Supplement Abstracts Submitted for the 70th Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
Purpose: Complete pharyngoesophageal disconnect is a rare complication of radiation therapy for head and neck malignancies. Surgery has been the mainstay of treatment for this condition. Lew et al (Head and Neck, Feb 2004) described a combined endoscopic/laryngoscopic approach to establishing luminal patency using a stiff guidewire. However, repeated dilation may be required to achieve maximum diameter, and the restenosis rate for radiation-induced strictures has been high. Mitomycin-C has been used with success in the prevention of recurrent laryngeal and tracheal stenosis and is thought to have an antiproliferative effect. We describe a novel one-step method of reconnection, dilation, and treatment for pharyngoesophageal disconnect.
Methods: Retrograde endoscopy through an existing gastrostomy tube tract is performed to the level of the disconnected proximal esophagus. Direct laryngoscopy is performed at the same time to visualize the light source below. An EUS needle (Echotip, Wilson Cook Corp) is advanced by the laryngoscopist with endoscopic guidance. A.035 mm ERCP guidewire (Jagwire, Microvasive corp) is passed through the EUS needle into the esophagus and grasped with a forcep. The wire is pulled back thru the gastrostomy and fixed in place. Savary style dilators are then passed per os, serially from the smallest to a minimum of 51 Fr. Before removing the guidewire, mitomycin-C pledgets are applied via laryngoscopy.
Results: Six patients with pharyngoesophageal disconnect after radiation therapy for head and neck malignancies underwent the combined procedure. Luminal patency was achieved in all patients, and all were able to progress to teaching for self dilation. One patient suffered a minimal localized esophageal perforation for which conservative management was used. Luminal patency was maintained in all patients with follow-up to 12 months after the initial procedure.
Conclusions: This combined one-step approach offers a less invasive and technically superior option to surgery. Dilation in one setting to 51 Fr can be performed with minimal complications. The EUS needle allows for a controlled puncture and passage of a guidewire. Despite their prior disconnect, these patients can be taught to perform self-dilation to prevent or delay recurrence without forming false tracts. Mitomycin-C topical treatments may provide an antiproliferative effect for radiation-induced strictures, however further long term studies are warranted.