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152 Koschny et al. | Journal of Clinical and Translational Research 2024; 10(2): 151-158
Although some authors advocate surgical reconstruction for metronidazole. Subsequently, the opened channel was dilated
complete esophageal obstruction [3,7], peroral and transgastric- (2 – 9 mm), and a nasogastric feeding tube was inserted to guide
retrograde rendezvous has been reported for recanalization of further bougienages.
subtotal [8-11] and complete esophageal obstruction in single
cases and case series [5,11-19] with a high technical and clinical 2.3. Data collection
success rate. However, a positive publication bias should be Data concerning oncological pretreatment, duration, and
considered when assessing this technique. Patients with cancers symptoms of esophageal obliteration were retrospectively
of the hypopharynx are at considerable risk for secondary collected from the patient´s file. Data on clinical symptoms at
malignancies of the esophagus [20]. Therefore, re-establishment presentation, diagnostic work-up, recanalization procedure,
of the pharyngoesophageal passage will not only allow swallowing bougienage treatments, complications, symptom development,
of saliva or even restore oral nourishment to improve the quality of and final outcomes were prospectively collected during each visit.
life but will also enable endoscopic surveillance in these patients.
Here, we report a case series of seven technically successful 3. Results
recanalizations of complete pharyngoesophageal obstruction The clinical background of patients with oncologic details
after radiotherapy by a transgastric-retrograde approach under
transillumination, fluoroscopic, and endoscopic guidance. and demographic data are listed in detail in Table 1. The mean
and median age was 64 and 70 years, respectively. Most patients
2. Methods (71%) were male. All but one patient received radiochemotherapy
for their initial oncological treatment. In all patients, a complete
2.1. Patients esophageal obliteration occurred with complete aphagia, which
Seven patients eligible for the combined antegrade and was verified by a computed tomography scan, lack of contrast
retrograde recanalization treatment presented with complete media passage, and upper endoscopy. The mean and median
esophageal obliteration, which was confirmed by upper endoscopy. length of obliteration was 16.8 and 20 mm, respectively. Details of
All patients gave their written informed consent for the treatment the recanalization procedure are given in Table 2, and the standard
and the publication of their data. procedure is depicted in Figure 1. The technical success rate of the
recanalization procedure in all seven patients was 100%.
2.2. Procedures Periprocedural complications occurred in only one patient
For recanalization of the upper esophageal entry, we performed where the preparation needle induced the formation of a 15 mm
a rendezvous technique: after percutaneous endoscopic wide soft-tissue pocket of the esophageal lumen adjacent to the left
gastrostomy (PEG) removal, the PEG channel was dilated to common carotid artery (Figure 2). To facilitate 6 weeks of pocket
8 mm (CRE PRO Wireguided Balloon Dilatation Catheter, obturation by granulation, weekly bougienages under antibiotic
Boston Scientific, Cork, Ireland), and a slim gastroscope (GIF coverage were carried out only up to 9 mm, and secretion drainage
XP160, 5.9 mm, Olympus, Hamburg, Germany) was propagated was ensured by wire-guided insertion of a small gastric tube after
into the stomach and retrograded into the esophagus up to the each bougienage.
distal end of the obliteration. Simultaneous transoral endoscopy After successful recanalization of the obliterated passage,
under fluoroscopy allowed us to measure the length of the an average of 30.9 (range 12 – 97) bouginages and balloon
obliteration. After endoscopy, the gastrostomy was kept open dilatations were performed on a weekly or biweekly basis to a
by a G-tube (Nutricia Flocare Gastrostomy tube, 14 Ch). On final mean diameter of 15.3 mm (range 10 – 20 mm). Additive
the following day (in some cases within the same procedure), treatment during bouginage was necessary in six of the seven
antegrade rigid pharyngoscopy and simultaneous retrograde patients (86%); two patients (#1, #5) needed temporary metal
esophagoscopy through the PEG channel were performed under stent implantation (fcSEMS) for fistula with final surgical fistula
general anesthesia. Under fluoroscopic, transillumination, and closure (Figure 3A). Due to the COVID-19-induced restrictions of
retrograde endoscopic guidance, the proximal blind end of the medical care, one patient (#3) omitted routine follow-up, developed
esophagus was punctured from the hypopharynx with a 1.9 mm another esophageal occlusion, and needed a second recanalization
straightened needle (Provox Vega Puncture Set, Atos Medical procedure. Three patients (#4, #6, #7) underwent microsurgical
GmbH, Troisdorf, Germany) or with the trocar needle of the scar excision to improve the entry into the recanalized segment
PEG set in the following cases after cutting the butterfly flanks to (Figure 3B). Three patients (#1, #4, #5) were treated with argon
allow passage through the pharyngoscope (Freka PEG Set Gastric plasma coagulation for enhanced scar formation and granulation
FR15, Fresenius Kabi AG, Bad Homburg, Germany). A guidewire tissue in addition to local triamcinolone treatment (Figure 3C).
was advanced through the needle into the esophagus and grasped After the treatment, all patients could at least consume semisolid
with forceps via the gastroscope. The obliteration was reopened food and swallow saliva. Two patients (#3, #5, 29%) resumed
either with an endoscopic ring cutter (ring knife model Prof. normal foot intake and remained PEG-independent, with one of
Dr. U. Will, 1.8 mm, MTW, Wesel, Germany) or a biliary dilation them needing ongoing bougienage. Patient #3 was still under
catheter (Cook Medical, Ireland) under intravenous antibiotic repeated bi- to tri-weekly bouginage, while the other patient (#5)
coverage with clindamycin or cefuroxime in combination with had been healthy, reporting no other complications and needing
DOI: https://doi.org/10.36922/jctr.23.00116