Endoscopic ultrasonography evaluation combined with guidewire-guided cystotome therapy for refractory benign esophageal stricture: Improving the safety of treatment

Here we report a patient with a refractory benign esophageal stricture treated using endoscopic ultrasound (EUS) evaluation combined with guidewire-guided cystotome therapy as a new endoscopic approach.

The gastroscopy of a 32-year-old patient with dysphagia after two endoscopic dilatations revealed complete esophageal stricture about 30 cm from the incisors ([Fig. 1] a). Preoperative small-probe EUS showed that the most severe stricture of the wall thickened to 1.0 cm with a length of 3 cm, and no obvious structural damage was observed ([Fig. 1] b). A yellow Zebra guidewire (Boston Scientific, Marlborough, Massachusetts, USA) was first passed through the stricture, followed by a 6-Fr cystotome with a diathermic metal tip (Cysto Gastro-Set; ENDO-FLEX, Voerde, Germany) through guidewire to the stricture. Current was applied until the tip of the cystotome crossed the stricture and severed the muscle layer ([Fig. 2] a) using a standard sphincterotomy setting and maintaining Endo-Cut I mode (monopolar, forced coagulation, Effect-3, Coag 40 watts) ([Video 1]). EUS was used repeatedly to assess the thickness of the esophageal wall to guide the incision direction throughout the process ([Fig. 2] b). Finally, a lumen diameter of 1.2 cm was achieved, enabling the gastroscope to pass through ([Fig. 3] a, b). The patient responded well without major complications.

Fig. 1 Complete esophageal stricture. a Gastroscopy image of complete esophageal stricture about 30 cm from the incisors. b The most severe stricture of the esophageal wall thickened to 1.0 cm with a length of 3 cm, and no obvious structural damage was observed in the small-probe endoscopic ultrasound (EUS) image.

Fig. 2 Incision therapy with EUS evaluation combined with guidewire-guided cystotome. a A 6-Fr cystotome with a diathermic metal tip crossed through the yellow Zebra guidewire to the stricture, and current was applied up to the tip to sever the muscle layer. b EUS image of the muscle layer being severed during incision (indicated by arrows).

Fig. 3 Gastroscopic images after incision treatment. a Gastroscopic image after complete incision of esophageal stricture. b Gastroscope could reach the stomach through the stricture.

Endoscopic ultrasound evaluation combined with guidewire-guided cystotome therapy for refractory benign esophageal stricture.Video 1

Dilation with bougies or balloons is the classic endoscopic treatment for benign esophageal strictures [1], but over 30% of patients need continuing dilation for more than two sessions during long-term follow-up [2]. Martínez-Guillén et al. described the management of complete gastrointestinal strictures using an EUS-guided puncture, but one of the four cases failed due to a long stricture (>3 cm) [3]. In our case, the use of small-probe EUS to repeatedly evaluate the thickness of the stricture and the depth of incision allowed for more precise treatment, and using a cystotome to pass through the guidewire allowed accurate control of the direction of the incision, thereby reducing the incidence of perforation complications.

This therapy could be a new method and an extremely safe and useful accessory in refractory benign esophageal strictures.

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Publication History

Article published online:
11 February 2025

• References

• 1 Egan JV, Baron TH. Standards of Practice Committee. et al. Esophageal dilation. Gastrointest Endosc 2006; 63: 755-760
• 2 de Wijkerslooth LR, Vleggaar FP, Siersema PD. Endoscopic management of difficult or recurrent esophageal strictures. Am J Gastroenterol 2011; 106: 2080-2092
• 3 Martínez-Guillén M, Gornals JB, Consiglieri CF. et al. EUS-guided recanalization of complete gastrointestinal strictures. Rev Esp Enferm Dig 2017; 109: 643-647