Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen

Treatment of locally advanced esophageal cancers with high-dose definitive concomitant chemoradiotherapy can lead to high-grade esophageal strictures, or, rarely, total obliteration of the lumen. Strictures can be successfully treated with various endoscopic techniques; however, complete obstruction is a technically challenging problem. Anterograde endoscopic techniques carry the risk of perforation or bleeding. A combined anterograde–retrograde dilation technique, described in a few reports, is another option but requires retrograde access through a prior ostomy [1] [2] [3] [4].

We report a novel method for managing complete esophageal obstruction using endoscopic ultrasound (EUS)-guided puncture for access to the distal lumen, previously described only in a case of total colonic stricture using a prototype forward-view echoendoscope [5].

A 62-year-old woman had received high-dose chemoradiation for a squamous cell esophageal carcinoma (stage IIIC) and her esophagus had completely occluded, with severe compromise to her quality of life ([Fig. 1]). Several attempts to pass a guide wire though the stricture were unsuccessful.

Fig. 1 Endoscopic view, showing complete obliteration of the esophageal lumen after high-dose chemoradiation in a 62-year-old woman.

We decided to attempt recanalization of the lumen using an EUS-guided access. The linear echoendoscope (GF-UCT140-AL5; Olympus, Tokyo, Japan) was advanced 24 cm from the incisors and the distal esophageal lumen was identified from the proximal end on the EUS image ([Fig. 2 a]). A 19G needle (Expect Flex; Boston Scientific Corp, Natick, Massachusetts, USA) was used to puncture the obstructed lumen under EUS guidance ([Fig. 2 b]). Contrast filling was visualized under fluoroscopy and a 0.035-inch guide wire (Microvasive Jagwire; Boston Scientific) was advanced through the EUS needle ([Fig. 3 a, b]). An 8-mm biliary balloon (Hurricane RX; Boston Scientific) was used to perform a first dilation under endoscopic and fluoroscopic guidance ([Fig. 3 c]). The endoscopic appearance after dilation was satisfactory, with re-establishment of luminal continuity ([Video 1]).

Fig. 2 a, b EUS images of the esophageal total stricture. a A thickened esophageal wall (arrows) continues through the stenosis. b EUS image of the 19G needle through the stricture (arrow).

Fig. 3 a Fluoroscopic image of the echoendoscope and an esophagogram obtained after the guided puncture. b, c Endoscopic views. b A 0.035-inch guide wire is advanced to the distal esophageal lumen. c Dilation up to 8 mm with a biliary balloon.

Successful treatment of a completely obstructed esophageal stricture using endoscopic ultrasound-guided puncture.

The patient underwent four additional endoscopic balloon dilations of up to 15 mm ([Fig. 4]). She responded well, gaining the ability to swallow secretions, drinks, and soft food, and without evidence of delayed complications.

Fig. 4 Endoscopic view after two balloon dilation sessions up to 15 mm, at 8-weeks follow-up after recanalization.

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• References

• 1 Goguen LA, Norris CM, Jaklitsch MT et al. Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis. Laryngoscope 2010; 120: 261-266
• 2 Mukherjee K, Cash MP, Burkey BB et al. Antegrade and retrograde endoscopy for treatment of esophageal stricture. Am Surg 2008; 74: 686-687
• 3 Gornals JB, Nogueira J, Castellvi JM et al. Combined antegrade and retrograde esophageal endoscopic dilation for radiation-induced complete esophageal stenosis. Dig Endosc 2012; 24: 483
• 4 Bueno R, Swanson SJ, Jaklitsch MT et al. Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction. Gastrointest Endosc 2001; 54: 368-372
• 5 De Lusong MA, Shah JN, Soektino R et al. Treatment of a completely obstructed colonic anastomotic stricture by using a prototype forward-array echoendoscope and facilitated by SpyGlass (with videos). Gastrointest Endosc 2008; 68: 988-992