Combined antegrade-retrograde recanalization of a completely obstructed esophagus by use of the FNA needle technique.

Radiation-induced occlusive esophageal strictures pose a significant management challenge. Various endoscopic techniques have been described to treat these strictures, including combined antegrade-retrograde recanalization (Video 1, available online at www.VideoGIE.org).

A 43-year-old woman presented with complete esophageal obstruction at the level of the upper esophageal sphincter after radiation for head and neck cancer (Fig. 1). She had been unable to swallow since completing radiation and was dependent on a PEG tube for nutrition.

Figure 1

Completely obstructed esophagus.

A gastroscope was advanced to the proximal end of the stricture at the level of the upper esophageal sphincter. A 6-mm diameter neonatal gastroscope was then passed through the patient’s gastrostomy tract and advanced in a retrograde manner up the esophagus to the distal end of the stricture. Fluoroscopy revealed that the distance between the 2 endoscopes was approximately 2 cm. We attempted to pass a 0.035-inch guidewire through the antegrade endoscope across the stricture, but we were unsuccessful in doing so.

We then attempted transillumination across the stricture. However, given the distance between the endoscopes, we could not visualize the light source. After additional maneuvering while ensuring fluoroscopic alignment of the 2 endoscopes (Fig. 2), transillumination was achieved (Fig. 3). We then used a 22-gauge FNA needle to puncture through the stricture in antegrade fashion (Fig. 4). Once the needle tip was visualized by the retrograde endoscope, we passed a 0.01-inch wire through the FNA needle. We grasped the guidewire with the downstream endoscope using pediatric forceps and pulled through the gastrostomy; over the wire, using fluoroscopic and endoscopic guidance, the stricture was dilated with a 6-mm biliary dilating balloon (Fig. 5). Next, the stricture was dilated by sequential Savary bougie dilation from 18F to 33F with moderate resistance under endoscopic and fluoroscopic guidance (Fig. 6). After dilation, we were able to advance in a retrograde manner, using the neonatal gastroscope, through the stricture into the mouth without resistance. There was no evidence of a perforation. The patient tolerated the procedure well without any adverse events.

Figure 2

Fluoroscopic view showing endoscope alignment.

Figure 3

Transillumination.

Figure 4

Needle puncture and wire passage.

Figure 5

Balloon dilation.

Figure 6

Fluoroscopic view showing Bougie dilation.

Postprocedurally, the patient tolerated sips of water in recovery for the first time in approximately 12 months. Over the following months, she underwent multiple repeated dilations. Her swallowing function recovered, and she is now tolerating a full unrestricted diet without dysphagia and has gained weight, with subsequent removal of her PEG tube.

In conclusion, combined antegrade-retrograde endoscopic esophageal recanalization is feasible and highly beneficial for many patients without treatment alternatives. Antegrade and retrograde transillumination, in addition to fluoroscopic endoscope alignment, are necessary before recanalization in order to minimize the risk of perforation and vascular injury. The use of a small-caliber FNA needle and wire to achieve recanalization may be a safer alternative to needle-knife electrodissection because a 22-gauge needle is less likely to create a perforation or serious vascular injury.

Disclosure

All authors disclosed no financial relationships relevant to this publication.