A 65-year-old patient was referred for endoscopic management of a complete radiation-induced
stricture, 5 cm in length, of the hypopharynx and esophagus ([Fig. 1], [Video 1]). He had a history of curative chemoradiation therapy for T2N1 squamous cell carcinoma
of the larynx. His nutrition was exclusively maintained through a percutaneous gastrostomy.
Recanalization of the esophagus was considered after a multidisciplinary discussion,
as previously described [1]
[2]
[3].
Fig. 1 Retrograde view of the atretic stricture.
Video 1 Video presentation of the endoscopic management of the stricture.
The percutaneous gastrostomy site was reinforced by providing endoscopic gastropexy
to the abdominal wall with four sutures using a double-needle device (Freka Pexact;
Fresenius Kabi Ltd, Runcorn, UK). The gastrostomy site was bougie-dilated to 14 mm
and a 9-mm endoscope was inserted. A mixture of hydroxyethyl starch and indigo carmine
was injected and the fibrotic tissue was dissected with a 1.5-mm Dual Knife (Olympus,
Tokyo, Japan) ([Fig. 2]). Step by step a new lumen was created up to the level of the hypopharynx. At this
level, a perorally introduced gastroscope was able to discern transillumination and
an endoscopic rendezvous was achieved ([Fig. 3]). At the end of the procedure, the proximal orifice was sufficiently dissected up
to 10 mm ([Fig. 4], [Fig. 5]). The patient was admitted for 48 hours for observation and discharged uneventfully.
No stent was placed due to the risk of intolerance and/or creation of a fistula [3].
Fig. 2 Retrograde view. Dissection of the stricture.
Fig. 3 Retrograde view. Transillumination.
Fig. 4 Antegrade view. Enlargement of the stricture to fit a standard endoscope.
Fig. 5 Inspection of the stricture 3 days later.
At 5 months of follow-up, the patient underwent serial endoscopic balloon dilations
up to 20 mm to keep the tunneled stricture patent. In conclusion, complete postradiation
strictures of the esophagus and hypopharynx could be managed by bidirectional dissection
of the fibrotic tissue. Although technically challenging, this procedure may spare
the need for more invasive and morbid surgery. The addition of gastropexy prior to
the main procedure and the bidirectional approach of recanalization are the two elements
that differentiate our approach from previously published case reports.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AD
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