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. Miah, Ian A. Zealley, Afshin Alijani, Barry McGuire, Rodney E. Mountain, Suresh Mahendran

Department of Anaesthesia, Ninewells Hospital and University of Dundee Medical School, Dundee, UK.
Department of Otorhinolaryngology-Head & Neck Surgery, Ninewells Hospital and University of Dundee Medical School, Dundee, UK.
Department of Radiology, Ninewells Hospital and University of Dundee Medical School, Dundee, UK.
Department of Upper Gastrointestinal Surgery, Ninewells Hospital and University of Dundee Medical School, Dundee, UK.

DOI: 10.4236/ijohns.2013.25038                

Abstract

Background: Complete hypopharyngo-oesophageal occlusion is a rare complication of head and neck radiotherapy and a range of other conditions. Absolute dysphagia is accompanied by aspiration and dependence 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 biliary 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 rule 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 procedures. In two cases, the excellent swallowing function was re-established, although one of these required prolonged post-treatment adjuvant interventions. In one case no swallowing function resulted, despite apparently successful re-establishment of luminal continuity. Conclusions: Complete fibrotic occlusion of the hypopharyngo-oesophageal 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 continuity in three cases of complete fibrotic occlusion of the hypopharyngo-oesophageal lumen. However variable responses to treatment suggest that both the underlying aetiology and the chronicity of the occlusion may influence the likelihood of a successful functional outcome. Until definitive management guidelines are established, we suggest that such cases are managed only by motivated multidisciplinary teams keen to develop their expertise in this area.

Keywords

Hypopharynx; Upper Oesophagus; Fibrotic Occlusion; Rendezvous Technique; Pharyngo-Oesophageal Continuity

Conflicts of Interest

The authors declare no conflicts of interest.

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