How effective are the anterograde-retrograde rendezvous procedure and serial dilations in reestablishing esophageal patency for patients with complete esophageal stricture following nonsurgical cancer treatment?
Background: It is estimated that more than 40% of head and neck cancer patients who receive radiation develop clinically significant treatment-attributable dysphagia, and between 3.3% and 23% of those develop esophageal strictures. There is considerable variability in reported risk factors, and their relative contribution to stricture formation is not fully understood. Quality-of-life consequences are significant, particularly for patients with high-grade strictures who are routinely gastrostomy tube-dependent and require repeated dilations to reestablish a patent alimentary tract.
Study design: Retrospective review of 24 patients treated with radiation therapy with or without concurrent chemotherapy between 2006 and 2012 who presented with complete or near-complete esophageal stricture.
Setting: Digestive disease center.
Synopsis: The larynx was the most common primary site, followed by oropharynx and oral cavity; where staging information was available, most were treated for advanced cancer. In all, 91.7% of patients had gastrostomy tubes at presentation for dilation. Patients presented for first dilation a median of eight months after gastrostomy tube placement. The initial endoscopic approach to stricture was anterograde, followed by combined approach. Strictures were universally present at or within 2 cm of the upper esophageal sphincter and were complete (no identifiable lumen) in 50% of patients. All patients were successfully dilated at initial endoscopy. Overall, this population required a median of nine dilations over a median follow-up of 21.0 months. Of 276 dilations performed, there was a 1.8% complication rate. After dilations, 42% of patients were able to return to a full oral diet without limitations, regardless of whether the stricture was complete. Sixteen of 17 patients who participated in semi-structured interviews reported improved swallow due to dilations, and 68% were “moderately” to “very satisfied” with their swallowing result. Limitations included clinical data that were not accessible or retrievable and a relatively small cohort.
Bottom line: Recannulation is possible even in cases of complete or near-complete stricture; patients with a history of smoking had a significantly lower likelihood of return to full oral diet.
Citation: Francis DO, Hall E, Dang JH, Vlacich GR, Netterville JL, Vaezi MF. Outcomes of serial dilation for high-grade radiation-related esophageal strictures in head and neck cancer patients. Laryngoscope. 2015;125:856-862.
—Reviewed by Amy Hamaker