Safety and efficacy of combined antegrade and retrograde endoscopic dilation for complete esophageal obstruction: a systematic review and meta-analysis

BACKGROUND: Complete esophageal obstruction (CEO) due to occlusive proximal stricture occurs after chemoradiation for head and neck cancers. A combined antegrade and retrograde endoscopic technique with controlled recanalization and dilation (CARD) has been shown to be an effective and safe method for regaining and maintaining esophageal luminal patency in the short term. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception through November 2018), to identify studies that reported the outcomes of CARD. The primary outcomes were the pooled rates of technical and clinical success, specifically improvement in dysphagia and independence from percutaneous endoscopic gastrostomy (PEG)-tube feeds. The secondary outcomes were the need for repeat dilations and the risks of complications, such as pneumomediastinum, perforation, and death. RESULTS: From a total of 19 studies (229 cases and 251 procedures) the calculated technical success rate was 88.9% (95% confidence interval [CI] 83.9-92.5, I(2)=0). The rates of improvement in dysphagia and being PEG-tube free were 58.4% (95%CI 50-66.3, I(2)=12.6) and 43.5% (95%CI 34.1-53.4, I(2)=30.6), respectively. The pooled rate of repeat dilatations was 78.9% (95%CI 69.7-85.8, I(2)=15.2). The risks of pneumomediastinum, perforation and death were 9.9% (95%CI 6.2-15.6, I(2)=0), 8% (95%CI 4.8-13, I(2)=0), and 6.8% (95%CI 3.4-13.1, I(2)=0), respectively. Minimal heterogeneity was noted in the analysis. CONCLUSIONS: The CARD procedure for CEO has a high technical success rate, but also a high rate of repeat dilations. Given its complexity and associated adverse events, this procedure should be restricted to centers with a high level of expertise.