Endoscopic ultrasound (EUS) has the potential to safely guide the creation of gastrointestinal
anastomoses [1]. Different methods have been studied in animal models [2] and more recently EUS-guided gastroenterostomy with a lumen-apposing stent has been
described in two small patient series [3]
[4].
A 58-year-old woman with junctional adenocarcinoma who had undergone total gastrectomy
with distal esophagectomy in October 2014 was referred to us with grade 4 dysphagia
in January 2015. Endoscopy revealed a completely obstructed esophagojejunal anastomosis,
the position of which was confirmed by imaging ([Fig. 1]).
Fig. 1 Imaging performed following the initial endoscopy showing the location of the completely
obstructed esophagojejunal anastomosis (white arrow) beyond the pulmonary artery (PA)
and in front of the descending aorta (Ao).
Initial access to the jejunum was accomplished under EUS guidance with a flexible
19G needle (Expect; Boston Scientific, Spencer, Indiana, USA) ([Fig. 2]). Once the tip of the needle had been advanced beyond the anastomosis, contrast
agent was injected to confirm that the needle was correctly located in the jejunum.
A 0.025-inch guidewire was advanced through the needle and looped in the intestinal
lumen. An over-the-wire exchange with a therapeutic forward-viewing endoscope was
performed and the anastomotic tract was dilated over the guidewire, first with a 7-Fr
biliary dilation catheter, then up to 6 mm using a biliary balloon. Finally, a fully-covered
biliary self-expanding metal stent (SEMS) was inserted and left in place for 1 week
to prevent anastomotic leakage and to consolidate the passage ([Fig. 3 a]).
Fig. 2 View during endoscopic ultrasound (EUS)-guided placement of a 19G flexible needle
(white arrow), which was passed through the esophagus into the jejunum.
Fig. 3 Endoscopic views showing: a the fully covered biliary self-expanding metal stent (SEMS) that was initially left
in place to consolidate the passage and prevent anastomotic leakage; b the fully covered lumen-apposing stent that was placed instead of the biliary SEMS
to dilate the neoanastomosis; c the appearance of the neoanastomosis after three sessions of balloon dilation.
The biliary stent was subsequently replaced with a fully-covered “yo-yo” stent (NAGI
stent; Taewoong, Seoul, Korea) with a 16-mm diameter ( [Fig. 3 b]). However, because of pain, this stent was removed after only 1 week and over three
consecutive sessions the neoanastomosis was progressively dilated with balloons up
to 20 mm ([Fig. 3 c]; [Video 1]).
The creation under endoscopic ultrasound (EUS) guidance of an esophagoenterostomy
for a completely obstructed esophagojejunal anastomosis. Initial imaging shows the
location of the obstructed esophagojejunal anastomosis (PA, pulmonary artery; Ao,
descending aorta). A 19G needle is used to access the jejunum under EUS guidance;
a guidewire is passed; an over-the-wire exchange with a therapeutic endoscope is performed;
the anastomotic tract is dilated with a biliary catheter then a balloon; a fully covered
self-expanding metal stent (SEMS) is placed. After 1 week an ultrathin endoscope is
passed through the neoanastomosis, before being exchanged for a therapeutic endoscope;
a fully covered “yo-yo” metal stent is placed. Finally, on the third endoscopy session
following removal of the stent, the neoanastomosis is shown being dilated by a balloon
up to 20 mm.
This is the first reported case of EUS-guided treatment of a completely obstructed
esophagoenteric anastomosis located in the mediastinum. EUS helped to achieve safe
access to the jejunum by avoiding inadvertent puncture of the surrounding mediastinal
structures, such as the pulmonary artery, descending aorta, and inferior vena cava,
which were located close to the anastomosis. No immediate or delayed major complications
were observed and patient was able to return to a regular diet on completion of the
endoscopic treatment.
Endoscopy_UCTN_Code_TTT_1AS_2AB
