Successful treatment of cervical esophageal obstruction using combined antegrade and retrograde dilation with an endoscopic ultrasound needle and fully covered stent

While complete esophageal obstruction is a technically challenging problem, the combined antegrade and retrograde dilation (CARD) procedure provides an endoscopic treatment option for these obstructions [1] [2] [3], and the addition of an endoscopic ultrasound (EUS) needle increases the speed and convenience of the procedure [4] [5]. Here we describe use of this technique for the successful treatment of a long cervical esophageal occlusion by using flexible endoscopes and a fully covered removable stent.

A 61-year-old man presented to another institution with complete esophageal obstruction, 8 months after treatment for a T2N2B tonsillar squamous cell carcinoma. He required a gastrostomy tube for nutrition and was unable to swallow his own secretions. A conventional CARD procedure was attempted but unsuccessful due to the size of the obstruction.

Subsequently, the patient self-referred to our center for the CARD–EUS needle procedure. A 6-mm upper endoscope (GIF-XP160; Olympus, Hamburg, Germany) was introduced through the gastrostomy and advanced retrograde to the distal aspect of the occlusion, which was located in the cervical esophagus ([Fig. 1 a]).

Fig. 1 a Original retrograde endoscopic view of the completely obstructed esophageal lumen. b Fluoroscopic images taken in anteroposterior and lateral views to assure correct scope alignment. c A 19-gauge endoscopic ultrasound (EUS) needle is advanced antegrade through the fibrotic obstruction under fluoroscopic guidance until it is visualized by the retrograde scope. d An 11-mm over-the-wire balloon dilating the distal section of the esophageal obstruction, advanced and illuminated by the antegrade endoscope, as visualized by the retrograde endoscope. e Neo-esophageal lumen post dilation. f A removable, fully covered stent is placed to maintain patency under fluoroscopic guidance. Landmarks: jaw (red arrow), clavicle (green arrow), ends of deployed stent (blue arrows), esophageal inlet (white arrow).

A 9-mm flexible upper endoscope (GIF-Q180; Olympus) was advanced perorally to the proximal aspect of the stricture where C-arm fluoroscopy in the anteroposterior and lateral positions was used to align the endoscopes ([Fig. 1 b]). A 19-guage EUS needle was advanced through the antegrade endoscope and used to traverse the 3.2-cm obstruction under fluoroscopic guidance until visualized by the retrograde endoscope ([Fig. 1 c]). A hydrophilic 0.035-inch guide wire was then used to pass a 6-Fr biliary dilation catheter. Wire-guided balloon dilators were used to dilate the stricture to 11 mm at three stations with good effect ([Fig. 1 d, e]). A 7-cm × 18-mm fully covered removable stent was placed, taking care to open the proximal aspect of the occlusion without introducing the stent into the oropharynx, which proved difficult ([Fig. 1 f]). The duration of the procedure was 80 minutes.

The stent was removed at 9 weeks, whereupon the patient was taught to perform periodic self-dilation with a Maloney rigid esophageal dilator, with good results.

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References

• 1 Baumgart D C, Veltzke-Schlieker W, Wiedenmann B et al. Successful recanalization of a completely obliterated esophageal stricture by using an endoscopic rendezvous maneuver.  Gastrointest Endosc. 2005;  61 473-475
• 2 Bueno R, Swanson S J, Jaklitsch M T et al. Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction.  Gastrointest Endosc. 2001;  54 368-372
• 3 Raju G S, Ahmed I. Team approach to the management of complex esophageal obstruction.  Gastrointest Endosc. 2002;  55 304
• 4 Moyer M T, Stack Jr. B C, Mathew A. Successful recovery of esophageal patency in 2 patients with complete obstruction by using combined antegrade retrograde dilation procedure, needle knife, and EUS needle.  Gastrointest Endosc. 2006;  64 789-792
• 5 McGrath K, Brazer S. Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction.  Gastrointest Endosc. 2002;  56 163-164