Endoscopic ultrasound-guided recanalization of a complete esophageal stricture

Complete esophageal strictures are rare and pose technical challenges in management. We present a case of a 34-year-old man with a long-standing history of uncontrolled gastroesophageal reflux disease (GERD) who was referred for management of a complete esophageal stricture. Prior to his presentation, a gastrostomy tube was placed surgically owing to severe malnutrition.

Esophagogastroduodenoscopy revealed a complete esophageal stricture at 35 cm from the incisors without a clear luminal opening ([Fig. 1]). Contrast was instilled and fluoroscopically confirmed the endoscopic findings of a complete esophageal stricture. The decision was made to attempt endoscopic ultrasound (EUS)-guided placement of a lumen-apposing metal stent (LAMS). Initial endosonographic evaluation did not reveal a clear window to target a safe recanalization attempt ([Fig. 2]). The gastrostomy tube was used to instill copious amount of sterile water to distend the stomach allowing a target for LAMS placement under fluoroscopic and endosonographic guidance ([Fig. 3]). Once a safe window was achieved, a 19G needle puncture was performed and a 0.0125-inch guidewire was passed into the gastric lumen ([Fig. 4]). The LAMS was then deployed over the guidewire using electrocautery, and the fluid instilled into the stomach was seen passing through the stent ([Fig. 5]). The LAMS was then dilated using the through-the-scope esophageal balloon dilator up to 10 mm. At 4 weeks post-procedure, the patient is tolerating a soft diet and has gained 16 pounds.

Fig. 1 Endoscopic view of the complete esophageal stricture.

Fig. 2 Endosonographic view prior to water irrigation through the gastrostomy tube, revealing no clear window to target lumen-apposing metal stent placement.

Fig. 3 Endosonographic view after water irrigation through the gastrostomy tube.

Fig. 4 Fluoroscopic view after 19G needle puncture and wire advancement into the gastric lumen.

Fig. 5 Recanalized esophageal lumen after deployment of lumen-apposing metal stent.

Gastrostomies have been utilized to recanalize complete esophageal strictures using an antegrade and retrograde endoscopic approach for proximal strictures [1] [2]. In our case, the gastrostomy tube was used to create a pocket of fluid in the stomach to allow a target for LAMS deployment in the distal esophagus ([Video 1]).

Video 1 Endoscopic ultrasound-guided recanalization of a complete esophageal stricture using a lumen-apposing metal stent.

EUS-guided recanalization using a LAMS is an efficacious and safe option for patients with complete esophageal strictures. These interventions may prevent the need for more invasive surgical interventions.

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Publikationsverlauf

Artikel online veröffentlicht:
16. April 2021

• References

• 1 Kim M, Kats D, Kahaleh M. Kissing scopes: treatment of complete esophageal obstruction using combined antegrade/retrograde approach. Endoscopy 2021; 53: E106-E107
• 2 Schembre D, Dever JB, Glenn M. et al. Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus. Endoscopy 2011; 43: 434-437