Complete esophageal obstruction (CEO) is a rare complication of chemo-radiotherapy performed for head and neck or esophageal malignancies.1 This incidence is dose-dependent and occurs in 0.8%-5% of patients receiving >60 Gy exposure.2 Although most often observed in malignant diseases, CEO can also occur as a late complication of benign diseases such as severe reflux disease (peptic stricture), caustic esophageal injury, eosinophilic esophagitis, and rarely congenital causes.3 Typical clinical symptoms include severe dysphagia or aphagia with the inability to tolerate secretions. van Twisk et al.4 described a combined antegrade-retrograde rendezvous procedure with recanalization and dilation (CARD) for endoscopic management of CEO, which remains the most commonly used approach. Other endoscopic techniques include per-oral endoscopic tunneling for restoration of the esophagus (POETRE) and endoscopic ultrasound (EUS)-guided recanalization.
A 66-year-old male with squamous cell carcinoma of the gastro-esophageal junction (GEJ) had received several sessions of chemo-radiotherapy. Therefore, he developed a lower esophageal-GEJ stricture and underwent multiple endoscopic dilatations. Computed tomography (CT) scans of the thorax and abdomen along with biopsies at the stricture site were negative for tumor recurrence. A fully covered esophageal self-expandable metallic stent (SEMS) was placed because of the refractory nature of the stricture; however, this corrective attempt failed. He had also undergone a percutaneous endoscopic gastrostomy (PEG) tube insertion to maintain adequate nutrition 1 year prior. He received continuous PEG feeds and was lost for follow-up for approximately 6 months. The patient presented to our outpatient clinic with absolute dysphagia that had persisted for 3 weeks. An upper gastrointestinal (UGI) endoscopy was performed using an Olympus GIF-H190 gastroscope and showed a completed esophageal obstruction at 38 cm from the upper incisors (Fig. 1A). A CT scan showed a dilated esophagus with contrast pooling at the GEJ level. Notably, blood analyses were normal. Endoscopic CARD was attempted using two Olympus GIF-H190 gastroscopes. The antegrade scope (referred to as G1) was passed into the esophagus until it reached the obstruction site, and the retrograde scope (referred to as G2) was passed through the matured gastrostomy site up to the GEJ. A Boston Scientific 0.035 jag-wire through the G2 scope failed to pass across the obstruction into the esophageal lumen. Despite multiple attempts, the guide wire could not be navigated across the obstruction from the G1 and G2 scopes. After appropriate counseling and consent, a decision to attempt recanalization through an antegrade approach was made. Using the G2 scope, the distal site of the obstruction at GEJ was thoroughly examined for ulcers, lesions, or mucosal abnormalities. Both the G1 and G2 scopes were positioned at the site of obstruction, causing minimal luminal indentation on both ends. This was confirmed using fluoroscopy and the length between the scope tips was measured to be approximately 1 cm (Fig. 1B). Transillumination of the G1 and G2 scopes was demonstrated, which indirectly represents a short length of the stricture (Fig. 1C). A luminal puncture was made at the maximum site of transillumination created by the G2 scope using a needle knife sphincterotome (RX Needle Knife XL, Boston Scientific) through the G1 scope. The puncture was confirmed by direct visualization of the needle entry into the stomach from the G2 scope followed by entry of the sphincterotome (Fig. 2A and B). The 0.035 inch wire (Jagwire™ High Performance Guidewire, Boston Scientific) passed from the G1 scope through the puncture site (Fig. 2C) and serial dilatation of the tract was made using 4-7 Fr biliary dilators (Sohendra® Biliary Dilation Catheter, Cook Medical) (4–7 Fr) (Fig. 2D). This was followed by serial wire-guided controlled radial expansion (CRE) balloon dilatation of up to 10 mm using a CRE™ PRO Wireguided Balloon Dilatation Catheter (Boston Scientific) (Fig. 2E, F). Following balloon dilatation, luminal recanalization was achieved (Fig. 3A) and an 18×100 mm fully covered esophageal SEMS (Niti-S Esophageal Covered Stent, TaeWoong Medical) was placed under endoscopic guidance with its proximal end at 35 cm and fixed at this position using two hemoclips (Fig. 3B). The patient was stable post-procedure and PEG feeds were continued. After the esophageal SEMS was in situ for 6 weeks, a UGI endoscopy was performed, which showed spontaneous migration of the SEMS into the stomach and adequate luminal restoration at the GEJ (Fig. 3C). The PEG tube was removed after a time and the patient stared oral feeding. At 3 months follow-up, the patient remained stable and oral feeds were continuing, with no recurrence of a stricture.
CEO is an uncommon complication that often occurs because of high-dose radiation for head and neck or esophageal malignancies. In rare cases, even benign esophageal diseases can lead to CEO. The underlying pathology is a progressive chronic inflammatory state with subsequent fibrosis and collagen deposition secondary to radiation exposure. This results in a connective tissue membrane that reduces the esophageal lumen frequently.5 Clinically, CEO is characterized by severe dysphagia or aphagia, and an esophagram typically shows an obstructed “blind” esophageal lumen.
In the paper, van Twisk et al.4 first described combined the antegrade-retrograde rendezvous procedure with recanalization and dilation to obtain CARD, but this approach was more commonly used after a case series published by Bueno et al.6 The principle of CARD involves using an antegrade scope (oral) and a retrograde scope (gastrostomy), which are placed in close proximity using fluoro-guidance. Both floppy tip biliary guidewires (0.035, 0.025, or 0.019 inch) and spring tip wires are used to assess luminal patency under fluoroscopy. Once a guide wire is passed across the obstruction site, luminal dilatation is performed using standard techniques.7 If the guide wire cannot be passed across the obstruction and the distance between the antegrade and retrograde scopes is ≤3 cm, an EUS approach is used. A linear echoendoscope is advanced to the site of obstruction, and the opposite end of the stricture is identified through EUS following the muscularis propria of the digestive wall. An EUS-guided puncture is performed with a 22-G or 19-G needle, followed by contrast filling, visualized using fluoroscopy, and a guide wire is passed through the gastrointestinal stricture. This is followed by over-the-wire stricture dilatation using standard bougie dilators or balloon dilators.8 POETRE can be performed in cases in which the antegrade and retrograde scopes are separated by >3 cm. After creating a submucosal “bleb,” submucosal tunneling is created after the injection of saline-indigo carmine solution. Submucosal tunneling then proceeds caudally and is achieved through repeat injections and dissection with a T-type Hybrid Knife.9
Blind antegrade endoscopic puncture or dilation is generally not performed owing to the risk of complications such as perforations and fistula. This risk is even higher in the neck and cervical esophagus as the region is surrounded by critical structures.10 Our patient had a short (approximately 1 cm) stricture in the distal esophagus/GEJ, which was confirmed using fluoroscopy. In addition, the exact point of antegrade puncture was determined using transillumination with both the antegrade and retrograde scopes. An antegrade free hand puncture was made with the needle knife positioned perpendicular to the site of maximum transillumination, and entry of the needle into the stomach was visualized using the retrograde scope from the matured gastrostomy site.
Although a blind antegrade puncture and dilatation of the CEO are not typically performed, antegrade puncture can be safely performed in limited cases. Patients with a distal CEO and a short segment obstruction (<1 cm), as confirmed by the length between the ante-retrograde scopes and relatively thinner septum, which is evident by transillumination, are possible candidates for attempting a safe antegrade puncture. In addition, this approach can be performed in a few selected groups of patients at centers without an EUS scope or competency. Informed consent was obtained for this case report.
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Author Contributions
Conceptualization: VP, PKJ; Data curation: NKR, PKJ; Investigation: VP, NKR; Methodology: all authors; Project administration: NKR; Supervision: PKJ; Validation: PKJ; Visualization: all authors; Writing–original draft: VP; Writing–review and editing: VP, PKJ.
Fig. 1.(A) Endoscopic image of complete esophageal obstruction. (B) Fluoroscopic image of antegrade (G1) and retrograde (G2) gastroscopes in close proximity; (C) Transillumination image of the G2 gastroscope.
Fig. 2.(A) Endoscopic visualization of needle knife entry into the stomach from the G2 scope. (B) Entry of the sphincterotome. (C) Endoscopic image of successful passage of guidewire into the stomach. (D) Entry of Sohendra dilator as visualized using the G2 scope. (E), Antegrade endoscopic image of controlled radial expansion balloon dilatating the stricture site. (F) Retrograde endoscopic image of the balloon.
Fig. 3.(A) Esophageal luminal recanalization. (B) Esophageal self-expandable metallic stent placed after recanalization. (C) Esophageal restoration on follow-up.
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