Page 61 - JCTR-10-2

Koschny et al. | Journal of Clinical and Translational Research 2024; 10(2): 151-158 155

A A

B

B
C

C

Figure 3. Additive treatments during bouginage. (A) After the eighth
bougienage of the recanalized esophagus (E), an esophago-tracheal
fistula became evident in patient #1 (*, left) and was endoscopically
closed by a fully covered 10 × 100 mm biliary stent (right). (B) To
widen the entrance into the recanalization below the arytenoid cartilage,
scar tissue was removed by repeated microsurgery, thereby shifting the
entrance to the middle (patient #4). (C) Due to recurrent scar formation
Figure 2. Periprocedural complications. (A) Axial computed and granulation tissue cytoreductive, argon plasma coagulation therapy
tomography plane of the upper thorax aperture demonstrates the soft was applied in patient #7.
tissue pocket (P) at the plane of the tracheostomy (TS) adjacent to the
common carotid artery (C), left subclavian artery (S) and left lung. The
gastric tube (GT) was placed as a placeholder in the esophageal lumen. Insertion of a feeding tube until repeated bougienages [18] or
The inset is an image showing the condition after tissue pocket healing even the temporal placement of a small-diameter covered metal
5 months later. (B) The time-consuming healing of the tissue pocket (P) stent (≤10 mm) [13,14] has been reported as approaches to keeping
delayed the progress of bougienages by approximately 100 days. (C) To the pharyngoesophageal passage open after recanalization.
keep the dilated esophageal entrance next to the arytenoid cartilage However, immediate metal stent insertion did not seem to reduce
(A) open until subsequent bougienage, two guidewires for two gastric the necessity of subsequent and repeated bougienages but was
tubes were inserted (upper left). Wire-guided and simultaneous insertion associated with a higher abscess formation rate [13]. In this case
of the two gastric tubes had to be assisted by Wendl tubes, one in each series, fully covered self-expanding metal stents (fcSEMSs)
nostril (upper right), which splinted the pharynx (lower left) and enabled were used only when fistulas coexisted with the recanalized
the simultaneous insertion of two gastric tubes (lower right). pharyngoesophageal channel and they did not reduce the need
for repeated bougienage. From our experience, the insertion
due to repeated maneuvers with the endosonography needle of a gastric tube as a placeholder is highly recommended until
(patient #4). Needle knife preparation [18] and puncture the lumen is stable enough to prevent reocclusion. To maintain
with the hard end of a wire [22], as well as puncture with a a functional passage, patients needed up to 32 [18] or even 37
trocar needle from the pharyngeal side [14], as in our cases, bougienages [4]. In this case series, up to 97 treatment sessions
have also been reported. Using a stiff needle for puncture were performed on one patient who did not agree to salvage
from the pharyngeal site offers some advantages regarding operation.
maneuverability, especially in obliterations over a longer An overall complication rate of 11% was reported in the
distance, but still harbors the risk of injuring adjacent and literature for the applied rendezvous technique [15]. It has been
vulnerable structures. Blunt preparation from the oral side reported that mediastinal emphysema [22], pneumothorax [12],
under fluoroscopic and endoscopic guidance and puncture of pneumomediastinum with periesophageal abscess formation
the remaining short segmented soft tissue might be preferable and cervical osteomyelitis, cervical abscess formation [13], and
in short-distance occlusions. microperforation [19] are mainly managed conservative mode. In
DOI: https://doi.org/10.36922/jctr.23.00116