Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen

Abstract

Treatment of locally advanced esophageal cancers with high-dose definitive concomitant chemoradiotherapy can lead to high-grade esophageal strictures, or, rarely, total obliteration of the lumen. Strictures can be successfully treated with various endoscopic techniques; however, complete obstruction is a technically challenging problem. Anterograde endoscopic techniques carry the risk of perforation or bleeding. A combined anterograde–retrograde dilation technique, described in a few reports, is another option but requires retrograde access through a prior ostomy [1–4]. We report a novel method for managing complete esophageal obstruction using endoscopic ultrasound (EUS)-guided puncture for access to the distal lumen, previously described only in a case of total colonic stricture using a prototype forward-view echoendoscope [5]. A 62-year-old woman had received highdose chemoradiation for a squamous cell esophageal carcinoma (stage IIIC) and her esophagus had completely occluded, with severe compromise to her quality of life (● Fig.1). Several attempts to pass a guide wire though the stricture were unsuccessful. We decided to attempt recanalization of the lumen using an EUS-guided access. The linear echoendoscope (GF-UCT140AL5;Olympus, Tokyo, Japan)wasadvanced 24cm from the incisors and the distal esophageal lumenwas identified from the proximal endon theEUSimage (● Fig.2a). A 19G needle (Expect Flex; Boston Scientific Corp, Natick, Massachusetts, USA) was used to puncture the obstructed lumen under EUS guidance (● Fig.2b). Contrast filling was visualized under fluoroscopy and a 0.035-inch guide wire (Microvasive Jagwire; Boston Scientific) was advanced through the EUS needle (● Fig.3a,b). An 8-mm biliary balloon (Hurricane RX; Boston Scientific) was used to perform a first dilation under endoscopic and fluoroscopic guidance (● Fig.3c). The endoscopic appearance after dilation was satisfactory, with reestablishment of luminal continuity (● Video 1). The patient underwent four additional endoscopic balloon dilations of up to 15mm (● Fig.4). She respondedwell, gaining the ability to swallow secretions, drinks, and soft food, andwithout evidence of delayed complications. Fig.2 a,b EUS images of the esophageal total stricture. a A thickened esophageal wall (arrows) continues through the stenosis. b EUS image of the 19G needle through the stricture (arrow).