Complete esophageal obstruction (CEO) is an uncommon but debilitating late complication of chemoradiotherapy for head and neck cancers, with reported incidence ranging from 0.8% to 5%. Affected patients experience profound dysphagia, often losing the ability to swallow even saliva, resulting in dependence on enteral feeding and markedly impaired quality of life. While traditional management relied on complex surgical reconstruction, the combined antegrade and retrograde endoscopic dilation (CARD) technique has emerged as a less invasive and increasingly preferred option. CARD facilitates safe recanalization of obstructed esophageal segments, but its use in upper esophageal strictures, particularly those near the upper esophageal sphincter, remains technically challenging and underreported. We present two cases of radiation-induced CEO involving the upper esophagus, emphasizing procedural strategies, outcomes, and practical considerations.

The first case involved a 54-year-old man treated previously with chemotherapy and radiotherapy for buccal squamous cell carcinoma. He presented with complete dysphagia (FOIS 1) and dependence on a pre-existing PEG tube. Endoscopic evaluation revealed total obstruction just below the pyriform fossa. CARD was performed using dual ultrathin gastroscopes introduced antegrade and retrograde, with transillumination enabling precise scope alignment in this anatomically difficult region. A needle-knife puncture was made through the fibrotic segment, followed by guidewire passage and sequential Savary dilation up to 15 mm. The procedure was technically successful and complication-free. After subsequent dilations, the patient achieved sustained recanalization and full PEG removal, ultimately tolerating a soft diet (FOIS 6) at one year.

The second case involved a 15-year-old boy with hypopharyngeal squamous cell carcinoma who also presented with absolute dysphagia and PEG dependence. CARD was performed with transillumination guidance, needle puncture, cystotome-assisted tract creation, and sequential balloon and mechanical dilatation. A nasogastric tube was left across the recanalized lumen to maintain patency. Although initial improvement allowed limited oral intake, early recurrence was noted. Repeat CARD and serial dilations resulted in improvement to FOIS 3 (liquids only), though PEG dependence persisted. Mild bleeding occurred but resolved spontaneously, consistent with the low complication rates reported in the literature.

These cases demonstrate that CARD is a safe and effective modality for managing radiation-induced CEO, even in anatomically constrained upper esophageal locations. Successful recanalization can significantly improve swallowing function and quality of life. However, recurrence remains a major limitation, particularly in pediatric patients and in severe post-radiation fibrosis, necessitating repeated interventions and long-term multidisciplinary follow-up. Overall, CARD offers a minimally invasive alternative to surgery, with meaningful functional benefits despite its inherent challenges.