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Mr A Madhavan Mr AW Phillips Mr SM Dresner

The bidirectional ‘Rendezvous’ endoscopic technique in the management of impassable strictures following radical chemo-radiotherapy for head and neck/oesophageal SCC. Mr A Madhavan Mr AW Phillips Mr SM Dresner. Introduction.

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Mr A Madhavan Mr AW Phillips Mr SM Dresner

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  1. The bidirectional ‘Rendezvous’ endoscopic technique in the management of impassable strictures following radical chemo-radiotherapy for head and neck/oesophageal SCC Mr A Madhavan Mr AW Phillips Mr SM Dresner

  2. 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 chemo-radiotherapy (2,3) • Affect cervical oesophagus • Dysphagia • Risk of aspiration

  3. 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)

  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

  5. Pre-operative Imaging

  6. Anterograde – Retrograde Approach • Under General anaesthetic • Rigid oesophagoscopy anterograde via mouth – ENT team • Retrograde via Percutaneous gastrostomy • Dilation of the Gastrostomy site with pneumatic dilatation 12mm • Pass 9mm endoscope • Use of guidewire +/- biopsy forceps to identify lumen • Savary Guillard dilatator passed down till oesophageal lumen patent • NG is left in, PEG replaced • Diet introduced gradually Anterograde Endoscope Oeosphageal Stricture Percutaneous Gastrostomy Retrograde Endoscope

  7. 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)

  8. 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

  9. 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 neuromotordefecit • Complications 5/30 (17%), anastomotic fistula 2/30 (6.7%)

  10. 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)

  11. 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

  12. References • 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. Intrathoracicoesophageal 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 GastrointestEndosc. 2012 Jul;76(1):25-31. doi: 10.1016/j.gie.2012.02.037. • Kos et al. Anterograde-Retrograderendevousapproach for radiation-inducedcompleteupperoesophageal sphincter stenosis: case report and literaturereview. Journal of Laryngology and Otology 2011, 125, 761-764 • Takeshi et al. Successfulendoscopic dilatation of a severestricture of the cervical oesophagusafterdefintivecombinedchemotherapy plus radiotherapy for oesophageal cancer. Oesophagus 2012 9;252-256

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