Complete esophageal obstruction with associated aphagia is a severe complication of
of locoregionally advanced head and neck cancer. Endoscopic combined anterograde-retrograde
rendezvous procedure with repermeabilization and dilatation has been increasingly
adopted to manage it. However, in cases of a large gap between the proximal and distal
esophagus and absence of transillumination, this classical approach is not possible.
In this report, we describe a novel, relatively simple and safe method of endoscopic
anterograde-retrograde rendezvous esophageal repermeabilization using forward-viewing
endoscopic ultrasound (EUS). EUS allows clearly targeting of the lumen and puncture,
avoiding potential interposed vessels. Specifically, this type of echoendoscope, designed
with a short rigid portion and wide angulation capability that increases maneuverability
and controlled visualization and puncture in the direct axis of the scope, has an
additional advantage in cases such as ours, in which narrowing of both esophageal
ends could hamper performance of a puncture with a regular side-viewing echoendoscope.
Introduction
Treatments for locoregionally advanced head and neck cancer (HNC), including surgery
and/or (chemo-)radiotherapy, can negatively impact swallowing function and, consequently,
quality of life (QoL). Cervical esophageal strictures are relatively common sequelae
following HNC treatment, with an incidence varying between 5 % and 15 % [1 ]. Manifestations range from minor issues to complete esophageal obstruction (CEO).
Historically, these strictures were treated with technically demanding surgeries [2 ]. Endoscopic techniques have since emerged as less invasive alternatives but require
the passage of at least a guidewire to achieve dilation and/or stenting. In cases
involving CEO, a combined anterograde-retrograde rendezvous procedure with repermeabilization
and dilatation, to restore esophageal continuity, was first described in 1998 [3 ]. Thereafter, several cases of this technique have been published and, recently,
a systematic review and meta-analysis has confirmed its role in management of this
complication [4 ]. However, it requires the presence of a very short gap between the proximal and
distal esophagus and transillumination.
In this report, we describe a novel, relatively simple and safe approach to endoscopic
anterograde-retrograde rendezvous esophageal repermeabilization using endoscopic ultrasound
(EUS) with a forward-viewing echoendoscope in two patients with CEO. In these specific
situations, a side-viewing echoendoscope could not be used due to angulation at the
entry point and transillumination was not possible due to the distance between proximal
and distant ends of the stricture.
Technical innovation
Clinical information
Two male patients aged 79 and 69 (Patient 1 and Patient 2, respectively) were referred
for aphagia after chemoradiation to treat squamous cell carcinoma of the oropharynx
(T3N2cM0) and of the hypopharynx (T4bN2cM0), respectively. They were exclusively fed
by percutaneous gastrostomy.
In both, endoscopy revealed complete obstruction at the level of the superior portion
of the esophagus, making it impossible to dilate under endoscopic or radiologic control.
The possibility of endoscopic esophageal repermeabilization was discussed with the
patients and consent was given to attempt treatment. In addition, Ethics Committee
approval was obtained to report these two cases (Ref: P2021/580).
Technical description
An EUS-guided endoscopic repermeabilization procedure was undertaken under general
anesthesia by two endoscopists and achieved according to the following steps:
The gastrostomy tube was removed and a 0.035-inch guidewire (Jagwire) was introduced
through the stoma and the gastrostomy was dilated using an 8-mm balloon (Hurricane).
An ultraslim endoscope (Olympus GIFP190) was introduced through the gastrostomy up
to the distal portion of the esophageal stricture.
A forward-viewing echoendoscope (Olympus TGF-UC-180 J, with a 3.8-mm working channel)
was introduced orally up to the proximal portion of the esophageal stricture and both
scopes could be visualized by fluoroscopy ([Fig. 1a ]).
Water was injected through the ultraslim endoscope, to localize the distal esophageal
lumen with EUS. A puncture was performed with a 19G EUS access needle (Echotip Cook)
from the proximal to the distal esophageal lumen ([Fig. 1b ]).
A 0.035-inch guidewire (Jagwire) was inserted through the needle and grasped with
a snare through the working channel of the ultraslim endoscope ([Fig. 1c ]).
The neo-tract was dilated with a 6.5F cystotome (Endoflex) using pure cut current
(Patient 1) or with an 8-mm balloon (Hurricane (Patient 2) ([Fig. 1d ]) and a biliary fully-covered 10 × 60 mm self-expandable metal stent (SEMS) (WallFlex)
was placed to cover the newly created tract ([Fig. 1e ] and [Fig. 1f ]). A nasogastric 7F catheter was placed through the stent to maintain the tract in
case of stent migration.
Gastrostomy tubes were replaced immediately after the procedure.
Five to 7 days later, the stent was removed with a rat-tooth forceps and, after dilation
up to 15 mm (CRE balloon), a partially-covered 18 × 23 × 150 mm Ultraflex esophageal
SEMS, with proximal release, was placed and adjusted with its proximal end 1 cm below
the superior esophageal sphincter ([Fig. 2 ]).
Two to 4 weeks later, the stent was removed either directly (Patient 1) or using the
stent-in-stent technique (Patient 2) in case of significant hyperplasia (using a fully-covered
Wallflex SEMS of same diameter and length implanted for 1 week).
Fig. 1 First session of esophageal repermeabilization using an EUS-forward scope: the EUS
scope and an ultra slim endoscope are seen aligned by fluoroscopy (a ); the EUS access needle is inserted through the proximal portion of the esophagus
to perform the puncture (b ); a guidewire is passed into the distal portion and grasped with the slim scope (c ); a balloon dilatation is performed (d ); and a fully-covered biliary stent is placed (e and f ).
Fig. 2 Second session of esophageal repermeabilization: After removing the fully-covered
SEMS, a guidewire is fed through distally (a ); a balloon dilatation of the tract is performed (b ); an esophageal partially-covered SEMS is placed (c ); and the stent is dilated to ensure its full expansion (d ).
No procedure-related complications occurred.
Both patients were allowed to eat soft food from the time of Ultraflex SEMS placement
and underwent concurrent active swallowing rehabilitation.
Follow-up
Patient 1 had relapse of dysphagia 2 weeks after stent removal, ultimately causing
difficulty swallowing saliva after 2 months. Recurrence of complete occlusion was
confirmed and no wire passage was possible to the distal esophagus. The patient consented
to repeat the repermeabilization procedure. A new reconstruction of the tract under
EUS was done following the same steps. After 2 weeks of stenting at a diameter of
18 mm, the stent was removed but a nasogastric catheter was left in place to avoid
repeated complete occlusion. Successive dilations at 15 to 18 mm were performed over
the next 3 months. Unfortunately, the patient passed away due to SARS-CoV-2-infection
during follow-up.
Patient 2 had a first endoscopic reevaluation 2 weeks after stent removal. A residual
stricture was dilated up to 18 mm with a CRE balloon ([Fig. 3 ]) and 80 mg methylprednisolone was locally injected. Nine months after initial therapy,
the patient has been able to resume oral feeding, requiring a single dilation at 18 mm.
Fig. 3 Third session of esophageal repermeabilization: after removing the stent, a residual
stricture is dilated (a) and contrast is administrated at the end of the procedure
to assess the efficacy of the procedure and exclude complications (b).
One month later, the patient was reevaluated with endoscopy. At that time, the tract,
although stenotic, could be passed with the endoscope. A new dilatation was performed
with a CRE balloon up to 19 mm and 80 mg methylprednisolone was administered in a
local injection.
Three months later, although the patient was able to eat soft food and maintained
swallowing rehabilitation treatment to further improve deglutition, a final dilatation
up to 20 mm was performed. The next follow-up endoscopic evaluation was planned for
12 months later.
Discussion
CEO, as a complication of esophageal/laryngeal radiotherapy, considerably alters QoL
and is challenging to treat. Endoscopy is currently the preferred modality for treating
esophageal strictures, and as illustrated here, can also be offered for management
of CEO. The anterograde endoscopic technique with blind puncture, initially used,
was abandoned because it carried higher and unnecessary risks (perforation, bleeding
or another inadvertent injury to surrounding critical structures in the neck and chest)
[5 ]. Currently, a combined anterograde-retrograde approach is preferred.
If the stricture is short (< 2 cm) and transillumination can be achieved, a combined
anterograde-retrograde rendezvous with direct puncture under endoscopic and fluoroscopic
control can be performed. If the stricture is longer and/or transillumination is not
possible, endoscopic recanalization can be more difficult, as it gets more challenging
to approach and align two endoscopes in the same axis. Surgery (or a combined endoscopic-surgical
approach) could be offered, but it is technically demanding in the context of prior
surgery and/or local irradiation, in often fragile patients.
EUS can be beneficial for repermeabilization of the esophagus because after injection
in the distal lumen with the second scope, the endoscopist can clearly target the
lumen and puncture, avoiding potential interposed vessels. A forward-viewing US scope
was first evaluated for transmural drainage of pancreatic pseudocysts [6 ]. To our knowledge, EUS-guided repermeabilization has been described in two cases
so far: one in the esophagus, using a side-viewing echoendoscope [7 ], and another in the colon, using a prototype forward-viewing echoendoscope [8 ]. In our cases, we used a forward-viewing echoendoscope. This type of echoendoscope
was designed with a short rigid portion and wide angulation capability, increasing
maneuverability and controlled visualization and puncture in the direct axis of the
scope. Specifically in the above-described cases, use of the forward-viewing echoendoscope
was advantageous because both esophageal ends were aligned and were narrowed, which
can hamper performance of a puncture with a side-viewing echoendoscope, as shown in
[Fig. 4 ]. Antegrade and retrograde approaches remain necessary because the only way to clearly
identify the distal lumen with EUS is to fill it with water.
Fig. 4 The view and puncture angles of a forward-viewing echoendoscope (a ) and a side-viewing echoendoscope (b ) in a simulation model of an esophageal complete obstruction with aligned proximal
and distal ends.
Another, more complex option is per-oral endoscopic tunneling for restoration of the
esophagus (POETRE), a recently reported technique using endoscopic submucosal tunneling
with combined anterograde-retrograde endoscopic dilatation [9 ]
[10 ]. A neoesophagus is developed through submucosal tunneling into the obstruction formerly
concluded to be too long for a regular rendezvous procedure. Another option could
also be the use of magnets to create the path. Magnetic compression anastomosis (magnamosis)
has successfully created esophagoesophageal anastomosis in cases of long-gap esophageal
atresia [11 ].
The advantages and disadvantages of each endoscopic techniques for esophageal repermeabilization
are summarized in [Table 1 ].
Table 1
Advantages and disadvantages of endoscopic techniques for esophageal repermeabilization.
Endoscopic techniques for esophageal repermeabilization
Advantages
Disadvantages
Standard endoscopic combined anterograde-retrograde
Technically easy
Only for short strictures, when transillumination can be achieved
Side-viewing echoendoscope
Long gaps
Narrow esophageal ends
Forward-viewing echoendoscope
Long gaps
Low availability
Magnets
Technically easy
Low availability
POETRE
Technically demanding
POETRE, per-oral endoscopic tunneling for restoration of the esophagus.
The major concern regarding endoscopic recanalization is the risk of recurrence. Patients
require regular follow-up with repeated endoscopies and dilatations, as needed, to
maintain the esophageal lumen. Residual stenosis is frequent and is not easily treated,
especially in proximal obstructions. Patient 1 had early recurrence, which surprisingly
led to a new CEO in less than 2 months. There are no standardized protocols for determining
the best follow-up timing after the rendezvous procedure and the first endoscopy in
the follow-up period was only performed once the patient manifested severe complaints,
at 2 months. In Patient 2, we considered this risk and organized the surveillance
more closely, with a good clinical result.
Another concern is the low availability of forward-viewing echoendoscopes today, which
may limit the use of this novel technique in clinical practice. Being able to swallow
following HNC treatment is one of the main functional priorities in patients and a
driver for health-related QoL [1 ].
Conclusions
We have described a novel, relatively simple, feasible and apparently safe method
for managing CEO using a forward-viewing endoscope, which should be considered when
attempting endoscopic esophageal recanalization. Efficacy has to be confirmed in larger
studies.
