Outcomes of serial dilation for high-grade radiation-related esophageal strictures in head and neck cancer patients.

Abstract

Dysphagia and esophageal stricture are frequent consequences of treatment for head and neck cancer. This study examines the effectiveness of the anterograde-retrograde rendezvous procedure and serial dilations in reestablishing esophageal patency to allow return to oral diet and gastrostomy tube removal in a cohort of patients with complete or near-complete esophageal stricture following nonsurgical cancer treatment. Retrospective review of patients treated with radiation therapy with or without concurrent chemotherapy presented with complete or near-complete esophageal stricture. Patients underwent serial dilations using combined anterograde-retrograde dilation (rendezvous) techniques. Medical records of patients having undergone treatment between 2006 and 2012 were reviewed, and semistructured interviews were also conducted to determine current swallowing function and actual patient experience. The primary outcome was swallowing improvement that allowed for return to oral diet and/or gastrostomy tube removal. Outcomes were compared between patients with complete and near-complete (<5 mm in diameter) strictures and univariate analysis performed to identify associations between patient, cancer, and treatment characteristics on odds of gastrostomy tube removal. Twenty-four patients (median age 59.5 years, 63% male, 91% Caucasian) underwent treatment. Fifty percent of patients had complete occlusion of the esophageal lumen. The majority of patients (92%) underwent either anterograde (54%) or combined antero-retrograde (38%) approach. Following a median (interquartile range) of 9 (6-20) dilation sessions, 42% of patients were able to return to an oral diet and/or had their gastrostomy tube removed. This outcome was independent of whether the stricture was complete or near complete (P = .67). Of patients who had their gastrostomy tubes removed, only 33.3% had ever smoked, compared to 92.3% of those whose tubes were not discharged (P = .007). Recannulation is possible even in cases of complete or near-complete stricture. Several factors appear to impact the likelihood of successful outcome, but in this study, only patients with a history of smoking had a significantly lower likelihood of return to full oral diet.