IJOHNS  Vol.2 No.5 , September 2013
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
ABSTRACT
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 endoscopic approaches resulted in successful re-establishment of luminal continuity in three cases of complete fibrotic occlusion of the hypopharyngo-oesophageal lumen. However variable responses to treatment suggest that both the underlying aetiology and the chronicity of the occlusion may influence the likelihood of a successful functional outcome. Until definitive management guidelines are established, we suggest that such cases are managed only by motivated multidisciplinary teams keen to develop their expertise in this area.

Cite this paper
M. Miah, I. Zealley, A. Alijani, B. McGuire, R. Mountain and S. Mahendran, "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," International Journal of Otolaryngology and Head & Neck Surgery, Vol. 2 No. 5, 2013, pp. 179-185. doi: 10.4236/ijohns.2013.25038.
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

 
 
Top