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Endoscopy 2011; 43(5): 434-437
DOI: 10.1055/s-0030-1256075
Case Report/Series

© Georg Thieme Verlag KG Stuttgart · New York

Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus

D.  Schembre1 , J.  B.  Dever2 , M.  Glenn1 , S.  Bayles1 , J.  Brandabur1 , R.  Kozarek1
  • 1Virginia Mason Medical Center – Gastroenterology, Seattle, Washington, USA
  • 2University of California at San Francisco – Gastroenterology, Fresno, California, USA
Further Information

D. SchembreMD 

Swedish Gastroenterology

1221 Madison St. Suite 1220
Seattle, WA 98104

Email: Drew.Schembre@swedish.org

Publication History

submitted 1 September 2010

accepted after revision 11 October 2011

Publication Date:
28 February 2011 (online)

Also available ateRef
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Table of Contents

Complete obstruction of the proximal esophagus is an uncommon complication of radiotherapy. Standard endoscopic dilation is not possible because no lumen exists. We describe a retrospective case series in which rendezvous endoscopy, tissue puncture, dilation, and stenting were used to restore function to a group of patients with complete esophageal obstruction. The series consisted of patients referred for complete esophageal obstruction after radiation therapy over 5 years. Ultimately, five patients underwent successful initial recanalization via rendezvous endoscopy. All patients were able to resume eating and four have been able to maintain oral alimentation with periodic dilation. One patient developed self-limited pneumomediastinum after needle puncture and cervical osteomyelitis after stenting, and another developed an anterior neck abscess after stenting. Rendezvous endoscopy can successfully treat complete esophageal obstruction resulting from radiation therapy. Temporary stenting may allow patients to swallow immediately and leave the hospital sooner but does not appear to reduce the need for subsequent dilation and may result in serious complications.

 

Introduction

Complete obstruction of the proximal esophagus is an uncommon but severe side effect of radiotherapy for head and neck cancers [1]. Standard endoscopic therapy is rarely beneficial because no lumen exists. Surgery is usually a poor option due to soft tissue damage from previous therapies. As a result, patients must constantly spit saliva and depend on feeding tubes for all nutrition and hydration. Those without a tracheostomy risk aspiration.

Esophageal strictures develop in up to 4 % of patients after radiation in excess of 4500 cGy [2]. When chemotherapy is given concurrently, stricture rates increase to as much as 21 % [3]. Severity varies from mild dysphagia amenable to simple dilation to complete obliteration of the lumen with separation of the proximal and distal esophagus by up to a centimeter or more. Re-establishing the esophageal lumen after complete obstruction has been reported in a small number of cases using a combined antegrade and retrograde (rendezvous) approach [4] [5] [6] [7] [8] [9]. This paper describes outcomes after rendezvous endoscopy and temporary stenting to re-establish esophageal patency in a series of patients at one institution.

 

Case series

Between 2000 and 2009, five patients were referred for possible endoscopic treatment for complete esophageal obstruction (no demonstrable lumen by endoscopy or contrast radiography) after radiation therapy for head and neck cancers ([Table 1]).

Table 1 Characteristics of five patients with complete esophageal obstruction after radiation therapy.
Patient no. Age/sex Cancer Radiation therapy Chemotherapy Surgery Duration obstructed
1 50/M Larynx Yes No Yes 30 months
2 71/M Hypopharynx Yes Yes No 14 months
3 74/M Esophagus Yes Yes No 5 months
4 67/M Tongue Yes Yes No 18 months
5 68/F Larynx Yes Yes Yes 6 months

All patients underwent simultaneous antegrade and retrograde (rendezvous) endoscopy. Retrograde endoscopy was performed with a flexible gastroscope through an existing gastrostomy while antegrade endoscopy was performed via the mouth with a flexible endoscope in three cases and rigid laryngoscope in two cases. In two patients the procedure was performed via the gastrostomy with a pediatric gastroscope and in three after dilation to 10 mm to allow passage of a standard gastroscope. A standard gastroscope was used in order to more easily pass an endoscopic ultrasound (EUS) needle and other larger instruments. In all cases, fluoroscopy was used to document the distance of the disconnection between the proximal and distal esophagus and to guide puncture. Results of the procedures are shown in [Table 2].

Table 2 Characteristics of five rendezvous endoscopy procedures performed to relieve complete esophageal obstruction.
Patient no. Stricture length Puncture No. of stents placed Size(s) Indwelling time per stent Complications
1 10 mm 19-g EUS needle 2 10-mm PCB SEMS
16-mm SEPS 		7 weeks
4 weeks 		Pain
2 20 mm 22-g EUS needle 3 9-mm PCB SEMS
10-mm PCB SEMS
12-mm SEPS 		4 weeks
2 weeks
5 weeks 		Pneumomediastinum, cervical osteomyelitis
3 2 – 3 mm 0.035-in. guide wire 0 None
4 3 mm 19-g EUS needle +wire+forceps 1 10-mm PCB SEMS 4 weeks None
5 5 mm 0.035-in. guide wire 1 10-mm PCB SEMS 2 weeks Anterior neck abscess
PCB SEMS, partially covered biliary self-expanding metal stent; SEPS, self-expanding plastic stent; g, gauge.

In each case, once a lumen was established, a wire was passed and dilation performed with small-diameter biliary or esophageal balloons up to 10 mm. Four patients underwent temporary stenting with a partially covered biliary Wallstent (Boston Scientific, Natick, Massachusetts, USA) that was left in place for an average of 4 weeks. Two patients underwent subsequent up-sizing with fully covered, self-expanding plastic stents (Polyflex; Boston Scientific) in an effort to reduce the need for subsequent dilations. All patients underwent dilute barium swallow 24 hours following the procedure to assess stent patency and position and aspiration. All patients were followed at weekly intervals for 1 month or more. Three patients were followed for 2 years, one died of recurrent cancer at just under 2 years, and one was lost to follow-up after he refused further treatment and the esophagus re-stenosed. Patients who required frequent dilations were offered the option of learning self-dilation.

All five patients underwent successful recanalization of the esophagus ([Table 3]).

Table 3 Outcomes of five rendezvous endoscopy procedures performed to relieve complete esophageal obstruction.
Patient no. Able to swallow immediately Able to discontinue tube feeds Requiring ongoing dilations Able to do self-dilation Duration of follow-up
1 Yes Yes Yes Yes 2 years (died)
2 Yes No Refused further treatment N/A N/A
3 Yes Yes Yes No 2 years
4 Yes Yes Yes Yes 2 years
5 Yes No Yes Yes 2 years

Four patients were able to leave the hospital within 24 hours of the procedure. No patient developed problems from the dilation of the gastrostomy, which contracted to predilation diameter after replacement of the gastrostomy tube. One patient developed pneumomediastinum during the procedure and was treated with broad-spectrum antibiotics and observed for 3 days without incident. The same patient developed a periesophageal abscess and cervical osteomyelitis 5 weeks following placement of a third stent for recurrent stricture. Although this was successfully treated with stent removal and antibiotics, the patient was not interested in further treatment and the esophagus re-stenosed. One patient developed an anterior cervical abscess 2 weeks after stent placement, which resolved after stent removal, incision and drainage, and antibiotic therapy. All patients reported some temporary discomfort, but only one required ongoing pain medication while a stent was in place. All patients gave informed consent. Study methods were approved by the Virginia Mason Internal Review Board

 

Discussion

Although esophageal stricture is common after radiation therapy for head and neck cancers, complete obstruction with obliteration of the lumen is rare [1] [2]. Once the lumen has completely closed, traditional endoscopic dilation techniques no longer work. Retrograde endoscopy has been used in this setting primarily to obtain a second perspective of the stricture in hope of identify an obscure lumen [9]. Reports of successful recanalization in the setting of complete obliteration of the lumen exist but series are small [5] [6] [7] [8].

Each patient with complete obstruction presents unique challenges. While thin membranes can be opened with a guide wire and forceps, longer segments require blind puncture. Lacking a device specifically designed for this purpose, we adapted an EUS needle. Precedent for the technique exists: Moyer et al. reported using a 19-gauge EUS needle to puncture a 3-cm esophageal obstruction [6]. Although the patient died soon after, the procedure itself was successful. We found puncture with an EUS needle to be challenging, first because orientation is difficult, even with fluoroscopy, and second because needles can deflect or bend when passing through dense scar tissue. For this reason, puncture through fibrous tissue much more than 10 mm may be exceptionally risky and is not advised. It seemed easier to pass the needle antegrade because the mid-esophagus tends to insufflate more consistently and presents a better target than the hypopharynx ([Fig. 1]).

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Fig. 1 Retrograde view of endoscopic ultrasound needle puncture of complete esophageal obstruction.

A 19-gauge needle will accept a 0.035-inch guide wire and a 22-gauge needle will accept a 0.025-inch wire. The 19-gauge needle is stiffer, but the 22-gauge needle may be less traumatic. Given the small number of cases, no conclusions can be drawn about the advisability of using either needle, or, for that matter, what level of risk exists for this technique in general.

In the majority of previously reported rendezvous cases, a temporary nasogastric tube was placed following recanalization and patients were given nil by mouth and observed for several days. In our series, we employed narrow-diameter, partially covered biliary stents in four of five patients in an attempt to seal any full-thickness tears or punctures, to allow earlier initiation of oral feeding and discharge and in an attempt to reduce re-stenosis. After needle puncture, a new tract is established that does not necessarily contain all the elements of an esophageal wall. In experiments with dogs in which the esophagus was completely transected, new esophageal mucosa eventually regenerated over an indwelling stent, even with a gap of 5 cm [10]. We hoped that placement of an occluding stent immediately after puncture and dilation might reduce leakage and promote re-epithelialization. Unfortunately, two of four patients developed abscesses after stent placement. This may have resulted from incomplete sealing of a small leak that developed at the time of the puncture, or as a result of tissue ischemia from the stent pressing on poorly perfused, irradiated tissue. Stents were also placed in an attempt to prevent re-stenosis. Removable stents have been used to permanently dilate recalcitrant esophageal strictures [11] [12], albeit inconsistently. Standard-diameter stents for strictures near the upper esophageal sphincter have been considered a relative contraindication because of airway compression, fistula, periesophageal ischemia, and infection [13], especially after radiation therapy [14]. However, specially designed, small-diameter, fully covered stents appear to work well in the proximal esophagus [15]. Unfortunately, these were not commercially available in the United States during this study. Instead, we used partially covered biliary stents with diameters from 8 to 10 mm ([Fig. 2]).

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Fig. 2 Ten-millimeter partially covered biliary metal stent abutting the larynx.

Despite lacking proximal flares, these stents stayed in place, and were well tolerated and easily removed without significant ingrowth of granulation tissue, even at 7 weeks.

Placement of removable stents did allow the three patients without evidence of perforation to begin taking liquids immediately and leave the hospital within 24 hours.

The high rate of periesophageal abscess formation after stenting is concerning. The one patient in this series who did not receive a stent had a shorter, less rigid stenosis that did not appear to need stenting or a nasogastric tube. Ultimately, all patients who underwent recanalization in this series still required periodic dilation after a stent was removed. This is not surprising as most studies show that re-stenosis occurs frequently following temporary stent removal for recalcitrant, benign strictures [16] [17]. Upsizing these stents or prolonged stenting did not appear to prevent re-stenosis and may have contributed to complications.

Puncture of complex postradiation strictures with an EUS needle appears to be effective for re-establishing luminal patency. Initial placement of a covered stent seems to be well tolerated, at least initially, and allows patients to resume swallowing liquids and leave the hospital soon after. Temporary stent placement does not appear to reduce the need for subsequent dilation and may lead to serious complications. Future controlled studies may wish to examine the safety and cost-effectiveness of short-term, small-diameter partially or fully covered metal stents after luminal recanalization of the proximal esophagus.

Video 1 Rendezvous endoscopy: antegrade first, then retrograde. A guide wire is passed through a small fistula but cannot completely penetrate interposing tissue. Passage of an endoscopic ultrasound needle is unsuccessful but forceps are ultimately used to create a defect through which a wire can pass. The tract is then dilated with a balloon and stented temporarily with a 10-mm covered biliary stent.

Competing interests: None

 

References

D. SchembreMD 

Swedish Gastroenterology

1221 Madison St. Suite 1220
Seattle, WA 98104

Email: Drew.Schembre@swedish.org

 

References

D. SchembreMD 

Swedish Gastroenterology

1221 Madison St. Suite 1220
Seattle, WA 98104

Email: Drew.Schembre@swedish.org

   Permissions and Reprints
Zoom

Fig. 1 Retrograde view of endoscopic ultrasound needle puncture of complete esophageal obstruction.

Zoom

Fig. 2 Ten-millimeter partially covered biliary metal stent abutting the larynx.