Anterograde-retrograde rendezvous approach for radiation-induced complete upper oesophageal sphincter stenosis: case report and literature review.

BACKGROUND: Strictures of the hypopharynx and oesophagus are frequently observed following (chemo)radiation. Anterograde dilatation of a complete stenosis carries a high risk of perforation. An alternative is described: a combined anterograde-retrograde approach. CASE REPORT: A 75-year-old man developed complete stenosis of the oesophageal inlet after primary radiotherapy for laryngeal carcinoma and full percutaneous endoscopic gastrostomy feeding. To prevent creation of a false route into the mediastinum, a dilatation wire was introduced in a retrograde fashion into the oesophagus, through the gastrostomy opening. The wire was endoscopically identified from the proximal side and then passed through a perforation created by CO2 laser. Anterograde dilatation was safely performed, and the patient returned to a normal diet. There is consensus in the literature that blind anterograde dilatation carries a high risk of perforation; therefore, an anterograde-retrograde rendezvous technique is advisable. CONCLUSION: In cases of complete obstruction of the oesophageal inlet, anterograde-retrograde dilatation represents a safe technique with which to restore enteric continuity.

Genesis of the decrement of intraluminal pressure in the UES during swallowing in rabbits.

The intraluminal pressure in the upper esophageal sphincter (UES) briefly decreases during swallowing. This decrement in pressure plays an important role in smooth transport of the ingested bolus from the pharynx to the esophagus. It is known that the decrement is caused by cessation of tonic activity of the cricopharyngeus (CP) muscle and also by elevation of the larynx. On the other hand, it is suspected that the recurrent laryngeal nerve (RLN) also contributes to the decrement, since our preliminary study showed for the first time that the decrement in UES pressure was much reduced after the RLN was sectioned. In the present study, we examined the genesis of the decrement of the UES pressure in anesthetized rabbits. When swallowing was elicited by repetitive electrical stimulation of the superior laryngeal nerve, the UES pressure briefly decreased and then abruptly increased. After bilateral sectioning of the RLN, the decrement of the pressure was significantly reduced, whereas the increment was little altered. Sectioning of the pharyngeal branch of the vagus nerve (X-ph) and the RLN mostly eliminated both the decrement and increment of the pressure, and abolished tonic and burst activities of the CP muscle. Electrical stimulation of peripheral end of the RLN decreased the pressure. These results indicate that the RLN and X-ph are involved in the decrement of the UES pressure during swallowing. The RLN generates the decrement by adducting the arytenoid cartilage and closing the glottis. The X-ph contributes to the decrement both by suppressing the tonic activity of the CP muscle and by regulating the laryngeal elevation.