A Simple Combined Antegrade Radiological and Retrograde Endoscopic Procedure to Recanalise Fibrotic Hypopharyngo-Oesophageal Occlusions: Technical Description and Lessons from Clinical Outcome in Three Cases

doi:10.4236/ijohns.2013.25038

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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 179-185

http://dx.doi.org/10.4236/ijohns.2013.25038 Published Online September 2013 (http://www.scirp.org/journal/ijohns)

A Simple Combined Antegrade Radiological and

Retrograde Endoscopic Procedure to Recanalise

Fibrotic Hypopharyngo-Oesophageal Occlusions:

Technical Description and Lessons from

Clinical Outcome in Three Cases*

Mohammed S. Miah1, Ian A. Zealley2, Afshin Alijani3, Barry McGuire4,

Rodney E. Mountain1, Suresh Mahendran 1#

1Department of Otorhinolaryngology-Head & Neck Surgery, Ninewells Hospital and

University of Dundee Medical School, Dundee, UK

2Department of Radiology, Ninewells Hospital and University of Dundee Medical School, Dundee, UK

3Department of Upper Gastrointestinal Surgery, Ninewells Hospital and University of

Dundee Medical School, Dundee, UK

4Department of Anaesthesia, Ninewells Hospital and University of Dundee Medical School, Dundee, UK

Email: #[email protected]

Received June 2, 2013; revised June 29, 2013; accepted July 9, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Complete hypophar yngo- o esoph ag eal o cclusion is a r ar e co mplication of h ead and n eck r ad ioth er apy an d

a range of other conditions. Absolute dysphagia is acco mpanied by aspiration and depend ence on gastrostomy feeding.

The condition presents a substantial management challenge. Surgical approaches to re-establish pharyngo-oesophageal

continuity are varied, highly invasive and are associated with unpredictable outcomes. Minimally invasive techniques

employing endoscopic and radiological techniques are emerging. This report describes a multidisciplinary approach

which translates two interventional radiology techniques used in the management of central venous occlusions and bil-

iary strictures to the management of three cases of complete hypopharyngo-oesophageal occlusion. Methods: Three

cases with different underlying aetiologies had treatment initiated between 2009 and 2011. Antegrade pharyngoscopic

access to the occlusions was accompanied by retrograde endoscopic access via a small gastrostomy. Luminal continuity

was re-established by the interventional radiology technique of “sharp recanalisation” followed by passage of a wide

bore nasogastric tube which was maintained in situ for 4 - 6 months, a duration of treatment analogous to that applied in

the radiological management of fibrotic biliary strictures. After treatment a radiological contrast swallows examination

was performed to gauge the calibre of the re-established lumen, assess functionality and to ru le out aspiration. Results:

Pharyngo-oesophageal continuity was re-established in all three cases on the first attempt. No complications occurred as

a result of the proced ures. In two cases, the excellent swallowing fun ction was re-established, although on e of these re-

quired prolonged post-treatment adjuvant interventions. In one case no swallowing function resulted, despite apparently

successful re-establishment of luminal continuity. Conclusions: Complete fibrotic o cclusion of the hypopharyngo-oeso-

phageal lumen is rare and presents a substantial management challenge. A minimally invasive treatment combining

antegrade radiological and retrograde endoscopic approaches resulted in successful re-establishment of luminal continu-

ity in three cases of complete fibrotic occlusion of the hypopharyngo-oesophageal lumen. However variable responses

to treatment suggest that both the underlyin g aetiology and the chronicity o f the occlusion may influence the likelihood

of a successful functional outcome. Until definitiv e management guidelines are estab lished, we suggest that such cases

are managed only by motivated multidisciplinary teams keen to develop their exp ertise in th is area.

Keywords: Hypopharynx; Upper Oesophagus; Fibrotic Occlusion; Rendezvous Technique; Pharyngo-Oesophageal

Continuity

*Meetings: The work was presented at the Tri-Society of Head & Neck Oncology Meeting on 2nd Septem ber 20 11 in Sin gapore.

#Corresponding a utho

M. S. MIAH ET AL.

180

1. Introduction

Complete fibrotic occlusion of the hypopharyngo-oeso-

phageal lumen is an uncommon but important complica-

tion of successful chemoradiotherapy treatment for head

and neck cancers [1]. Fibrotic occlusion may also occur

after head and neck surgery, corrosive ingestion, chronic

gastro-oesophageal reflux disease, neuromuscular disor-

ders or sepsis [2 ,3]. Affected patients are severely debili-

tated. Their absolute dysphagia necessitates dependence

on gastrostomy feeding but they remain at risk from sa-

liva aspiration.

A variety of techniques to re-establish the pharyngo-

oesophageal lumen have been described, including major

surgical procedures involving excision of the occluded

segment followed by reconstruction: this approach is as-

sociated with substantial surgical risk and outcomes are

unpredictable [2-5]. The surgical approach may require

multiple procedures followed by repeated dilatation pro-

cedures to maintain the established lumen.

We describe the successful translation of two interven-

tional radiology tech niques which h ave been successfu lly

applied successfully to re-establish anatomic pharyngo-

oesophageal continuity in patients without recourse to

major surgery. We present our experience managing

three patients with differing aetiologies and report out-

comes.

2. Materials and Methods

Between March 2009 and August 2011 three patients

with complete fibrotic occlusion s of the hypo pharynx /up-

per-oesophagus were referred to the otolaryngology de-

partment. All patients had complete dysphagia and were

dependent on gastrostomy tub e feeding.

2.1. Case 1

A 62-year-old male smoker developed absolute dys-

phagia soon after treatment of a T3N0M0 laryngeal car-

cinoma by chemoradiotherapy. Mucositis led to intoler-

ance of oral feeding and he became totally dependant on

his gastrostomy feeding tube. Once the mucositis had re-

solved it became apparent that he had developed absolute

dysphagia. Total occlusion of the hypopharynx/upper-

oesophageal segment was observed at rigid pharyngo-

scopy and at barium swallow (Figure 1(A)).

2.2. Case 2

A 76-year-old female presented with a 10-year histor y of

progressive dysphagia to solids and semi-solids associ-

ated with weight loss and recurrent ch est infections. This

was accompanied by episodes of absolute dysphagia. A

previous barium swallow had demonstrated delay in ini-

tiating swallowing with marked prominence of crico-

pharyngeus with proximal hold up in the hypopharynx.

There was a prior history of chronic gastroesophageal re-

flux disease and Sjogren’s syndrome. Previous flexible

oesophagoscopy had identified a tight cricopharyngeal

sphincter which led to rigid oesophagoscopy and dilata-

tion, this procedure being repeated a further five times,

followed by two external approach cricopharyngeal myo-

tomy procedures and three botulinum toxin injections.

These various procedures led to transient symptomatic

improvement but eventually the absolute dysphagia could

not be resolved and she became dependent on gastros-

tomy feeding. At this stage rigid pharyngoscopy and ba-

rium swallow demonstrated total fibrotic occlusion of the

pharyngo-oesop hageal lumen (Figure 1(B)).

2.3. Case 3

A 46-year-old male non-smoker presented with absolute

dysphagia two years after treatment of a T3N2M0 lateral

pharyngeal wall carcinoma with ablative and reconstruc-

tive surgery (split-lip mandibu lotomy, excision of tumour,

radial forearm free flap reconstruction and neck dissec-

tion). Post-operatively he had struggled with oral intake

and this deteriorated further during chemoradiotherapy:

as he developed significant mucositis he became totally

dependant on his gastrostomy feeding tube. Rigid pha-

ryngoscopy and barium swallow demonstrated total fi-

brotic occlusion of the pharyngo-oesophageal lumen (Fig-

ure 1(C)).

2.4. Technical Note

The principal aim of the re-canalisation procedure we de-

scribe is to re-establish anatomic pharyngo-oesophageal

continuity without recourse to major surgery. The tech-

nique we have employed to re-establish and maintain th e

pharyngo-oesophageal lumen involves adaptation of two

interventional radiology techniques; the first developed

to re-establish luminal co ntinuity in occluded great veins

in the mediastinum (the so-called “sharp recanalisation”

procedure) and the second developed to manage chal-

lenging bile duct strictures non-op eratively (Figure 2) [6 ,

7].

The procedure is performed under general anaesthetic.

The initial step is to establish that the occlusion is short.

If an occlusion had been greater than 3 - 4 cm in length

we would not have proceeded to the “sharp recanalisa-

tion” technique as the risk of injury to non-target struc-

tures in the neck would have been considered too high. A

rigid pharyngoscope is clamped into position such that

that the upper limit of the occlusion is both visualised

and accessible. Through an upper midline mini-laparo-

tomy (3 cm in length) the gastric body is delivered and a

12 mm conventional laparoscopic port is inserted into the

stomach and secured with a purse string suture. The

M. S. MIAH ET AL. 181

A B

Figure 1. Pre-treatment radiological contrast swallow im-

ages for Cases 1-3, labeled A-C respectively. In each case

complete occlusion of the hy popharyngo-oe sophageal lumen

is evident: no contrast passes into the cervical oesophagus.

Figure 2. Images A-D demonstrate the key elements of the

recanalisation procedure. A: Rigid pharyngoscopic view of

the upper limit of the occlusion; B: Retrograde flexible oe-

sophagoscopy via mini-laparotomy and gastrostomy; C:

Flexible oesophagoscopic view of the lower limit of the oc-

clusion; D: Endoscopic view of puncture through the oc clu-

sion using the radiological needle.

laparoscopic port thus creates a convenient air-tight ret-

rograde access into the stomach for the insertion of the

flexible oesophagoscope. The port also facilitates gastric

insufflation with carbon dioxide, in addition to the endo-

scopic gas insufflation, for better visualization and nego-

tiation of the gastro-oesophageal junction. The flexible

oesophagoscope is advanced up the oesophagus until the

lower aspect of the occlusion is encountered. Once the

antegrade pharyngoscope and the retrograde flexible oe-

sophagoscope are in place an image intensifier is posi-

tioned for lateral fluoroscopy of the cervical region.

Fluoroscopy is employed to gauge the length of the oc-

cluded segment. An interventional radiologist then uses a

long needle and co-axial catheter assembly (Rosch-Uchi-

da Transjugular Liver Access Set, Cook Medical, Amer-

sham, UK) to puncture across the occlusion from the

upper end, using a combination of direct visualization

and fluoroscopy for needle guid ance. Entry into th e distal

oesophageal lumen is confirmed by watching the flex ible

oesophagoscope images from below the occlusion. After

the co-axial needle and catheter assembly has been ad-

vanced into the oesophageal lumen below the occlusion

the needle component is withdrawn and a 260 cm stiff

radiological guidewire (Amplatz, Boston Scientific, Na-

tick, MA, USA) passed down the catheter into the distal

oesophageal lumen where it is grasped via the flexible

oesophagoscope, thus achieving “rendezvous” between

the patent lumen above and below the occlusion. The

guidewire is then withdrawn down through the distal oe-

sophagus and out through the mini-laparotomy, thereby

creating through-and-through guidewire access across the

occlusion.

Gentle dilatation of the occlusion is performed using

an 8 mm balloon catheter in order to create a channel

wide enough to accommodate passage of an 18 Fg Ryle’s

tube. In order to convert the per-oral guidewire access

across the occlusion into per-nasal access a radiological

catheter is inserted through the nose and its tip pulled out

of the mouth. The upper end of the guidewire is then fed

retrogradely into the tip of the per-nasal catheter and,

once a sufficient length of guidewire has been thus de-

ployed, the per-nasal catheter containing the upper end of

the guidewire is withdrawn back through the mouth and

nose until the guidewire is exiting per nares.

At this stage a modified 18 Fg Ryle’s tube is passed

over the guidewire and through the occlusion, under fluo-

roscopic guidance. The Ryle’s tube is modified by cut-

ting a cruciate incision in its tip in order that it may be

advanced over the guidewire with the smallest possible

profile: this manoeuvre avoids the larger, eccentric pro-

file which would result if the Ryle’s tube were advanced

over the guidewire via the side-hole at the tip of the tube.

Finally the Ryle’s tube is secured using a nasal septal

bridle and the gastrostomy and mini-laparotomy are

closed.

Postoperatively, the patients receive a seven day co urs e

M. S. MIAH ET AL.

182

of proton pump inhibitor to minimize the risk of bleed

from the gastrostomy site. A post-operative chest radio-

graph was performed to rule out a pneumomediastinum,

and the patients were observed closely in order to iden-

tify mediastinitis early should it develop. In all three

cases the Ryle’s tubes were left in-situ for a minimum of

4 - 6 months. This duration of dwell time was based on

long-term patency reported in analogous studies on the

percutaneous catheter management of fibrotic bile duct

strictures [7].

The patients were encouraged to swallow fluids as and

when they feel able, and were followed-up as outpatients

initially at two weeks and thereafter at two monthly in-

tervals to gauge tolerance of the treatment regime and

assess progress on swallowing. After 4 - 6 months rigid

pharyngoscopy under general anaesthetic was performed

to inspect and record the condition of the re-established

lumen, and the Ryle’s tubes were removed. Subsequently

a radiological water-soluble contrast swallow examina-

tion was performed to assess the patency and function of

the previously occluded segment.

3. Results

Re-establishment of pharyngo-oesophageal luminal pa-

tency was achieved using this technique was successful

on the first attempt in all three cases. A functional swal-

low was re-established in two of the three cases. No com-

plications were observed.

3.1. Case 1

During the recanalisation procedure the occluded seg-

ment was found to be 1.5 cm long. The patient reported

some discomfort from the presence of the Ryle’s tube but

tolerated its presence for the recommended duration.

During the later weeks of the treatment period the patient

reported symptoms consistent with bile reflux. At rigid

pharyngoscopy at the end of treatment a patent lumen

substantially wider than the Ryle’s tube itself was evi-

dent around the tube: there was also evidence of bile re-

flux (Figure 3). The patient tolerated oral fluids and soft

diet soon after removal of the Ryle’s tube. The subse-

quent radiological water-soluble contrast swallow study

demonstrated re-establishment of the hypopharynx/up-

per-oesophagus lumen with no hold up of contrast (Fig-

ure 4(A)). The previously occluded segment was found

to be distensible and no aspiration was observed. The

gastrostomy tube was removed two weeks after removal

of the Ryle’s tube. At 42 month follow-up the patient

was managing an oral diet, including most solids and all

fluids, and had gained 13 kilograms in weight. His emo-

tional affect, previously withdrawn and depressed, was

enormously improved. No further intervention has been

required.

3.2. Case 2

During the recanalisation procedure the occluded seg-

ment was found to be 2 cm long. The patient tolerated

the presence of the Ryle’s tube very well. However, de-

spite the fact that hypopharyngeal-oesophageal luminal

continuity was achieved using the technique described

the patient was unable to swallow fluids during the whole

of the treatment period, and also after removal of the

Ryle’s tube at 6 months. A radiological water-soluble

contrast study demonstrated a rat’s tail appearance of the

cervical oesophagus at the level of the previously re-

canalised occlusion, accompanied by dilatation of the oe-

sophagus above this level and hold up of contrast (Fig-

ure 4(B)). No active peristalsis was observed. To date,

this patient has not been able to produce a functional

swallow.

3.3. Case 3

During the recanalisation procedure the occluded seg-

ment was found to be 2 cm long. At rigid pharyngo scopy

the fibrotic occlusion appeared to be substantially more

dystrophic and distorted than the other two cases. This

patient did not tolerate the presence of the Ryle’s tube

well. An early re-inspection of the occlusion site was

performed at three months at the patient’s request. The

re-established lumen was found to be patent and expan-

sile clinically: the lumen accommodated the 18 Fg Ryle’s

tube alongside two fully inflated 8 mm balloon catheters

(Figure 5). Biopsies were taken and these demonstrated

the presence of active granulation tissue. In view of this

finding the patient agreed to persist with the Ryle’s tube

in situ for a further month. During this period intensive

swallow therapy support was also instituted. After a total

of four months of treatment the patient was still unable to

swallow fluids but reported reflux of gastrostomy feed

solution. The Ryle’s tube was removed and the patient

Figure 3. Rigid pharyngoscopic images of the mature re-

canalised hypopharyngo-oesophageal lumen in case 1 be-

fore (image A) and after (image B) removal of the Ryle’s

tube which had been in situ for six months. The diameter of

the lumen was substantially greater than the Ryles’ tube

itself. Bile reflux was evident after removal of the Ryle’s

tube (image B): this patient had reported symptoms of bile

reflux during the latter weeks of treatment.

M. S. MIAH ET AL. 183

continued with swallowing therapy exercises. Over the

next two months further balloon dilatation procedures

were performed under rigid pharyngoscope endoscopic

guidance in order to maintain the calibre of the recanal-

ised lumen during this extended period of swallowing

therapy exercises. Six months after the recanalisation

procedure the patient was swallowing fluids with ease,

and has subsequently been building up consistencies. A

radiological water-soluble contrast study at nine months

post re-canalisation demonstrated a patent and functional

pharyngo-oesophageal lumen (Figure 4(C)). At 18 months

follow-up, this patient is now managing soft diet and

semi-solids.

4. Discussion

Management of fibrotic hypopharyngo-oesophageal oc-

clusions presents a major challenge. Surgical resection of

the occluded segment and reconstruction carries substan-

tial procedural risks and outcomes are unpredictable [2,

3,8].

Figure 4. Post-treatment radiological contrast swallow im-

ages for Cases 1-3, labeled A-C respectively. Images A and

C demonstrate the functional recanalised hypopharyngo-

oesophageal lumen which was the final result for cases 1

and 3 respectively. Image B demonstrates the non-func-

tional outcome which was the final outcome for case 2.

There is a rat’s tail appearance in the cervical oesophagus

with no evidence of peristaltic activity, and hold up of con-

trast in the dilated hypophary nx above.

Figure 5. Rigid pharyngoscope images in Case 3 before

balloon dilatation (A) and during dilation of twin radio-

logical balloon catheters (B). The images demonstrate that

the recanalised lumen exhibits elasticity and that it can ac-

commodate the 18 Fg Ryle’s tube and two inflated 8 mm

balloon catheters simultaneously. Despite this apparently

excellent outcome this patient required extensive post-treat-

ment swallowing therapy and several further one-off dilata-

tion procedures before a satisfactory functional swallow

was re-established.

Interventional radiology “sharp recanalisation” tech-

niques applied from the upper end of the occlusion, with-

out simultaneous access at the lower aspect of the occlu-

sion, may be unsafe because of the potential for inadver-

tent puncture of non-target structures and creation of fis-

tulae to the pleura, lung, mediastinum, or airway [4,5].

The technique described is an adaptation of percuta-

neous, radiologically-guided approaches to the manage-

ment of occlusions of the great veins of the mediastinum

and bile duct strictures (Figure 2) [6,7]. Success rates for

recanalization of mediastinal great veins ranging between

80% - 100% [6] have been reported. The long term suc-

cess employing the technique with bile duct strictures is

dependent on the duration the stent is in situ with mini-

mum recommended duration of 6 months [7]. Further

support for this has been gained from our own experience

managing patients with severe hypopharynx/upper-oe-

sophagus strictures with radiological balloon dilatation

M. S. MIAH ET AL.

184

followed by long-term Ryle’s tube placement (several

months). We have previously reported durable functional

outcomes achieved with 1 - 4 years follow-up in three

patients [9].

Concurrent antegr ade-retrograde r endezvous technique

has been described previously, with different technical

approaches and variable outcomes [4,5,8,10,11]. Most

commonly the rendezvous technique relies on retrograde

flexible oesophagoscopy or fluoroscopy through the gas-

trostomy tube site. During an early attempt in our ex-

perience using this approach we attempted this manoeu-

vre but were unable to cannulate the oesophagus. This

may have been due to our inexperience and/or the invo-

lutional changes in the oesophagus and at the gastro-

oesophageal junction which occur after the prolonged

oesophageal redundancy which inevitably results from

the upstream occlusion. We had also learned of an at-

tempted retrograde oesophagoscopy via the gastrostomy

site at another centre which resulted in loss of continuity

at the gastrostomy site, requiring immediate laparotomy

for repair and creatio n of a second remote gastrostomy. It

was these experiences which led us to opt for securing

robust, controllable retrograde access by means of a

mini-laparotomy. This limited open surgical approach

was selected in preference to a laparoscopic approach in

view of the presence of local adhesions related to the

pre-existing gastrostomy feeding tube insertion. A further

difference between the technique described and previ-

ously reported rendezvous procedures is the long dura-

tion (4 - 6 months) of nasogastric tube placement which

follows the initial recanalisation procedure.

Oxford et al. and Maple et al. described the short term

use of nasogastric tubes as stents to maintain patency of

the re-established hypopharyngo-oesophageal lumen [8,

10] after serial balloon dilatations. In their series’ gas-

trostomy tube feeding was discontinued in 67% and 57%

respectively. Five of the six patients treated by Oxford et

al maintained hypopharyngo-oesophageal luminal pa-

tency with a minimum follow-up of 12 months. Two of

the seven cases described by Maple et al developed evi-

dence of oesophageal microperforation after their ren-

dezvous procedures, and a further case developed early

re-stenosis requiring repeated subsequent dilatation pro-

cedures. A paediatric case described by Zur et al. re-

quired seventeen dilatation procedures during an 18-

month period, accompanied by kenalog injections and

topical mitomycin-C application on two occasions [11].

An encouraging observation made at rigid pharyngo-

scopy at the end of the six month treatment period in the

first case described here was the large calibre of the re-

established hypopharyngo-oesophageal lumen in com-

parison to the diameter o f the Ryle’s tub e (Figure 3). We

hypothesise that this phenomenon may have been due to

continuous relative movement of the tube and the muco-

sal surface during the treatment period.

4.1. Anatomic versus Functional Outcome

The procedure described successfully re-established pha-

ryngo-oesophageal luminal continuity in all three cases

on the first attempt. However the varied outcomes indi-

cate that re-establishment of luminal continuity does not

necessarily confer the immediate return of a functional

swallow.

Two of the cases had fibrotic occlusion after oncologi-

cal treatment for pharyngeal cancers: Case 1 had chemo-

radiotherapy only whereas Case 3 had major ablative and

reconstructive surgery followed by radiotherapy. At the

time of recanalisation it was noted that Case 3 appeared

to have a greater extent of mature fibrosis than the other

cases. We speculate that this is due to two factors 1) the

presence of a free flap and 2) the prolonged interval to

the recanalisation attempt.

Of all 3 cases, Case 1 has clearly enjoyed the best out-

come developing a durable functional swallow imme-

diately after treatment. Case 3 required intensive swallow

therapy and repeated dilatations before also developing a

durable functional swallow: his own motivation and per-

severance have undoubtedly been an important contrib-

uting factor in this outcome.

Case 2 never established a functional swallow. While

the precise aetiology of the occlusion in this case was

unclear the history supported a diagnosis of chronic gas-

troesophageal reflux disease leading to stricture forma-

tion and even tually complete fibro tic occlusio n. The mul-

tiple prior interventions (five dilatations, two myotomies

and three botulinum toxin injections) may have exacer-

bated the neurological component of the chronic inflam-

matory process at the site of occlusion. Following appar-

ently successful treatment a radiological contrast swal-

low demonstrated complete absence of any muscular

contractility around the site of the recanalised occlusion.

It appeared that there was no effective propulsive force to

propel ingested fluid through the abundant, redundant

hypopharyngeal mucosa above the recanalised segment.

An attempt to place a stent across the recanalised seg-

ment was unsuccessful; a failure attributed to the pres-

ence of the excess mucosal tissue. No further interven-

tion is planned. This patient remains dependent on gas-

trostomy tube feeding.

The outcome in case 2 suggests that re-establishment

of functional swallow is more likely to be successful in

patients with no prior history of oesophageal dysfunction

before developing fibrotic occlusion. The outcome in

case 3 suggests that a combination of ablative and recon-

structive surgery with adjuvant treatments, followed by a

prolonged period of absolute dysphagia prior to the in-

tervention described, may have all contributed towards a

more protracted course to a functional outcome. The ex-

M. S. MIAH ET AL.

185

perience of the three cases suggests that some degree of

patient selection coupled with careful patient counseling

may be important if recanalisation procedures such as

that described are to be successful in re-establishing a

functional swallow. The scarcity of cases of complete

occlusion is reflected in the limited literature on mini-

mally invasive recanalisation techniques such as that de-

scribed. In view of this, and the varied outcomes de-

scribed in this manuscript, it is suggested that until de-

finitive advice on patient selection and recanalisation

techniques has been developed these cases are managed

only in centres where efforts are being made to develop

an experience base. It is also suggested that a multidisci-

plinary team approach, with detailed prospective plan-

ning and patient education, is necessary for minimally

invasive recanalisation therapy techniques such as this to

be effective.

4.2. Ethical Considerations

Thankfully despite the increasing use of chemoradio-

therapy as primary treatment modality in locally ad-

vanced malignancies of the upper aerodigestive system

especially those with Human Papilloma Virus associated

aetiology, cases of complete fibrotic occlusion are rare.

Although the technique described is novel it is, in effect,

merely an adaptation of existing surgical and, interven-

tional radiology procedures for which complications and

outcomes are established. This background of a transla-

tional approach to therapy formed the basis of our dis-

cussion with all three patients. However they were also

informed that the combination of techniques was novel

and that consequently the outcomes pertaining to swal-

low could not be predicted with any degree of certainty.

All three patients benefited from a multidisciplinary team

approach and w ere fully co gnisant of the fact that the ex-

perience base for minimally invasive recanalisation pro-

cedures such as that described is small and in evolution.

5. Conclusion

Total fibrotic occlusion of the hypopharynx/upper-oe-

sophagus tract is rare but poses a substantial man ag ement

challenge. The minimally invasive recanalisation de-

scribed combines elements of existing surgical and inter-

ventional radiology techniques, none of which require

extraordinary or unusual experience or expertise. Al-

though luminal continuity was re-established in all three

cases, the variable outcomes suggest that the underlying

aetiology and the chronicity of the occlusion may be im-

portant variables influencing the likelihood of re-estab-

lishing a functional swallow. We suggest that until de-

finitive management algorithms can be developed, this

type of procedure only be performed for patients who

ave been appropriately counseled and only by motivated

multidisciplinary teams who are keen to develop their

expertise in this area.

REFERENCES

[1] H. B. Caglar, R. B. Tishler, M. Othus, et al., “Dose to

Larynx Predicts for Swallowing Complications after In-

tensity-Modulated Radiotherapy,” International Journal

of Radiation Oncology Biology Physics, Vol. 72, No. 4,

2008, pp. 1110-1118. doi:10.1016/j.ijrobp.2008.02.048

[2] M. Chirica, C. de Chaisemartin, N. Munoz-Bongrand, et

al., “Colonic Interposition for Esophageal Replacement

after Caustic Ingestion,” Journal De Chirurgie (Paris),

Vol. 146, No. 3, 2009, pp. 240-249.

[3] J. W. Hong, H. S. Jeong, D. H. Lew, et al., “Hypopharyn-

geal Reconstruction Using Remnant Narrow Pharyngeal

Wall as Omega-Shaped Radial Forearm Free Flap,” Jour-

nal of Craniofacial Surgery, Vol. 20, No. 5, 2009, pp.

1334-1340.

[4] S. J. Tang, S. Singh and J. M. Truelson, “Endotherapy for

Severe and Complete Pharyngo-Esophageal Post-Radia-

tion Stenosis Using Wires, Balloons and Pharyngo-Eso-

phageal Puncture (PEP) (with Videos),” Surgical Endo-

scopy, Vol. 24, No. 1, 2010, pp. 210-214.

[5] B. Pogorzelski, R. Kiesslich and W. Mann, ”Rendezvous

Technique for Complete Hypopharyngeal Stenosis. Indi-

cations and Variations of Combined Endoscopy,” HNO,

Vol. 57, No. 8, 2009, pp. 781-788.

[6] S. Athreya, P. Scott, G. Annamalai, et al., “Sharp Re-

canalization of Central Venous Occlusions: A Useful

Technique for Haemodialysis Line Insertion,” British

Journal of Radiology, Vol. 82, No. 974, 2009, pp. 105-

108. doi:10.1259/bjr/19820366

[7] S. Misra, G. B. Melton, J. F. Geschwind, et al., “Percuta-

neous Management of Bile Duct Strictures and Injuries

Associated with Laparoscopic Cholecystectomy: A Dec-

ade of Experience,” Journal of the American College of

Surgeons, Vol. 198, No. 2, 2004.

doi:10.1016/j.jamcollsurg.2003.09.020

[8] J. T. Maple, B. T. Petersen, T. H. Barron, et al., “Endo-

scopic Management of Radiation-Induced Complete Up-

per Esophageal Obstruction with an Antegrade-Retro-

grade Rendezvous Technique,” Gastrointestinal Endo-

scopy, Vol. 64, No. 5, 2006, pp. 822-828.

doi:10.1016/j.gie.2006.06.026

[9] M. S. Miah, I. A. Zealley, R. E. Mountain and S. Mahen-

dran, “Severe Benign Hypopharynx/Upper-Oesophageal

Strictures: Successful Treatment with a Novel Interven-

tional Radiology Technique in Three Patients,” Clinical

Otolaryngology, Vol. 37, No. 4, 2012, pp. 313-317.

[10] L. E. Oxford and Y. Ducic, “Retrograde Balloon Dilation

of Complete Cervical Esophageal and Hypopharyngeal

Strictures,” The Journal of Ototaryngotography, Vol. 55,

No. 5, 2006, pp. 327-331. doi:10.2310/7070.2005.0127

[11] K. B. Zur, P. E. Putnam and M. J. Rutter, “Combined

Retrograde and Anterograde Hypopharyngeal Puncture

and Dilatation in a Child with Complete Hypopharyngeal

Stenosis,” International Journal of Pediatric Otorhino-

laryngology, Vol. 71, No. 1, 2007, pp. 153-157.

doi:10.1016/j.ijporl.2006.07.023