Success of endoscopic pharyngoesophageal dilation after head and neck cancer treatment

Abstract

Objective To assess clinical success and safety of endoscopic pharyngoesophageal dilation after chemoradiation or radiation for head and neck cancer and to identify variables associated with dilation failure. Study Design Case series with chart review Methods Between 2000 and 2008 one hundred and eleven patients treated with chemoradiation or radiation for head and neck cancer with subsequent pharyngoesophageal stenosis requiring endoscopic dilation were identified. Patients were evaluated for endoscopic dilation technique, severity of stenosis, technical and clinical success and intra and post operative complications. The Diet/GT Score, range 1–5, was utilized to measure swallow success. Variables associated with dilation failure were analyzed by univariate and multivariate logistic regression. Results 271 dilations were analyzed, with 42 combined antegrade retrograde dilations, 208 dilations over a guidewire and 21 dilations without guidewire. Intraoperative patency and successful dilation of the stenotic segment was achieved in 95% of patients. A Diet/GT score of 5 (gastrostomy tube removed and soft/regular diet) was attained in 84/111 (76%) patients. Safety analysis showed complications occurred in 9% of all dilations. Perforations were noted in 4% of all procedures with only two esophageal perforations requiring significant intervention. Multiple dilations were associated with an increased risk for perforations. Further logistic regression analyses revealed that the number of dilations was indicating a poor outcome and low Diet/GT score. Conclusion Pharyngoesophageal stenosis, occurring after chemoradiation and radiation treatment, can be successfully and safely treated with endoscopic dilation techniques. Patients with restenosis, requiring multiple dilations, have a higher risk of persistent dysphagia. Level of Evidence 2b individual retrospective cohort study

Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

“…We found that initial lumen diameter, number of dilations, and nonrecurrent strictures were predictive factors for overall efficacy. The first two factors have previous been described [23]. Our predictive factors for efficacy were only significant in the univariate analysis, which may be explained by the small and complex population analyzed, requiring multiple dilations, more than what was reported in previous similar studies [23].…”

“…A recent meta-analysis [7] reported an estimated overall clinical success rate per patient (with a post-chemotherapy and RT or RT alone stricture) of 72.9% (95% CI 65.7-80.1%), with data suffering from significant heterogeneity as success was defined by resolution or improvement of different dysphagia scales. Previous findings stated that a soft/ normal diet may be achieved in > 70% [12,16,23,28] compared to 60% reported in our cohort. On the other hand, our dysphagia improvement perception rate was 58.3% Fig.…”

“…excellent and followed the one previously described by Francis et al [22]. Moreover, our independence of gastrostomy tube rate was better than in most previous studies [22,23,28]. We found that initial lumen diameter, number of dilations, and nonrecurrent strictures were predictive factors for overall efficacy.…”

“…We designed our definition of overall efficacy as a trilogy where dysphagia improvement assessed as a "patient-reported outcome" needs to be associated with a 6-month period of absence of further dilations and PEG feeding. These criteria made our efficacy definition more demanding and therefore hard to compare with previously described endoscopic dilation efficacy rates [2,12,15,16,18,20,23]. A recent meta-analysis [7] reported an estimated overall clinical success rate per patient (with a post-chemotherapy and RT or RT alone stricture) of 72.9% (95% CI 65.7-80.1%), with data suffering from significant heterogeneity as success was defined by resolution or improvement of different dysphagia scales.…”

“…Most authors defined clinical success as resolution of dysphagia (or tolerance of soft diet) measured by different scores [2, 12, 14-16, 18, 19], often requiring a variable dilation-free period [11,13,18,20,21] and considering percutaneous endoscopic gastrostomy (PEG) status [20,22,23]. Francis et al [22] also reported patient satisfaction with the dilation program.…”