S1998 Two Scopes Are Better Than One: Esophageal Recanalization With the Rendezvous Procedure

Abstract

Introduction: Esophageal strictures can occur in patients with head & neck cancers treated with radiotherapy. Rate of stricture in these cases is estimated to be between 2-16%. We present a case of severe esophageal stricture treated with combined antegrade-retrograde endoscopic dilation and biliary stent placement. Case Description/Methods: 76-year-old female with squamous cell carcinoma of the hypopharynx, with PEG tube for nutrition, presented with persistent dysphagia following completion of radiotherapy. Barium esophagram showed severe pharyngeal dysphagia with esophageal backflow and aspiration. Laryngoscopy and transnasal esophagoscopy revealed a blind ending pouch in the proximal esophagus. After unsuccessful attempts to pass a guidewire through the stenosis under direct visualization, we were consulted to discuss a combined approach. Rendezvous recanalization with access through both the mouth and gastrostomy site was planned. An endoscope was passed through the mouth to the level of the esophagus, revealing severe stenosis with complete obstruction in the hypopharynx. Under fluoroscopic guidance, we attempted to advance a guidewire through the stenosis, but were unsuccessful. An endoscope was then reintroduced through the mature gastrostomy. The scope was advanced to the esophageal stricture in retrograde. A transnasal esophagoscope was used through the mouth for antegrade access. From the retrograde endoscope, a guidewire was passed through the stenosis and captured through the mouth. Under fluoroscopy, a 6-7-8mm x 5.5cm CRE balloon dilator was passed over guidewire through the mouth, and dilation was performed to 6mm. We decided to use a biliary stent given the location of the stricture in the hypopharynx where placement of a larger esophageal stent is not feasible and would cause severe discomfort given the larger diameter. A 10mm x 60mm WallFlex biliary stent was successfully deployed across the stenosis. After repeat dilation was performed twice more 2 weeks apart, her esophagus remains patent at 18mm. On latest follow-up, she is able to tolerate PO liquids and pureed food. Discussion: High-grade stenosis is difficult to treat, often requiring a multidisciplinary approach. In cases of high-grade esophageal stenosis, an antegrade-retrograde endoscopic approach can be employed to dilate the esophageal segment. Recent meta-analysis shows esophageal recanalization using the rendezvous procedure to have a technical success rate >85%, dysphagia improvement rate >55%, and PEG-tube free rate >40%.Figure 1.: Endoscopic view of esophageal stricture (a), fluoroscopic image of antegrade and retrograde scope with wire passing through the stricture (b), endoscopic view of biliary stent in place (c), fluoroscopic image of biliary stent in place (d). Watch the video at https://bit.ly/3eNvMxi.