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raversing Difficult Esophagealtrictures from the Retrograde Approachuhammad Hasan, MD, and John T. Maple, DO

Esophageal strictures are common and are categorized as simple or complex. Complexstrictures are long, severely narrowed, angulated and/or are irregular. In this article wediscuss the management challenge that complex strictures pose. Some complex stricturesmay require a transgastric (retrograde) approach for safe and effective endoscopic man-agement. For complete esophageal obstruction caused by a complex stricture, an ante-grade-retrograde rendezvous technique using fluoroscopic guidance and careful dissectioncan provide successful non-operative esophageal recanalization.Tech Gastrointest Endosc 10:149-154 © 2008 Elsevier Inc. All rights reserved.

KEYWORDS esophageal stricture, retrograde, dysphagia, endoscopy, gastrostomy, rendezvous

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sophageal strictures are common and arise from a numberof etiologies, including malignancy and benign processes.

enign strictures arise as a result of injury to the esophagus; annitial inflammatory response characterized by edema, vascularongestion, and inflammatory cell recruitment is later followedy collagen deposition and the formation of irreversible fibrosis.eptic strictures from prolonged esophageal acid exposure rep-esent the most common injury mechanism in benign strictures,lthough the incidence of these lesions is declining in the era ofidespread proton pump inhibitor usage.1 Many other etiolo-ies of benign strictures, including medication-induced,chatzski’s rings, prior caustic ingestion, infectious esophagitis,osinophilic esophagitis, radiation-induced, or postsurgicalnastomoses, are commonly seen as well.

Benign esophageal strictures can be generally categorized asimple or complex. Simple strictures are short (�2 cm), straight,nd typically allow passage of a diagnostic gastroscope predila-ion. In contrast, complex strictures are longer, severely nar-owed, and angulated or irregular.2 Complex strictures are moreikely to recur than simple strictures2,3 and may require a diver-ent treatment approach from the commonly employed dilationechniques used for simple strictures. Of the aforementionedtiologies, radiation injury and caustic ingestion are the mostommon causes of complex strictures.

Simple esophageal strictures are generally managed with ei-her wire-guided bougie dilators (eg, Savary–Gilliard; Cook En-

ivision of Digestive Diseases and Nutrition, University of Oklahoma HealthSciences Center, Oklahoma City, OK.

he authors have no direct financial interests that might pose a conflict ofinterest in connection with the submitted manuscript.

ddress reprint requests to John T. Maple, DO, Assistant Professor of Med-icine, Division of Digestive Diseases and Nutrition, University of Okla-homa Health Sciences Center, 920 Stanton L. Young Blvd., WP 1360,

tOklahoma City, OK 73117. E-mail: john-maple@ouhsc.edu

096-2883/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.oi:10.1016/j.tgie.2008.07.005

oscopy, Winston–Salem, NC) or through-the scope (TTS) bal-oon dilators, often multisized controlled radial expansionalloons (Boston Scientific, Natick, MA). A third method, bou-ie dilation without wire guidance (eg, Maloney dilators), haseen associated with a greater risk of perforation than the otherwo techniques and is thus less frequently employed.4 Whereasire-guided bougie dilation transmits both radial forces as well

s longitudinal shear forces, TTS balloons transmit only radialorces. Despite these mechanistic differences, wire-guided bou-ie dilation and TTS balloon dilation are similarly effective andafe in simple strictures.5,6 Perforation rates of 0.1% to 0.4%ave been reported in unselected series of esophageal dilation,redominantly for peptic strictures.4,7–9

However, the risk for perforation is increased when antegradeilation is used in patients with complex esophageal stricturesaused by caustic ingestion or radiation, ranging from 2% to7%.9–15 Although techniques varied somewhat in these series,ll employed an antegrade bougie technique. These soberingomplication rates highlight the management challenge thatomplex strictures pose. For issues including both maximizinghe safety of dilating technique and optimizing safe wire tra-ersal of nearly obstructing or completely obstructing complextrictures, many gastroenterologists are exploring and advocat-ng transgastric retrograde approaches to complex esophagealtrictures.

istorical Perspective:Death by Bougie” anducker’s Endless String

he concept of a retrograde approach in the management ofomplex esophageal strictures may seem clever or novel tohe current generation of gastrointestinal endoscopists, but

his is far from being a new technique and was, in fact, the

149

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150 M. Hasan and J.T. Maple

tandard of care for managing complex caustic strictures forost of the 20th century. Thus, to some degree, gastroenter-

logists must learn what they have forgotten, or may neverave known, from a literature base that predates flexible en-oscopy.In most series of benign esophageal strictures before 1950,

austic ingestion (often lye) was the most common etiology,head of peptic strictures, postsurgical anastomotic stric-ures, congenital strictures, and radiation-induced strictures,mong others.16 The Federal Caustic Poison Act of 1927 re-uired clear labeling of strong acids and bases available forousehold uses with the word “POISON,” as well as instruc-ions for medical care in the event of ingestion.16 Subse-uently, the Poison Prevention Packaging Act of 1970 limitedhe concentration of caustic agents in household cleaners andequired childproof packaging of containers.17 Both of theseegislative acts, along with changing social trends (eg, pur-hasing, rather than making soap), have led to a decline in thencidence of caustic strictures, but this was formerly a com-

on and formidable problem.In the 19th century, young patients with caustic ingestions

ere often managed expectantly, and many later presentedith severe dysphagia and cachexia. Peroral bougie dilationas often complicated by esophageal perforation, even whenswallowed string was used as a guide. The French internistrousseau lamented that “sooner or later all cases of stricturef the esophagus die of the bougie.”18 Surgeons as early asillroth had noted that the esophagus was frequently dilatedr “bowel-shaped” above a complex stricture but was funnel-haped below.19 This observation, coupled with the first suc-essful gastrostomies in 1876 and 1877,20 prompted some toonsider retrograde dilation of complex strictures via a gas-rostomy as early as 1883 (Shedde) and 1894 (Von-acker),16,20 as a possible safer alternative to antegrade dila-

ion.Dr. Gabriel Tucker was a Philadelphia otolaryngologist

ho had trained with Dr. Chevalier Jackson, one of the fa-hers of esophagoscopy. In 1924, Tucker published a land-ark paper in which he described the management of caustic

sophageal strictures via retrograde dilation through a gas-rostomy, using a bougie that he designed.19 Patients (usuallyhildren) would swallow a string that was passed transna-ally. The string was then grasped with an instrument (eg,ight-angle retractor) passed via a mature gastrostomy,ulled out through the gastrostomy, and tied to the othernd, creating a loop. Though it posed a cosmetic issue, theendless” string maintained esophageal patency between di-ations and allowed a safe method for guided bougie dilation.t the time of dilation, the string was cut and the proximalortion brought out through the mouth. The end of the stringxiting the gastrostomy was tied to a loop on the tapered endf the Tucker dilator. After removal of the tube, traction washen applied to the string exiting the mouth, pulling theougie across the gastrostomy and retrogradely into thesophageal stricture. Although Tucker’s initial descriptionncluded leaving the bougie across the stricture for 30 min-tes, this technique was subsequently modified to focusore on a graduated increase in dilator size. Once a bougie

ize of 30 French (Fr) in children or 40 Fr in adults had beenttained with this method, a transition to peroral dilation was

ften made.16 u

The use of Tucker dilators with an indwelling patencytring remained a safe and frequently employed treatment forhe most severe caustic strictures for most of the 20th cen-ury. A number of factors have likely contributed to the de-lining use of this technique, including earlier interventionn strictures (facilitating antegrade techniques), improve-ents in flexible endoscopes, the development of better and

afer dilating systems (both bougie and balloon-based), thehift in management of esophageal disorders from otolaryn-ologists to gastroenterologists, surgeons becoming moreacile with flexible endoscopes and associated devices/echniques, and the need for gastrostomy with retrogradepproaches. Nonetheless, guided retrograde bougie dila-ion has a proven track record of efficacy and safety; al-hough iatrogenic perforations have undoubtedly oc-urred using this method, this author and others haveeen unable to find a description of esophageal perforationith this technique.11

The first reports of retrograde management of complexsophageal strictures in the gastroenterology literature ap-ear in the 1970s. Roling described a patient with a distalsophageal stricture related to prolonged use of a nasogastricube that could not be traversed with antegrade passage of auestow wire. A gastrostomy tract was bougie-dilated, and aexible gastroscope was passed via the gastrostomy, allowingetrograde passage of a wire, which easily traversed the stric-ure. This facilitated subsequent placement of a heavy silktring, allowing repeated antegrade dilations with Puestowetal olives.21 Other endoscopists reported using transgas-

ric retrograde esophagoscopy in conjunction with peroralarium to define the distal and proximal margins of com-letely obstructing upper esophageal strictures to optimizeurgical planning.22,23

urrent Approaches toomplex Stricture Managementsing Retrograde Techniques

t present, the majority of complex esophageal strictures thatastrointestinal endoscopists are likely to encounter will beadiation-induced. The risk for perforation associated withhe endoscopic management of these complex strictureshiefly lies with the dilation itself; and series with more ag-ressive dilating technique also report a higher rate of perfo-ation14,15 than those in which smaller caliber dilation end-oints (eg, 11 to 14 mm) were routinely accepted.24,25

owever, even safe traversal of the stricture with a guidewireo allow subsequent dilation may be difficult in some com-lex radiation strictures. Particularly in the upper esophagusr hypopharynx, it can be technically difficult to identify therue lumen of the esophagus due to distorted anatomy andriable nature of the mucosa. Although no conclusive dataxist, the risk for complications with standard antegrade wireccess may be increased in these circumstances, and adversevents even with antegrade wire probing in this situationave been reported.26

In these instances where a severe, complex esophagealtricture is encountered and/or safe traversal of the strictureith a wire is not possible, consideration can be given to

sing a retrograde approach to traversing the stricture. The

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Retrograde approach to esophageal strictures 151

ajority of patients encountered with complex radiation-nduced esophageal strictures will already have a matureeeding gastrostomy in place; this allows for immediate ret-ograde esophagoscopy. If not, retrograde esophagoscopy vianewly created surgical gastrostomy in the operative suiteay be an option. Otherwise, it is advisable to allow 2 to 3eeks for maturation of a newly created surgical or radiologicastrostomy before instrumentation to avoid disruption ofhe tract. Retrograde esophagoscopy via jejunostomy fortricture management has also been reported.27

When accessing a 20- to 24-Fr gastrostomy, generally anltraslim (5.5 to 6.0 mm external diameter) endoscope cane passed without tract dilation. If a larger working channel isesired, tract dilation with wire-guided bougies or wire-uided hydrostatic endoscopic retrograde cholangiopancre-tography (ERCP) dilating balloons can be performed to per-it passage of a 9- to 10-mm diagnostic gastroscope. On

etrograde intubation of the esophagus and identification ofhe distal end of the stricture, a hydrophilic-tip ERCP guide-ire passed on its own or via a 5-Fr cannula toward theouth will often successfully traverse the stricture. The wireasses out of the mouth and allows subsequent antegradeougie or balloon dilation in a guided manner (Fig. 1),28,29

lthough balloon dilation via the retrograde instrument haslso been reported.30 This transgastric retrograde approachas also been applied for placement of esophageal stents inatients with both complex strictures and tracheoesophagealstulae.31,32

otal Esophageal Occlusionnd Antegrade–Retrogradeendezvous Approaches

n cases where a complex stricture leads to total esophagealcclusion, a retrograde approach in the endoscopic man-gement of these strictures becomes mandatory. Althoughotal esophageal occlusion has historically often necessi-

igure 1 (A) Schematic drawing of retrograde guidewire passagecross a stricture under endoscopic and fluoroscopic guidance.B) The wire is passed out through the mouth, allowing subsequentntegrade bougie dilation. (Reprinted with permission.29)

ated surgical correction,22,23,33 a number of case series p

ver the past decade have detailed successful endoscopicanagement using an antegrade–retrograde rendezvous

pproach.26,27,29,30,34-41 Again, perhaps surprisingly, this ap-ears to represent re-learning of an old method. In Chevalierackson’s 1934 text Bronchoscopy, Esophagoscopy, and Gastros-opy, the use of antegrade and retrograde rigid esophago-copes simultaneously under dual-plane fluoroscopy isescribed to dissect and recanalize a completely atreticsophageal lumen in rendezvous fashion.42

Complex strictures resulting in complete esophageal oc-lusion appear to occur most commonly after radiation foread and neck cancers, and as such, are frequently in theroximal esophagus or hypopharynx. Optimal sedation andirway control are important for success in antegrade–retro-rade rendezvous procedures, and accordingly, most are per-ormed under general anesthesia, although the use of con-cious sedation has been reported.26,27,35,40 The antegradenstrument may be a flexible gastroscope managed by a gas-rointestinal endoscopist or a rigid esophagoscope managedy a head and neck surgeon (as described in a separate chap-er). As previously mentioned, the retrograde instrumentassed via a mature gastrostomy or jejunostomy may be anltraslim gastroscope (eg, GIF-XP160 SlimSIGHT; Olympusmerica, Melville, NY), or, following gastrostomy/jejunos-

omy tract dilation, a standard diagnostic gastroscope. Al-hough the complete occlusion may be only a thin (�3 mm)emilucent membrane in many cases, allowing transillumi-ation from the opposing instrument to be observed, rou-ine fluoroscopy is advocated to ensure proper instrumentlignment.

A number of methods have been described for initial tra-ersal of the tissue comprising the obliterated segment ofsophagus. These include: use of a cold biopsy forceps,29,36

dissection” with a 0.035-inch ERCP guidewire26,27,35 or therm proximal end of a Savary wire,40 use of a needle–knife,37

se of a 19-gauge endoscopic ultrasound needle,37,38,41 andse of a microlaryngoscope blade.30 In some cases, dissectionrom both the retrograde and antegrade instrument may beeeded.26,39 Puncture is most often performed via the retro-rade instrument, although antegrade puncture has also beenescribed.26,40 On successful stricture traversal, a guidewireay be passed retrogradely, grasped by the antegrade instru-ent, and drawn out of the mouth, allowing for immediateilation. Although recanalization of occluded segments as longs 3 cm has been described using this endoscopic technique,37,41

onger atretic segments should be approached with caution and,n some cases, referred for surgical management.

Given the proximal location of these strictures, wire-uided bougies appear to be well-suited for dilation, al-hough TTS esophageal dilating balloons and biliary hydro-tatic dilating balloons have also been used for initial dilation.s these patients uniformly require subsequent serial dilation

or varying lengths of time, keeping the initial dilation diam-ter modest (eg, 7 to 11 mm) to maximize safety seems rea-onable, although endpoints are typically individualizedased on visual and tactile feedback.26,35 All patients requirelacement of a nasogastric tube to prevent early reclosuref the newly recanalized segment. The gastrostomy tube iseplaced and kept until peroral intake is satisfactory. Rep-esentative endoscopic and fluoroscopic images from a

atient with complete esophageal obstruction managed

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152 M. Hasan and J.T. Maple

ith an endoscopic rendezvous technique are shown inigure 2.Complications associated with antegrade–retrograde

endezvous for total esophageal obstruction have included f

sophageal/hypopharyngeal microperforation, associated withediastinal air on CT or chest x-ray, with or without neck

repitus on examination. In the reports in which microper-

gure 2 Images from an antegrade–retrograde rendezvous proce-ure for total esophageal occlusion. (A) Complete upper esopha-al obstruction as viewed from above. (B) View from below of

ght from endoscope in hypopharynx above membranous stric-re, after some dissection. (C) An ERCP catheter puncturing theembrane. (D) This fluoroscopy image shows two opposed endo-opes, separated only by the thin membranous obstruction. (E)n antegrade endoscopic image of the strictured area in the upperophagus at a follow-up examination 8 days after the rendezvousrocedure. (Reprinted with permission.26)

FidgelitumscAesp

oration occurred, it was usually a clinically unsuspected ra-

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Retrograde approach to esophageal strictures 153

iographic finding that resolved in all cases with conservativeanagement (eg, antibiotics) alone, and was likely guide-ire-related.26,40 Dehiscence of the gastrostomy tract duringilation and gastrostomy site infection have also been re-orted as complications arising from this procedure.40 Grossransmural perforation, bleeding, and mortality have noteen reported with this technique.Esophageal recanalization does not remedy the ana-

omic and functional abnormalities caused by radiationamage, thus, complete restoration of swallowing func-ion may not occur. However, many patients will be able toeet fluid and caloric requirements with oral intake alone,

nd training by a speech pathologist may maximize recov-ry of function. A multidisciplinary approach at a center ofxcellence is recommended in the care of these complexatients.

ummaryomplex esophageal strictures are more difficult to manage

han simple benign strictures and are associated with a higherate of complications with access and dilation. Some complextrictures, in which safe antegrade traversal of the strictureith a guidewire is not possible, may be effectively managedsing transgastric retrograde techniques. For completesophageal obstruction caused by complex radiation-in-uced strictures, an antegrade–retrograde rendezvous tech-ique using fluoroscopic guidance and careful dissectionan provide successful nonoperative esophageal recanali-ation. Although endoscopic retrograde approaches andntegrade–retrograde rendezvous techniques appear to beafe, experience is limited to small case series, and moreobust data are needed to refine the techniques and ensureptimum safety.

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