A 63-year-old woman who had undergone resection of adenocarcinoma at the gastroesophageal
junction was admitted with complete obstruction of the esophagogastric anastomosis
([Fig. 1]). For the past 2 years, gastrostomy tube feeding had been her only source of enteral
nutrition. Endoscopic ultrasound (EUS)-guided rendezvous recanalization of the obstruction
was attempted to allow her to resume oral intake ([Video 1]).
Fig. 1 Completely obstructed esophagogastric anastomosis in a 63-year-old woman.
Video 1 Endoscopic ultrasound-guided rendezvous recanalization of a completely obstructed
esophagogastric anastomosis.
An antegrade linear ultrasound endoscope was placed at the blind end of the esophagus
to locate the gastric lumen, determine the optimal puncture site, and guide the puncture
process. A retrograde standard endoscope with biopsy forceps was introduced via the
gastrostomy tube to offer direct vision of the gastric lumen, assist puncture, and
function as a location sign with a strong echo ([Fig. 2]). A 19-gauge needle was advanced towards the gastric lumen under Doppler EUS guidance
([Fig. 3]). Once the needle had passed beyond the obstruction, a guidewire was inserted through
it. Next, a 6-Fr biliary dilation catheter was advanced over the guidewire. Sequential
endoscopic balloon dilations were then performed over a 2-month period before a fully
covered retrievable metal stent (60 × 20 mm) was deployed ([Fig. 4]). No adverse event occurred. The patient started to eat semiliquid food and gained
weight, so the gastrostomy tube was removed. After 2 months, the esophageal stent
was retrieved, followed by another dilation, and the tract from the esophagus to the
stomach was seen to be well formed ([Fig. 5]).
Fig. 2 The endoscope with forceps (green arrow) in the gastric lumen was detected by endoscopic
ultrasound (EUS) as a strong echo, from the tip of which the puncture route was marked
(yellow dotted line).
Fig. 3 A 19-gauge needle (white arrow) was advanced towards the gastric cavity under Doppler
EUS guidance.
Fig. 4 A fully covered retrievable metal stent (60 × 20 mm) was placed.
Fig. 5 The stent was removed, followed by another dilation, and the tract from the esophagus
to the stomach was seen to be well formed.
The treatment of a completely obstructed esophagogastric anastomosis was often reported
as part of the treatment of complete esophageal obstruction (CEO), and combined antegrade–retrograde
endoscopic dilation (CARD) has been the most widely used approach in CEO [1]
[2]. However, the fluoroscopically guided access procedure is not precise enough because
of limited real-time guidance and the invisibility of adjacent structures and vessels;
this is why we introduced EUS into the scenario. Although we report it here in the
setting of anastomotic obstruction, the technique may be extrapolated to the treatment
of CEO from other causes.
Endoscopy_UCTN_Code_TTT_1AO_2AN
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply (currently EUR
375), discounts and wavers acc. to HINARI are available.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
