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Ann Thorac Surg 2006;82:1243-1244
© 2006 The Society of Thoracic Surgeons
Department of Surgery, Union Memorial Hospital, JPB, 3333 N Calvert St, Suite 610, Baltimore, MD 21218-2895
(Email: richard.heitmiller{at}medstar.net).
Few clinical problems are more frustrating to deal with and complex to manage than an occluded, or nearly occluded, cervical esophageal stricture. If the lumen remains open, the stricture can be managed with serial dilatations or with an increasing array of luminal stents. Cervical strictures can sometimes renarrow, even close, very quickly. Once this happens, they can no longer be dilated using the antegrade route. Options for management now become limited and invasive: open anastomoplasty or redo reconstruction.
Garcia and colleagues [1] report a technique that uses retrograde passage of a guidewire to permit antegrade dilatation of the stricture. A flexible endoscope is introduced through dilated gastrostomy or jejunostomy tube tracks to access the cervical stricture from below. Stricture dilatation was successful without perforation in all 8 patients.
As with many good studies, reported solutions lead to new questions. In this study, the authors access the distal gastrointestinal tract through gastrostomy or jejunostomy. Obviously, their technique requires a preexisting enterostomy tube. It is implied that these tracks can be routinely dilated to accept a flexible endoscope. Is this always the case? Other questions raised by this work include: Does the enterostomy tube site need to be initially prepared specifically for this method? Who should perform it? and Can this method be adapted to an open approach if no enterostomy sites are present?
This article underscores the fact that getting the stricture dilated open is only one piece of the swallowing puzzle: posttreatment functional outcome varies according to the etiology of the stricture. Post-chemoradiation head and neck cancer patients fare the worst. Half of these patients (3 of 6) could not tolerate any oral feedings after dilatation because of preexisting, post-chemoradiation swallowing dysfunction. It is not stated if this subset of patients had any benefit from treatment, such as the ability to at least handle their secretions, of if they could be identified predilatation. Patients with postesophagectomy anastomotic strictures appear to do much better, although there were only two. Regardless of the cause of stricture, most patients continue to require long-term maintenance dilatations.
Still, Garcia and colleagues [1] have described an interesting and apparently effective method of minimally invasively opening tight and occluded cervical esophageal strictures.
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