Endoscopic rendezvous technique and esophageal fistulae: sometimes it is worth working in the dark!

We read with interest the article by Schembre et al. on the use of the rendezvous technique in patients with a completely obstructed esophagus [1]. The combined antegrade and retrograde access to both proximal and distal margins of esophageal strictures was initially described by Bueno et al. in 2001 [2]. Since then, a few case series describing the outcomes of the rendezvous technique have been published [1] [3] [4] [5] [6] [7].

The main technical difficulty is the presence of a completely obliterated lumen. When thin membranes are present, recanalization may be obtained by puncture, with the help of transillumination by using an endoscopic retrograde cholangiopancreatography catheter [4] or biopsy forceps [2] [3] or by removing the obstructing tissue with a biopsy forceps [2]. In cases where a longer distance separates the tips of the two endoscopes, a blind puncture may be needed, as was recently described with the use of an endoscopic ultrasound needle [1] [5] or needle-knife [6] as a puncturing device. The new track thus created may not necessarily contain all the elements of the esophageal wall, which is sealed thereafter with the placement of a stent. However, in patients with malignant stenosis, the anatomy is often altered by malignancy itself, radiation treatment, and possible esophageal fistula to the lung, pleura, mediastinum or airway ([Fig. 1]).

Fig. 1 A 57-year-old patient, with history of advanced bronchial carcinoma under radiotherapy, was admitted for complete esophageal stenosis. Gastroscopy revealed a communication of the mid-esophagus with the bronchial tree.

In the case of fistulae, multiple orifices may be present and the identification of the one that corresponds to the true distal lumen of the esophagus becomes challenging. In order to overcome this difficulty, the following technique could be applied: after alignment of the two endoscopes under fluoroscopy, the light source of the retrograde or antegrade endoscope is turned off for a few seconds, in order to let the light transmitted from the other endoscope guide us towards the right direction ([Fig. 2 ] a – c).

Fig. 2 Technique to overcome the difficulty of identifying the true distal lumen of the esophagus when multiple orifices are present due to fistulae. a Simultaneous antegrade and retrograde view of a complete mid-esophageal malignant stenosis in communication with a mediastinal cavity and the bronchial tree. The true esophageal lumen could not be identified due to the presence of multiple orifices that corresponded either to fistulae or bronchi. b By turning off the light source of the retrograde pediatric endoscope, with an outer diameter of 5.9 mm, the orifice that corresponded to the true esophageal lumen was recognized, with the help of the light transmitted by the other standard endoscope. c Antegrade view of the rendezvous. Notice that the light source of the retrograde endoscope is turned off.

In this way the orifice that corresponds to the esophageal lumen may be identified correctly, avoiding blind canalization. Endoscopy is all about light, but sometimes it is worth working in the dark.

References

• 1 Schembre D, Dever J B, Glenn M et al. Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus.  Endoscopy. 2011;  43 434-437
• 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 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
• 4 Maple J T, Petersen B T, Baron T H et al. Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique.  Gastrointest Endosc. 2006;  64 822-828
• 5 Al-Haddad M, Pungpapong S, Wallace M B et al. Antegrade and retrograde endoscopic approach in the establishment of a neo-esophagus: a novel technique.  Gastrointest Endosc. 2007;  65 290-294
• 6 Moyer M T, Stack B C, Mathew A et al. 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
• 7 Dellon E S, Cullen N R, Madanick R D et al. Outcomes of a combined antegrade and retrograde approach for dilatation of radiation-induced esophageal strictures (with video).  Gastrointest Endosc. 2009;  71 1122-1129