A Simple Combined Antegrade Radiological and Retrograde Endoscopic Procedure to Recanalise Fibrotic Hypopharyngo-Oesophageal Occlusions: Technical Description and Lessons from Clinical Outcome in Three Cases
Background: Complete hypopharyngo-oesophageal occlusion is a rare complication of head and neck radiotherapy and a range of other conditions. Absolute dysphagia is accompanied by aspiration and dependence on gastrostomy feeding. The condition presents a substantial management challenge. Surgical approaches to re-establish pharyngo-oesophageal continuity are varied, highly invasive and are associated with unpredictable outcomes. Minimally invasive techniques employing endoscopic and radiological techniques are emerging. This report describes a multidisciplinary approach which translates two interventional radiology techniques used in the management of central venous occlusions and biliary strictures to the management of three cases of complete hypopharyngo-oesophageal occlusion. Methods: Three cases with different underlying aetiologies had treatment initiated between 2009 and 2011. Antegrade pharyngoscopic access to the occlusions was accompanied by retrograde endoscopic access via a small gastrostomy. Luminal continuity was re-established by the interventional radiology technique of “sharp recanalisation” followed by passage of a wide bore nasogastric tube which was maintained in situ for 4-6 months, a duration of treatment analogous to that applied in the radiological management of fibrotic biliary strictures. After treatment a radiological contrast swallows examination was performed to gauge the calibre of the re-established lumen, assess functionality and to rule out aspiration. Results: Pharyngo-oesophageal continuity was re-established in all three cases on the first attempt. No complications occurred as a result of the procedures. In two cases, the excellent swallowing function was re-established, although one of these required prolonged post-treatment adjuvant interventions. In one case no swallowing function resulted, despite apparently successful re-establishment of luminal continuity. Conclusions: Complete fibrotic occlusion of the hypopharyngo-oesophageal lumen is rare and presents a substantial management challenge. A minimally invasive treatment combining antegrade radiological and retrograde
References
[1]
H. B. Caglar, R. B. Tishler, M. Othus, et al., “Dose to Larynx Predicts for Swallowing Complications after Intensity-Modulated Radiotherapy,” International Journal of Radiation Oncology Biology Physics, Vol. 72, No. 4, 2008, pp. 1110-1118. doi:10.1016/j.ijrobp.2008.02.048
[2]
M. Chirica, C. de Chaisemartin, N. Munoz-Bongrand, et al., “Colonic Interposition for Esophageal Replacement after Caustic Ingestion,” Journal De Chirurgie (Paris), Vol. 146, No. 3, 2009, pp. 240-249.
[3]
J. W. Hong, H. S. Jeong, D. H. Lew, et al., “Hypopharyngeal Reconstruction Using Remnant Narrow Pharyngeal Wall as Omega-Shaped Radial Forearm Free Flap,” Journal of Craniofacial Surgery, Vol. 20, No. 5, 2009, pp. 1334-1340.
[4]
S. J. Tang, S. Singh and J. M. Truelson, “Endotherapy for Severe and Complete Pharyngo-Esophageal Post-Radiation Stenosis Using Wires, Balloons and Pharyngo-Esophageal Puncture (PEP) (with Videos),” Surgical Endoscopy, Vol. 24, No. 1, 2010, pp. 210-214.
[5]
B. Pogorzelski, R. Kiesslich and W. Mann, ”Rendezvous Technique for Complete Hypopharyngeal Stenosis. Indications and Variations of Combined Endoscopy,” HNO, Vol. 57, No. 8, 2009, pp. 781-788.
[6]
S. Athreya, P. Scott, G. Annamalai, et al., “Sharp Recanalization of Central Venous Occlusions: A Useful Technique for Haemodialysis Line Insertion,” British Journal of Radiology, Vol. 82, No. 974, 2009, pp. 105-108. doi:10.1259/bjr/19820366
[7]
S. Misra, G. B. Melton, J. F. Geschwind, et al., “Percutaneous Management of Bile Duct Strictures and Injuries Associated with Laparoscopic Cholecystectomy: A Decade of Experience,” Journal of the American College of Surgeons, Vol. 198, No. 2, 2004.
doi:10.1016/j.jamcollsurg.2003.09.020
[8]
J. T. Maple, B. T. Petersen, T. H. Barron, et al., “Endoscopic Management of Radiation-Induced Complete Upper Esophageal Obstruction with an Antegrade-Retrograde Rendezvous Technique,” Gastrointestinal Endoscopy, Vol. 64, No. 5, 2006, pp. 822-828.
doi:10.1016/j.gie.2006.06.026
[9]
M. S. Miah, I. A. Zealley, R. E. Mountain and S. Mahendran, “Severe Benign Hypopharynx/Upper-Oesophageal Strictures: Successful Treatment with a Novel Interventional Radiology Technique in Three Patients,” Clinical Otolaryngology, Vol. 37, No. 4, 2012, pp. 313-317.
[10]
L. E. Oxford and Y. Ducic, “Retrograde Balloon Dilation of Complete Cervical Esophageal and Hypopharyngeal Strictures,” The Journal of Ototaryngotography, Vol. 55, No. 5, 2006, pp. 327-331. doi:10.2310/7070.2005.0127
[11]
K. B. Zur, P. E. Putnam and M. J. Rutter, “Combined Retrograde and Anterograde Hypopharyngeal Puncture and Dilatation in a Child with Complete Hypopharyngeal Stenosis,” International Journal of Pediatric Otorhinolaryngology, Vol. 71, No. 1, 2007, pp. 153-157.
doi:10.1016/j.ijporl.2006.07.023
