The bidirectional ‘Rendezvous’
endoscopic technique in the
management of impassable
strictures following radical chemoradiotherapy for head and
neck/oesophageal SCC
Mr A Madhavan
Mr AW Phillips
Mr SM Dresner
Introduction
• Oesophageal strictures common complication
post chemo-radiotherapy for advance neck
and thoracic malignancies (1,2)
• Incidence 3.4% patients receiving
radiotherapy alone, 18-26% receiving chemoradiotherapy (2,3)
• Affect cervical oesophagus
– Dysphagia
– Risk of aspiration
Introduction
• Subsequent fibrosis, tissue fragility and
altered anatomy
– Difficulty identifying oesophageal lumen
• Management challenging
– Conventional endoscopy difficult
• Location – Cervical oesophagus
– “Blind” use of guide wire/balloon dilatation – false
lumen or frank perforation (4)
Method
• Retrospective review between 2011 – 2013
• Standard Anterograde-retrograde approach
• Total of 7 patients
– 6 patients with oropharyngeal carcinoma
– 1 patient with distal oesophageal carcinoma
• All patients had PEG prior to adjuvant treatment
• Pre-procedure investigations
– Barium Swallow +/- CT neck/thorax
• All patients complete obstruction at level of stricture
Pre-operative Imaging
Anterograde – Retrograde Approach
1. Under General anaesthetic
2. Rigid oesophagoscopy anterograde
via mouth – ENT team
3. Retrograde via Percutaneous
gastrostomy
• Dilation of the Gastrostomy
site with pneumatic dilatation
12mm
• Pass 9mm endoscope
4. Use of guidewire +/- biopsy forceps
to identify lumen
5. Savary Guillard dilatator passed
down till oesophageal lumen patent
6. NG is left in, PEG replaced
7. Diet introduced gradually
Anterograde
Oeosphageal
Stricture
Endoscope
Percutaneous
Gastrostomy
Retrograde
Endoscope
Results
Total of 7 patients
• Male : Female – 5:2
• Age – 59 (42 – 71)
• 6 patients with oropharyngeal carcinoma
• 2 patients had total laryngectomy
• Adjuvant Treatment
• 4 patients – chemoradiotherapy
• 2 patients – radiotherapy
• 1 patients with oesophageal carcinoma
• Length of stay – 6 (4-20)
Results
Intra-operative complication
• 1 patient – stomach detached from abdominal
wall at gastrostomy site following dilatation
• Required laparoscopy for repair
Post operative
• Follow up with ENT team
• All patients tolerating soft diet
Discussion
• Anterograde-retrograde rendevous technique
described Van Tisk et al in 1998 (5)
• Boyce et al (6)
– 25 year experience with endoscopic lumen restoration
(ELR), Median F/U – 22 months
– Standard approach, tri-plane fluroscopy, retrogarde
dilatation, swallowing rehab therapy
– 33 patients with head/neck cancers
– Successful cannulation + procedure 39/33 (91%)
– Return to soft diet 15/30 (50%), 10/30 (33%) unsafe
swallow due to neuromotor defecit
– Complications 5/30 (17%), anastomotic fistula 2/30 (6.7%)
Discussion
• Use of guidewire and bougie dilatation
• Long stenosis use of blunt instrument +/- CO2
laser (7)
• Retrograde approach use of rigid
bronchoscope (7)
• Use of ERCP catheter for cannulation of
stricture (8)
Conclusion
• Safe approach for patients with oesophageal
strictures post radio-chemotherapy
• Individual cases may need variation in
technique
• Good outcomes
– 6/7 patients able to soft diet
– Positive impact quality of life
• Swallowing rehabilitation post treatment
References
1.
2.
3.
4.
5.
6.
7.
8.
De Boer et al. Rehabilitation Outcomes of longterm survival treated for head and
neck cancers. Head Neck. 1995; 17 503-515
Laurell et al. Stricture of the proximal oesophagus in head and neck carcinoma
patients after radiotherapy. Cancer 2003; 97:1693-1700
Lawson et al. Frequency of oesophageal stenosis after simultaneous modulated
accelerated radiation therapy and chemotherapy for head and neck cancer.
American journal of Otolaryngology 2008:29; 13-19
Banergee et al. Intrathoracic oesophageal perforation following bougienage: a
protocol for management. Aust N Z Journal Surg. 1989;59: 563-6
Van Twisk et al. Retrograde approach to pharyngo-oesophageal obstruction.
Gastrointestinal Endoscopy 1998; 48:296-9
Boyce et al. Endoscopic lumen restoration for obstructive aphagia: outcomes of
a 25-year experience Gastrointest Endosc. 2012 Jul;76(1):25-31. doi:
10.1016/j.gie.2012.02.037.
Kos et al. Anterograde-Retrograde rendevous approach for radiation-induced
complete upper oesophageal sphincter stenosis: case report and literature
review. Journal of Laryngology and Otology 2011, 125, 761-764
Takeshi et al. Successful endoscopic dilatation of a severe stricture of the cervical
oesophagus after defintive combined chemotherapy plus radiotherapy for
oesophageal cancer. Oesophagus 2012 9;252-256