Re-establishment of the digestive lumen in a postesophagectomy anastomotic atresia under endoscopic ultrasound guidance

A 71-year-old man was referred to our department with a post-esophagectomy anastomotic atresia. Nine months previously, he had undergone transhiatal esophagectomy for esophageal intramucosal squamous carcinoma. Frustratingly, he developed a serious post-esophagectomy stenosis. Several esophageal bouginage and stent procedures failed to stop the progressive stenosis. Finally, a jejunal nutrition tube was placed for feeding, piercing the epigastric skin.

After the large amount of retained fluid had been suctioned, the upper esophagus appeared to be blocked and a guidewire could not be advanced under esophagogastroduodenoscopy guidance ([Fig. 1]). Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to reconnect the esophagus and stomach ([Fig. 2 a]). Reverse-direction transnasal gastroscopy from the jejunal fistula and digital subtraction angiography were used to monitor the process ([Fig. 2 b]). A zebra guidewire was then placed into the channel to guide the subsequent dilation with a cystotome and placement of a stent. After removing the stent 2 months later without complications, the reopening of the esophageal lumen was confirmed to have been successful ([Fig. 3]). All the procedures are shown in [Video 1].

Fig. 1 The upper esophagus was blocked and a guidewire could not be advanced.

Fig. 2 Endoscopic ultrasound (EUS)-guided fine-needle aspiration was performed to reconnect the esophagus and stomach. a EUS guidance. b Digital subtraction angiography guidance.

Fig. 3 Esophagogastroduodenoscopy 2 months later. a The fully patent lumen-apposing metal stent. b The anastomotic stoma after stent removal.

Video 1 Re-establishment of the digestive lumen in a post-esophagectomy anastomotic atresia. Up to three monitors including endoscopic ultrasound, digital subtraction angiography, and reverse-direction transnasal gastroscopy from the jejunal fistula were used to supervise and guide the whole procedure.

Anastomotic atresia developing from severe post-esophagectomy stricture has not been reported previously [1] [2]. This case presents a novel way of re-establishing the digestive tract lumen under EUS guidance for anastomotic atresia, suggesting that EUS-FNA could play a greater role in the interventional therapy of digestive tract atresia [3].

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• References

• 1 Kappelle WF, van Hooft JE, Spaander MCW. et al. Treatment of refractory post-esophagectomy anastomotic esophageal strictures using temporary fully covered esophageal metal stenting compared to repeated bougie dilation: results of a randomized controlled trial. Endosc Int Open 2019; 7: E178-E185
• 2 Ahmed Z, Elliott JA, King S. et al. Risk factors for anastomotic stricture post-esophagectomy with a standardized sutured anastomosis. World J Surg 2017; 41: 487-497
• 3 van Lennep M, Singendonk MMJ, DallʼOglio L. et al. Oesophageal atresia. Nat Rev Dis Primers 2019; 5: 26