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 1.Under General anaesthetic 2.Rigid oesophagoscopy anterograde via mouth – ENT team 3.Retrograde via Percutaneous gastrostomy Dilation of the Gastrostomy site with pneumatic dilatation 12mm Pass 9mm endoscope 4.Use of guidewire +/- biopsy forceps to identify lumen 5.Savary Guillard dilatator passed down till oesophageal lumen patent 6.NG is left in, PEG replaced 7.Diet introduced gradually Oeosphageal Stricture Anterograde Endoscope Retrograde Endoscope Percutaneous Gastrostomy

8. 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)

9. 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

10. 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 neuromotor defecit – Complications 5/30 (17%), anastomotic fistula 2/30 (6.7%)

11. 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)

12. 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

13. References 1.De Boer et al. Rehabilitation Outcomes of longterm survival treated for head and neck cancers. Head Neck. 1995; 17 503-515 2.Laurell et al. Stricture of the proximal oesophagus in head and neck carcinoma patients after radiotherapy. Cancer 2003; 97:1693-1700 3.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 4.Banergee et al. Intrathoracic oesophageal perforation following bougienage: a protocol for management. Aust N Z Journal Surg. 1989;59: 563-6 5.Van Twisk et al. Retrograde approach to pharyngo-oesophageal obstruction. Gastrointestinal Endoscopy 1998; 48:296-9 6.Boyce et al. Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience Gastrointest Endosc. 2012 Jul;76(1):25-31. doi: 10.1016/j.gie.2012.02.037. 7.Kos et al. Anterograde-Retrograde rendevous approach for radiation-induced complete upper oesophageal sphincter stenosis: case report and literature review. Journal of Laryngology and Otology 2011, 125, 761-764 8.Takeshi et al. Successful endoscopic dilatation of a severe stricture of the cervical oesophagus after defintive combined chemotherapy plus radiotherapy for oesophageal cancer. Oesophagus 2012 9;252-256