Outcomes of serial dilation for high‐grade radiation‐related esophageal strictures in head and neck cancer patients

Abstract

Objective Dysphagia and esophageal stricture are frequent consequences of treatment for head and neck cancer. This study examines the effectiveness of the anterograde-retrograde rendezvous procedure and serial dilations in re-establishing esophageal patency to allow return to oral diet and gastrostomy tube removal in a cohort of patients with complete or near-complete esophageal stricture following non-surgical cancer treatment. Study Design Retrospective review of patients treated with radiation therapy with or without concurrent chemotherapy presented with complete or near-complete esophageal stricture. Patients underwent serial dilations using combined anterograde-retrograde dilation (rendezvous) techniques. Methods Medical records of patients having undergone treatment between 2006 and 2012 were reviewed and semi-structured interviews were also conducted to determine current swallowing function and actual patient experience. The primary outcome was swallowing improvement that allowed for return to oral diet and/or gastrostomy tube removal. Outcomes were compared between patients with complete and near complete (<5 mm diameter) strictures and univariate analysis performed to identify associations between patient, cancer, and treatment characteristics on odds of gastrostomy tube removal. Results Twenty-four patients (Median age, 59.5 yrs; 63% male; 91% Caucasian) underwent treatment. 50% of patients had complete occlusion of the esophageal lumen. The majority (92%) patients underwent either anterograde (54%) or combined antero-retrograde (38%) approach. Following a median (IQR) 9 (6-20) dilation sessions, 42% of patients were able to return to an oral diet and/or had their gastrostomy tube removed. This outcome was independent of whether the stricture was complete or near complete (p=0.67). Of patients who had their gastrostomy tubes removed, only 33.3% had ever smoked, compared to 92.3% of those whose tubes were not discharged (p=0.007). Conclusions Recannulation is possible even in cases of complete or near-complete stricture. Several factors appear to impact the likelihood of successful outcome, but in this study, only patients with a history of smoking had a significantly lower likelihood of return to full oral diet.

The Swallow Physiology Change of Balloon Dilatation on Pharyngeal Dysphagia

“…BD is a common procedure used to treat CPD and pharyngo-upper esophageal strictures in dysphagia patients [2,6,10,14,15]. There have not been any studies investigated the effectiveness of BD in dysphagia management from the perspective of swallow physiology changes.…”

“…These conditions can be seen in strokes of various locations, including subcortical and supratentorial, lateral medullary and cerebellum [4][5][6]. PSR was also found in head and neck cancer patients [7], most commonly caused by reduced tongue mass and limited tongue mobility that was associated with total or partial glossectomy with or without reconstruction [8,9], and radiation-induced esophageal strictures as well [10]. Radiation therapy post nasopharyngeal carcinoma is associated with impaired pharyngeal contraction, which can lead to PSR [11].…”

“…Several methods have been used to treat Cricopharyngeal Muscle Achalasia (CMA), such as rigid dilators [12] or Botox injection planning [13], but as one of more convenient, less invasive methods, Balloon Dilatation (BD) has been used in more studies to treat cricopharyngeal dysfunction and pharyngo-upper esophageal strictures [2,6,10,[14][15][16]. It has been shown to improve UES relaxation and pharyngeal contraction amplitudes [6,14,15].…”

“…It has been shown to improve UES relaxation and pharyngeal contraction amplitudes [6,14,15]. Recannulation through serial dilation is possible even in cases of complete or near-complete cricopharyngeus stricture in head and neck cancer patients after radiation therapy [10,15]. Therefore, it is hypothesized that BD will be effective in reducing PSR.…”

Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

“…Most authors defined clinical success as resolution of dysphagia (or tolerance of soft diet) measured by different scores [2, 12, 14-16, 18, 19], often requiring a variable dilation-free period [11,13,18,20,21] and considering percutaneous endoscopic gastrostomy (PEG) status [20,22,23]. Francis et al [22] also reported patient satisfaction with the dilation program.…”