelson JM. Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP). Surg Endosc 2010; 24: Dellon ES, Cullen NR, Madanick RD, et al. Outcomes of a combined antegrade and retrograde approach for dilatation of radiation-induced esophageal strictures. Gastrointest Endosc 2010;71: Maple JT, Petersen BT, Baron TH, Kasperbauer JL, Wong Kee Song LM, Larson MV. Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique. Gastrointest Endosc 2006;64: HEAD & NECK DOI /HED MAY