A novel technique for the treatment of radiation-induced acquired esophageal atresia in a head and neck cancer patient. All authors have no disclosures. We present a 63-year-old female with a history of piriform sinus T3N2BM0 squamous cell carcinoma treated with chemoradiation, who presented to RGI clinic with significant dysphagia secondary to hypopharyngeal scarring. She finished three months of chemoradiation therapy with complete clinical response and follow-up imaging. During treatment, she developed severe dysphagia with inability to clear her secretions, necessitating surgical percutaneous gastrostomy tube placement. T3N2BM esophagram revealed poor oral bolus formation and delivery with thins and nectar liquids. ENT planned for esophageal dilation but found significant laryngeal and hypopharyngeal scarring with no inter-arachnoid region and no obvious esophageal introitus. This prompted the referral to RGI clinic. Upon discussion, decision to pursue upper endoscopy was made. Upper endoscopy under general anesthesia revealed obliteration of the hypopharynx. Despite gentle pressure, the endoscope was unable to be advanced, as you can see in the video. A retrograde approach was pursued and a pediatric gastroscope was inserted through the gastrostomy site and advanced into the esophagus to the area of stenosis. Using low-flow CO2 insufflation, gentle pressure was applied with a to and fro semicircular rotational movement as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner. The mucosa began to unfurl and the oropharynx was reached. The pediatric gastroscope was removed and an adult endoscope was reinserted in an antegrade fashion to the gastric antrum. A guide wire was threaded into the biopsy channel and the endoscope was withdrawn in an exchange process. Single dilation with an 18 millimeter dilator was performed with minimal resistance. The endoscope was reinserted and revealed adequate rent with no evidence of perforation. After recovery, the patient was discharged home the same day and was able to tolerate a soft diet. She did extremely well with no complications after the procedure. Approximately six months after, she did complain of dysphagia and required repeat dilation. These patients represent a challenge and require aggressive and unconventional interventions to reestablish luminal patency, such as a rendezvous or hybrid procedure that includes EUS with fluoroscopy in addition to endoscopy. It is plausible that with radiation therapy, the esophageal mucosa is denuded and the submucosa is exposed on the opposite walls, causing tissue adherence and eventual luminal atresia. The ability of the blunt tip of the endoscope to dissect its way through the atresia without causing any mucosal or deep tears argues for this hypothesis. If the esophagus fails to yield to the pressure of the endoscope in the anti-grade approach, a retrograde approach via gastrostomy should be tried. Failure to achieve luminal patency despite attempts for both approaches raises suspicion for underlying malignancy and adequate biopsies need to be obtained. We describe a novel yet simple technique to treat patients with acquired esophageal atresia post radiation for head and neck cancer who have not undergone laryngectomy. This technique allows for generous dilation, yielding complete resolution of the stenosis in a single session with no complications. Using this approach, the patient can be discharged home the same day and can resume immediate oral intake. Over the past five years, we have performed this technique in four other patients in both the anti-grade and retrograde approaches with similar success and efficacy. All patients had no complications. This highlights the effectiveness of this novel technique in the treatment of acquired esophageal atresia.

radiation-induced acquired esophageal atresia

head and neck cancer

dysphagia

hypopharyngeal scarring

chemoradiation therapy