Retrograde endoscopic balloon dilation of chemotherapy- and radiation-induced esophageal stenosis under direct visualization

Abstract 

Introduction

Esophageal stricture is a common complication following combined chemotherapy and radiation for advanced oropharyngeal cancer and severely compromises patients' quality of life. The severity of the stenosis after concomitant therapy, combined with the proximal location of these strictures, renders standard bougienage techniques difficult, and the risk of perforation significant. Retrograde endoscopic dilation has recently been described as a safe alternative to rigid endoscopic dilation or unguided bougienage. However, the near complete, or complete, stenosis seen in some of these patients may also be unamenable to retrograde endoscopic dilation.

Setting

Academic, tertiary care referral center.

Methods

Seven patients with advanced head and neck cancer treated with combined chemotherapy and radiation developed severe dysphagia requiring intervention for near total, or total, upper esophageal stenosis. An alternative technique for dilation is described. In this technique, a flexible endoscope is advanced in a retrograde fashion through the patient's gastrostomy site to the distal edge of the stenotic segment. Under direct visualization, a balloon is advanced up to the stenotic segment and is sequentially inflated to dilate the lumen. This procedure is performed under conscious sedation in an ambulatory setting.

Results

The first patient in the series developed a pneumothorax during attempted passage of the guidewire in a retrograde fashion. Six subsequent patients were successfully dilated using the retrograde progressive balloon dilation technique without any complications. All 6 patients had significant improvement in their oral intake, and 1 patient subsequently had the gastrostomy tube removed.

Conclusions

A retrograde endoscopic progressive balloon dilation for esophageal dilation under direct visualization provides palliation of swallowing difficulties in patients whose stenoses are not amenable to traditional techniques. The risks of perforation and other complications resulting from blind dilation of strictures may be decreased if an appropriate technique is used on an individualized basis.