CASE STUDIES Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique John T. Maple, DO, Bret T. Petersen, MD, Todd H. Baron, MD, Jan L. Kasperbauer, MD, Louis M. Wong Kee Song, MD, Mark V. Larson, MD Rochester, Minnesota, USA Background: Esophageal strictures occur in 3% to 4% of patients with head and neck cancer who undergo radiation therapy. Some patients develop complete obstruction of the upper esophagus. Antegrade dilatation is often unsuccessful and many of these patients require surgery. Objective: To describe the outcomes and complications of an endoscopic antegrade-retrograde rendezvous procedure to restore esophageal patency. Design: Retrospective review of 8 cases treated with an endoscopic rendezvous procedure between August 2001 and April 2005. Medical records of consenting patients were abstracted for clinical history, procedural suc- cess, complications, and follow-up. Setting: A large tertiary referral center. Patients: Eight patients with head and neck or upper esophageal cancer and complete upper esophageal ob- struction from radiation stricturing who underwent an attempted rendezvous procedure. Main Outcome Measurements: Clinical procedural success, reported adverse events. Results: Seven patients were men, and median age was 65 years. The median interval between radiation and the rendezvous procedure was 11 months. In 7 of 8 cases esophageal patency was restored and no major compli- cations occurred. Two esophageal microperforations resolved without intervention. Most patients responded well to subsequent serial dilations and many discontinued gastrostomy tube use. Limitations: Retrospective, selection bias. Conclusions: An antegrade-retrograde rendezvous technique with subsequent dilation appears to be safe and effective for endoscopic management of complete upper esophageal obstruction induced by radiotherapy and can obviate the need for esophageal resection. Injury to the GI tract is a well-recognized complication of external-beam radiation therapy. 1 Stricturing in the proxi- mal esophagus has been reported in 3% to 4% of patients with head and neck cancer 2 and 2% to 16% with lung can- cer 3 after treatment with radiotherapy. Esophageal strictur- ing has been associated with dosimetric parameters of the radiation therapy 2-4 and the occurrence of acute esophageal toxicity. 3 Radiation-induced esophageal strictures often re- quire repeated dilation sessions to effectively palliate dys- phagia, 5,6 and complications such as perforation and fistulae can occur with dilation treatments. 6 For strictures refractory to serial bougienage, positive outcomes have been described with intralesional steroid injection, 7 place- ment of self-expanding plastic 8 and partially covered metal stents, 9 and esophageal resection. 2,6 Difficult upper esophageal strictures are not uniformly amenable to antegrade dilation. Because of their location, distorted anatomy, and friable nature, visualization of the true esophageal lumen is often suboptimal. The risk for esophageal perforation with standard antegrade wire ac- cess and dilation may be increased. A variety of techniques have been described to facilitate access to these strictures. One such technique uses rigid laryngoscopy extended into the upper esophagus to anteriorly displace the larynx and ‘‘open up’’ the postcricoid esophagus for optimal Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.06.026 822 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 5 : 2006 www.giejournal.org