HSC Section 6 Nov2016 Green Book

Peng et al

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statis- tics, 2002. CA Cancer J Clin . 2005;55(2):74-108. 2. Francis DO, Weymuller EA Jr, Parvathaneni U, Merati AL, Yueh B. Dysphagia, stricture, and pneumonia in head and neck cancer patients: does treatment modality matter? Ann Otol Rhinol Laryngol . 2010;119(6):391-397. 3. Nguyen NP, Sallah S, Karlsson U, Antoine JE. Combined chemotherapy and radiation therapy for head and neck malig- nancies: quality of life issues. Cancer . 2002;94(4):1131-1141. 4. Lazarus CL, Logemann JA, Pauloski BR, et al. Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy. Laryngoscope . 1996;106(9, pt 1):1157-1166. 5. Smith RV, Kotz T, Beitler JJ, Wadler S. Long-term swallow- ing problems after organ preservation therapy with concomi- tant radiation therapy and intravenous hydroxyurea: initial results. Arch Otolaryngol Head Neck Surg . 2000;126(3):384- 389. 6. Silvain C, Barrioz T, Besson I, et al. Treatment and long-term outcome of chronic radiation esophagitis after radiation ther- apy for head and neck tumors. A report of 13 cases. Dig Dis Sci . 1993;38(5):927-931. 7. Laurell G, Kraepelien T, Mavroidis P, et al. Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer . 2003;97(7):1693-1700. 8. Hutcheson KA, Lewin JS. Functional outcomes after chemo- radiotherapy of laryngeal and pharyngeal cancers. Curr Oncol Rep . 2012;14(2):158-165. 9. Lee WT, Akst LM, Adelstein DJ, et al. Risk factors for hypo- pharyngeal/upper esophageal stricture formation after concur- rent chemoradiation. Head Neck . 2006;28(9):808-812. 10. Best SR, Ha PK, Blanco RG, et al. Factors associated with pharyngoesophageal stricture in patients treated with concur- rent chemotherapy and radiation therapy for oropharyngeal squamous cell carcinoma. Head Neck . 2011;33(12):1727- 1734. 11. Nguyen NP, Smith HJ, Sallah S. Evaluation and management of swallowing dysfunction following chemoradiation for head and neck cancer. Curr Opin Otolaryngol Head Neck Surg . 2007;15(2):130-133. 12. Platteaux N, Dirix P, Dejaeger E, Nuyts S. Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia . 2010;25(2):139-152. 13. Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in head and neck oncology. Laryngoscope . 2002;112(12):2242-2243. 14. Lew RJ, Shah JN, Chalian A, Weber RS, Williams NN, Kochman ML. Technique of endoscopic retrograde puncture and dilatation of total esophageal stenosis in patients with radiation-induced strictures. Head Neck . 2004;26(2):179-183. 15. Salassa JR. A functional outcome swallowing scale for stag- ing oropharyngeal dysphagia. Dig Dis . 1999;17(4):230-234.

there was no report of preintervention or postintervention G-tube status. Ahlawat et al 24 performed dilation on 24 patients and reported technical success (endoscopic dilation to 14 mm) in 19 patients and functional success (occasional dysphagia to solid foods) in 18 patients. Again, G-tube sta- tus was not available. Our technique improves on these out- comes, however, as the rate of conversion from G-tube dependence to predominantly oral nutrition—75% in our study population—greatly exceeds the success rates reported previously. 6,7,23,24 Furthermore, whereas others have demonstrated good results (81% of patients maintain- ing weight with oral diet) from dilation of the hypopharynx and upper esophagus, 25 we have achieved these results without complications and with serial dilations in the clinic setting without general anesthesia. Our use of the TNE accomplishes both diagnostic and therapeutic purposes. Transnasal esophagoscopy is well tol- erated in awake patients in the office setting, and we employ the same scope in the operating room, which is beneficial for consistency in assessing the degree of stenosis. Exposure for rigid esophagoscopy may be quite difficult or impossi- ble following CRT, and thus use of the flexible TNE improves our ability to treat challenging cases. Some of the residual esophageal lumens are quite small, and using the 5.1-mm TNE allows successful passage through the steno- sis that is not always achieved with the larger gastroscopes. Similarly, the small size allows retrograde passage through the gastrostomy without requiring dilation, thus minimizing morbidity; our results compare very favorably to another series of 45 patients using the retrograde approach reporting G-tube site morbidities in 7 of 63 (11%) procedures. 26 The ability to perform transnasal esophagoscopy and dilation in the office setting confers additional advantages, not in the least that general anesthesia and its concomitant risks are avoided. Conclusion Patients with esophageal stenosis after CRT can be success- fully managed, with the majority achieving a full oral diet. Transnasal esophagoscopy is an important tool in our arma- mentarium of management of esophageal stenosis follow- ing chemoradiation for head and neck cancer. The versatility of transnasal esophagoscopy as an adjunct to esophageal dilation, with either guidewire or balloon dilators, allows for its use in both operative and office settings. As demon- strated here, our algorithm is well tolerated, highly effec- tive, and associated with little morbidity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

130