Endoscopic ultrasound-guided esophagojejunostomy of a complete anastomotic stricture

A 76-year-old man, diagnosed with anastomotic fistula after radical total gastrectomy and esophagojejunostomy (Roux-en-Y) due to gastric adenocarcinoma, was managed with thoracotomy and fistula repair. At 8 weeks after surgery, the patient was referred to our hospital because of progressive aphagia and persistent vomiting. Esophagography and gastroscopy revealed complete obstruction at the esophagojejunal anastomosis ([Fig. 1]). The first attempt at endoscopic ultrasound (EUS)-guided rendezvous directly through the stricture was unsuccessful.

Fig. 1 Complete esophagojejunal anastomotic stricture. a Esophagogram shows obvious dilation of the esophageal lumen and complete obliteration at the lower esophagus. b Gastroscopic view of scar tissue.

Therefore, we attempted bypass recanalization to create a new esophagojejunostomy under EUS guidance ([Video 1]). A forward-viewing echoendoscope was placed near the stricture and jejunal peristalsis was demonstrated on the EUS image. A 19G needle was used to puncture the esophageal wall and enter the jejunal lumen ([Fig. 2] a). Contrast was instilled and fluoroscopy of the distal jejunum confirmed successful puncture. A guidewire was then passed through the needle into the efferent loop ([Fig. 2] b). To avoid electrocautery risk to the thoracic aorta, a 6Fr and an 8.5Fr bougie were used separately to dilate a passage between the esophagus and jejunum ([Fig. 2] c). Considering the diameter and maneuverability of the passage, we chose a biliary fully covered self-expanding metallic stent (FCSEMS, 10 × 80 mm) to deploy through the passage ([Fig. 2] d, e). Instilled contrast was seen flowing into the distal jejunum without leakage ([Fig. 2] f).

Endoscopic ultrasound-guided recanalization to bypass complete stricture of esophagojejunal anastomosis.Video 1

Fig. 2 Recanalization to bypass the stricture using a biliary fully covered self-expanding metallic stent (FCSEMS) to create a new esophagojejunostomy. a A 19G needle was used to puncture the esophagus and enter the jejunal lumen. b A guidewire was passed into the efferent jejunal lumen under esophagography. c Bougies were used to dilate the passage. d A biliary FCSEMS was deployed along the guidewire through the passage. e Final gastroscopic view of the stent. f Contrast instilled into the stent flowed into the distal jejunal lumen without leakage.

After 2 days, the patient was able to eat soft food without vomiting or pain. After 3 months, fluoroscopy showed smooth flow through the anastomosis, and the biliary FCSEMS was then replaced by an esophageal FCSEMS (20 × 80 mm). After 4 months, the esophageal stent was finally removed, leaving an ideal passage between esophagus and jejunum ([Fig. 3]). No complications were seen during the follow-up.

Fig. 3 Stricture after EUS-guided bypass recanalization: a–c after 1 month, d after 4 months. a Fluoroscopy shows smooth flow through the new anastomosis. b Gastroscopic view of a clear and open passage after removal of the biliary FCSEMS. c Placement of the esophageal FCSEMS. d Ideal passage between the esophagus and jejunum after stent removal.

To the best of our knowledge, this is the first case report of EUS-guided recanalization bypassing the stricture of a complete esophageal stenosis. It may be a promising recanalization method to treat esophageal stenosis when conventional approaches fail.

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