Digestive Endoscopy 2015; 27: 310–316
doi: 10.1111/den.12345
Original Article
Endoscopic balloon dilatation for pharyngo-upper esophageal stricture after treatment of head and neck cancer Ryuhei Maejima,1 Katsunori Iijima,1 Tomoyuki Koike,1 Nobuyuki Ara,1 Kaname Uno,1 Waku Hatta,1 Takenori Ogawa,2 Ken-ichi Watanabe,2 Yukio Katori2 and Tooru Shimosegawa1 1
Division of Gastroenterology, Tohoku University Graduate School of Medicine and 2Department of Otorhinolaryngology-Head and Neck Surgery, Tohoku University School of Medicine, Sendai, Japan Background and Aim: Dysphagia caused by pharyngo-upper esophageal stricture is a complication of treatment for head and neck cancer. Endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for stricture in many areas of the gastrointestinal tract. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures that developed after treatment for head and neck cancer. Methods: From January 2010 to December 2013, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures occurring after surgery and/or chemoradiotherapy for head and neck cancer were retrospectively examined. Results: Mean number of EBD sessions per patient was 6.6
ryngeal edema) occurred in a total of 125 dilatation sessions (1.6%). Regarding the influence of chemoradiotherapy on the outcome of EBD, patients who had undergone chemoradiotherapy plus surgery experienced significantly more restenosis during the follow-up period compared to those who had undergone surgery alone (50% vs 0%, P < 0.05).
Conclusions: This retrospective analysis demonstrated the efficacy and safety of exclusive EBD for pharyngo-upper esophageal strictures occurring after treatment for head and neck cancer, indicating that the therapeutic application of EBD could be extended to such strictures. Patients who underwent chemoradiotherapy and surgery experienced more restenosis; hence, such patients should be carefully followed up after EBD treatment.
(1–30), and mean maximum diameter of dilation was 15.8 (11– 20) mm. Technical success was achieved in 16 of 19 (84.2%) patients, and only two major complications (bleeding and pha-
Key words: dysphagia, endoscopic balloon dilation (EBD), head and neck cancer, pharyngo-upper esophageal stricture, restenosis
INTRODUCTION
lower esophagus.5 However, only a single study, as far as we know, has addressed the usefulness of EBD for pharyngoupper esophageal strictures.6 In addition, although reconstruction of the digestive system using a free jejunal graft is widely accepted after laryngo-pharyngo-cervical esophagectomy,7,8 none of the previous studies addressed balloon dilation therapy for strictures formed in the jejunal graft. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures, especially those formed in free jejunal grafts after treatment for HNSCC.
D
YSPHAGIA AS A result of pharyngo-upper esophageal stricture is a common complication after treatment for squamous cell carcinomas originating from the head and neck (HNSCC).1 Some previous studies have reported the efficacy of dilation using wire-guided bougie dilators or fluoroscopically guided balloon dilation as a treatment for pharyngoupper esophageal strictures.2–4 Meanwhile, endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for strictures in many regions of the gastrointestinal (GI) tract, especially for strictures of the middle–
METHODS Corresponding: Iijima Katsunori, Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan. Email: kiijima@med .tohoku.ac.jp Received 24 June 2014; accepted 4 August 2014.
bs_bs_banner
310
Patients
W
E RETROSPECTIVELY REVIEWED our endoscopic database obtained from January 2010 to December 2013 in order to identify all patients who received
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2015; 27: 310–316
EBD for pharyngo-esophageal stricture 311
EBD for pharyngo-upper esophageal stricture after surgery and/or chemoradiotherapy (CRT) for HNSCC. Thus, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures were examined. All patients complained of varying degrees of dysphagia after treatment for HNSCC, and then received endoscopic examination to investigate the cause of the symptoms at Tohoku University Hospital. We defined a stricture as the condition when a standard 9.8-mm diameter endoscope (H260; OLYMPUS Co. Ltd, Tokyo, Japan) could not pass through the site without resistance. Thus, inclusion criteria of this analysis were endoscopically recognized stricture as well as the complaints of dysphagia after treatment for HNSCC. All patients had post-therapeutic, fibrotic strictures. Meanwhile, exclusion criteria were malignant strictures either detected by endoscopy or computed tomography (CT) scan, systematic bleeding tendency, and other serious general diseases. All patients provided informed consent prior to the dilation therapy, and this retrospective analysis was approved by the Tohoku University School of Medicine Ethics Committee (2014-1-41).
Endoscopic balloon dilation procedure Before the procedure, the distal margin of the stricture was checked using an ultrathin, 5.0-mm diameter endoscope (XP260N; OLYMPUS Co. Ltd) in each case. While advancing the guidewire through the accessory channel of a standard endoscope, a through-the-scope (TTS) balloon catheter (CRE balloon, Microvasive; Boston Scientific Corporation, Natick, MA, USA) was passed through the guidewire into the stricture under endoscopic visualization. When an ultrathin endoscope could not pass into the stricture, the same procedure was carried out under fluoroscopy. Then, the balloon was inflated with water to the recommended pressure for periods ranging from 60 to 120 s. When patients experienced pain during the procedure, the balloon was immediately deflated and removed. The diameter of balloon was determined according to the severity of the stricture and, in general, the procedure was started with a 10–12-mm balloon catheter. The balloon catheter is designed to inflate to three distinct diameters in the range of 3-mm increments according to increments in pressure during in vivo dilatation. Thus, the diameters were increased by up to 3 mm during one dilation session. Initially, there was a dilation session once every 1 or 2 weeks for patients in outpatient care, and the intervals were gradually extended.
Dysphagia assessment Dysphagia was assessed based on medical records on patient diet prior to each EBD session. According to our recent report,9 dysphagia was graded as follows: score 0, no dys-
phagia; 1, solid food dysphagia once in 4 months; 2, solid food dysphagia once in 2 months; 3, solid food dysphagia once every 2–4 weeks; 4, solid food dysphagia once every 1–2 weeks; 5, solid food dysphagia once every 1–7 days; 6, solid food dysphagia with every meal; and 7, dysphagia to solid and liquid food.
Response to therapy and follow up The dilation procedure was considered successful if a standard 9.8-mm endoscope could pass the stricture site without resistance. Patients were instructed to undergo follow-up endoscopic examination at 3–6-month intervals or whenever the dysphagia deteriorated, and their symptom scores on dysphagia were also assessed at each hospital visit. The follow-up period was defined as the period from the last dilation session to the last consultation in our hospital. Restenosis was defined as the condition when additional dilation was required more than 6 months after the last dilation.
Statistics Clinical parameters of patient profiles were shown as mean (range) for continuous variables and ratio (percentage) for categorical variables. Success rate among patients and complication rate among the total EBD sessions were calculated. Statistical differences between the two groups were analyzed by Student’s unpaired t-test for continuous variables and by Fisher’s exact test for categorical variables. Changes in the dysphagia score prior to and after EBD were assessed by Wilcoxon test and, in this analysis, dysphagia score after EBD was the lowest among the scores reported by patients at each hospital visit after the treatment. Kaplan–Meier method was used to estimate duration until restenosis after EBD. Analyses were carried out using JMP® 10 (SAS Institute Inc., Cary, NC, USA), and a P-value
doi: 10.1111/den.12345
Original Article
Endoscopic balloon dilatation for pharyngo-upper esophageal stricture after treatment of head and neck cancer Ryuhei Maejima,1 Katsunori Iijima,1 Tomoyuki Koike,1 Nobuyuki Ara,1 Kaname Uno,1 Waku Hatta,1 Takenori Ogawa,2 Ken-ichi Watanabe,2 Yukio Katori2 and Tooru Shimosegawa1 1
Division of Gastroenterology, Tohoku University Graduate School of Medicine and 2Department of Otorhinolaryngology-Head and Neck Surgery, Tohoku University School of Medicine, Sendai, Japan Background and Aim: Dysphagia caused by pharyngo-upper esophageal stricture is a complication of treatment for head and neck cancer. Endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for stricture in many areas of the gastrointestinal tract. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures that developed after treatment for head and neck cancer. Methods: From January 2010 to December 2013, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures occurring after surgery and/or chemoradiotherapy for head and neck cancer were retrospectively examined. Results: Mean number of EBD sessions per patient was 6.6
ryngeal edema) occurred in a total of 125 dilatation sessions (1.6%). Regarding the influence of chemoradiotherapy on the outcome of EBD, patients who had undergone chemoradiotherapy plus surgery experienced significantly more restenosis during the follow-up period compared to those who had undergone surgery alone (50% vs 0%, P < 0.05).
Conclusions: This retrospective analysis demonstrated the efficacy and safety of exclusive EBD for pharyngo-upper esophageal strictures occurring after treatment for head and neck cancer, indicating that the therapeutic application of EBD could be extended to such strictures. Patients who underwent chemoradiotherapy and surgery experienced more restenosis; hence, such patients should be carefully followed up after EBD treatment.
(1–30), and mean maximum diameter of dilation was 15.8 (11– 20) mm. Technical success was achieved in 16 of 19 (84.2%) patients, and only two major complications (bleeding and pha-
Key words: dysphagia, endoscopic balloon dilation (EBD), head and neck cancer, pharyngo-upper esophageal stricture, restenosis
INTRODUCTION
lower esophagus.5 However, only a single study, as far as we know, has addressed the usefulness of EBD for pharyngoupper esophageal strictures.6 In addition, although reconstruction of the digestive system using a free jejunal graft is widely accepted after laryngo-pharyngo-cervical esophagectomy,7,8 none of the previous studies addressed balloon dilation therapy for strictures formed in the jejunal graft. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures, especially those formed in free jejunal grafts after treatment for HNSCC.
D
YSPHAGIA AS A result of pharyngo-upper esophageal stricture is a common complication after treatment for squamous cell carcinomas originating from the head and neck (HNSCC).1 Some previous studies have reported the efficacy of dilation using wire-guided bougie dilators or fluoroscopically guided balloon dilation as a treatment for pharyngoupper esophageal strictures.2–4 Meanwhile, endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for strictures in many regions of the gastrointestinal (GI) tract, especially for strictures of the middle–
METHODS Corresponding: Iijima Katsunori, Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan. Email: kiijima@med .tohoku.ac.jp Received 24 June 2014; accepted 4 August 2014.
bs_bs_banner
310
Patients
W
E RETROSPECTIVELY REVIEWED our endoscopic database obtained from January 2010 to December 2013 in order to identify all patients who received
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2015; 27: 310–316
EBD for pharyngo-esophageal stricture 311
EBD for pharyngo-upper esophageal stricture after surgery and/or chemoradiotherapy (CRT) for HNSCC. Thus, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures were examined. All patients complained of varying degrees of dysphagia after treatment for HNSCC, and then received endoscopic examination to investigate the cause of the symptoms at Tohoku University Hospital. We defined a stricture as the condition when a standard 9.8-mm diameter endoscope (H260; OLYMPUS Co. Ltd, Tokyo, Japan) could not pass through the site without resistance. Thus, inclusion criteria of this analysis were endoscopically recognized stricture as well as the complaints of dysphagia after treatment for HNSCC. All patients had post-therapeutic, fibrotic strictures. Meanwhile, exclusion criteria were malignant strictures either detected by endoscopy or computed tomography (CT) scan, systematic bleeding tendency, and other serious general diseases. All patients provided informed consent prior to the dilation therapy, and this retrospective analysis was approved by the Tohoku University School of Medicine Ethics Committee (2014-1-41).
Endoscopic balloon dilation procedure Before the procedure, the distal margin of the stricture was checked using an ultrathin, 5.0-mm diameter endoscope (XP260N; OLYMPUS Co. Ltd) in each case. While advancing the guidewire through the accessory channel of a standard endoscope, a through-the-scope (TTS) balloon catheter (CRE balloon, Microvasive; Boston Scientific Corporation, Natick, MA, USA) was passed through the guidewire into the stricture under endoscopic visualization. When an ultrathin endoscope could not pass into the stricture, the same procedure was carried out under fluoroscopy. Then, the balloon was inflated with water to the recommended pressure for periods ranging from 60 to 120 s. When patients experienced pain during the procedure, the balloon was immediately deflated and removed. The diameter of balloon was determined according to the severity of the stricture and, in general, the procedure was started with a 10–12-mm balloon catheter. The balloon catheter is designed to inflate to three distinct diameters in the range of 3-mm increments according to increments in pressure during in vivo dilatation. Thus, the diameters were increased by up to 3 mm during one dilation session. Initially, there was a dilation session once every 1 or 2 weeks for patients in outpatient care, and the intervals were gradually extended.
Dysphagia assessment Dysphagia was assessed based on medical records on patient diet prior to each EBD session. According to our recent report,9 dysphagia was graded as follows: score 0, no dys-
phagia; 1, solid food dysphagia once in 4 months; 2, solid food dysphagia once in 2 months; 3, solid food dysphagia once every 2–4 weeks; 4, solid food dysphagia once every 1–2 weeks; 5, solid food dysphagia once every 1–7 days; 6, solid food dysphagia with every meal; and 7, dysphagia to solid and liquid food.
Response to therapy and follow up The dilation procedure was considered successful if a standard 9.8-mm endoscope could pass the stricture site without resistance. Patients were instructed to undergo follow-up endoscopic examination at 3–6-month intervals or whenever the dysphagia deteriorated, and their symptom scores on dysphagia were also assessed at each hospital visit. The follow-up period was defined as the period from the last dilation session to the last consultation in our hospital. Restenosis was defined as the condition when additional dilation was required more than 6 months after the last dilation.
Statistics Clinical parameters of patient profiles were shown as mean (range) for continuous variables and ratio (percentage) for categorical variables. Success rate among patients and complication rate among the total EBD sessions were calculated. Statistical differences between the two groups were analyzed by Student’s unpaired t-test for continuous variables and by Fisher’s exact test for categorical variables. Changes in the dysphagia score prior to and after EBD were assessed by Wilcoxon test and, in this analysis, dysphagia score after EBD was the lowest among the scores reported by patients at each hospital visit after the treatment. Kaplan–Meier method was used to estimate duration until restenosis after EBD. Analyses were carried out using JMP® 10 (SAS Institute Inc., Cary, NC, USA), and a P-value
