Emerging techniques and efficacy of endoscopic esophageal reconstruction and lumen restoration for complete esophageal obstruction

Background and study aims: Complete esophageal obstruction (CEO) is a rare occurrence characterized by progressive esophageal stricture, which eventually causes lumen obliteration. With recent advances in flexible endoscopy, various innovative techniques exist for restoring luminal continuity.

The primary aim of this study was to assess the efficacy and safety of patients undergoing combined antegrade-retrograde endoscopic dilation for CEO at our institution. The secondary aim was to review and highlight emerging techniques, outcomes, and adverse events after endoscopic treatment of CEO.

Patients and methods: Our electronic endoscopy database was retrospectively reviewed to identify patients who underwent combined antegrade and retrograde endoscopy for CEO. Patient and procedural data collected included gender, age, technical success, pre- and post-dysphagia scores, and adverse events.

Results: Six patients (67 % male, mean age 71.6 years [range 63 – 80]) underwent technically successful esophageal reconstruction with combined antegrade-retrograde endoscopy. All patients noted improvement in dysphagia with mean pre-procedure dysphagia score of 4 reduced to 1.33 (range 0 – 3) post-procedure. There were no adverse events and mean follow-up time was 17.3 months (range 3 – 48).

Conclusions: Combined antegrade and retrograde endoscopic therapy for CEO is feasible and safe. We present our experience with endoscopic management of complete esophageal obstruction, and highlight emerging techniques, outcomes and adverse events related to this minimally invasive modality.

• Reference

• 1 Lawson JD, Otto K, Grist W et al. Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer. Am J Otolaryngol 2008; 29: 13-19
• 2 Hernandez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51: 460-462
• 3 Zhou JH, Jiang YG, Wang RW et al. Management of corrosive esophageal burns in 149 cases. J Thorac Cardiovasc Surg 2005; 130: 449-455
• 4 Tucker GF. Cicatricial stenosis of the esophagus with particular reference to treatment by continuous string retrograde bougienage with the author's bougie. Ann Otol Rhinol Laryngol 1924; 3: 1180-1213
• 5 van Twisk JJ, Brummer RJ, Manni JJ. Retrograde approach to pharyngo-esophageal obstruction. Gastrointest Endosc 1998; 48: 296-299
• 6 De Barbosa JC, Da Rocha RM, Da Cunha FC. Impenetrable cicatricial obliteration of the thoracic esophagus; treatment by combined thoracotomy and endoscopy, with report of two cases. J Am Med Assoc 1953; 152: 1103-1105
• 7 Bueno R, Swanson SJ, Jaklitsch MT et al. Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction. Gastrointest Endosc 2001; 54: 368-372
• 8 Wagh MS, Yang D, Chavalitdhamrong D et al. Per-oral endoscopic tunneling for restoration of the esophagus (POETRE). Gastrointest Endosc 2014; 80: 330
• 9 Vakil N, Morris AI, Marcon N et al. A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am J Gastroenterol 2001; 96: 1791-1796
• 10 Cotton PB, Eisen GM, Aabakken L et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 11 Lew RJ, Shah JN, Chalian A et al. Technique of endoscopic retrograde puncture and dilatation of total esophageal stenosis in patients with radiation-induced strictures. Head Neck 2004; 26: 179-183
• 12 Maple JT, Petersen BT, Baron TH et al. Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique. Gastrointest Endosc 2006; 64: 822-828
• 13 Moyer MT, Stack Jr BC, Mathew A. Successful recovery of esophageal patency in 2 patients with complete obstruction by using combined antegrade retrograde dilation procedure, needle knife, and EUS needle. Gastrointest Endosc 2006; 64: 789-792
• 14 Garcia A, Flores RM, Schattner M et al. Endoscopic retrograde dilation of completely occlusive esophageal strictures. Ann Thorac Surg 2006; 82: 1240-1243
• 15 Steele NP, Tokayer A, Smith RV. Retrograde endoscopic balloon dilation of chemotherapy- and radiation-induced esophageal stenosis under direct visualization. Am J Otolaryngol 2007; 28: 98-102
• 16 Dellon ES, Cullen NR, Madanick RD et al. Outcomes of a combined antegrade and retrograde approach for dilatation of radiation-induced esophageal strictures (with video). Gastrointest Endosc 2010; 71: 1122-1129
• 17 Goguen LA, Norris CM, Jaklitsch MT et al. Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis. Laryngoscope 2010; 120: 261-266
• 18 Schembre D, Dever JB, Glenn M et al. Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus. Endoscopy 2011; 43: 434-437
• 19 Fowlkes J, Zald PB, Andersen P. Management of complete esophageal stricture after treatment of head and neck cancer using combined anterograde retrograde esophageal dilation. Head Neck 2012; 34: 821-825
• 20 Boyce HW, Estores DS, Gaziano J et al. Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience. Gastrointest Endosc 2012; 76: 25-31
• 21 Gavriel H, Duong C, Spillane J et al. Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy. Head Neck 2013; 35: 733-737
• 22 Grooteman KV, Wong Kee Song LM, Vleggaar FP et al. Functional outcome of patients treated for radiation-induced complete esophageal obstruction after successful endoscopic recanalization (with video). Gastrointest Endosc 2014; 80: 175-181
• 23 Zald PB, Andersen PE. Fatal central venous air embolism: a rare complication of esophageal dilation by rendezvous. Head Neck 2011; 33: 441-444
• 24 Eisdorfer RM, DiLorenzo JC, Miskovitz P. A complication of PEG change. Gastrointest Endosc 1991; 37: 108
• 25 Gornals JB, Consiglieri C, Castellvi JM et al. Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen. Endoscopy 2014; 46 (Suppl. 01) UCTN E2-3
• 26 Kachaamy T, Lott D, Crujido LR et al. Esophageal luminal restoration for a patient with a long lye-induced stricture via tunnel endoscopic therapy during a rendezvous procedure followed by self-dilation (with video). Gastrointest Endosc 2014; 80: 192-194
• 27 Babich JP, Diehl DL, Entrup MH. Retrograde submucosal tunneling technique for management of complete esophageal obstruction. Surg Laparosc Endosc Percutan Tech 2012; 22: e232-235
• 28 Coia LR, Myerson RJ, Tepper JE. Late effects of radiation therapy on the gastrointestinal tract. Int J Radiat Oncol Biol Phys 1995; 31: 1213-1236