Introduction

A 28-year-old woman with Type I diabetes presented with severe dysphagia after pregnancy. Endoscopy showed a “blind” esophagus, with complete esophageal obstruction (Fig. 1). An endoscopic approach was unsuccessful in finding an access for the guidewire and no evidence of contrast medium passage was seen. Endoscopic ultrasound was used to study the esophageal layers and try to see behind the stricture. The wall was thickened (10 mm), with prevalence of the submucosa.

Aims & Methods

A mild insufflation of air, used as ultrasonographic contrast, allowed the endosonographer to see a hyperechoic line that was interpreted as the sub-millimetric remnant of the esophageal lumen (Fig. 2). A 19 G access needle was used to puncture, under EUS guidance, the esophageal wall (Fig. 3) starting from the hyperechoic line inside the esophagus (video 1). After initial resistance, under fluoroscopic view of the needle path, a point of least resistance was felt and the needle tip, inserted for almost 5 cm, was visualized below the diaphragm.

Results

A guidewire was inserted into the needle and under fluoroscopic view was seen creating a loop inside the stomach (Fig.4). A Hurricane RX biliary balloon dilation catheter (6 mm diameter, 4 cm length) was passed through the stricture and the first dilation was performed (Fig.5). In the following weeks, other dilations were performed with Savary bougies and the esophageal lumen was restored (Fig. 6). Forceps biopsies revealed acute and chronic inflammation, with severe fibrosis and no signs of eosinophilic esophagitis or tumor.

Conclusion

After 3 months, the patient could eat normally and a weight increase of 3 kg was observed. Complete esophageal obstruction may arise from both benign and malignant diseases. The treatment must be managed in centers with extensive experience of operative endoscopy, since the approach may be challenging [1-3]. We proposed an alternative, ultrasonographic-guided approach to esophageal restoration.

References

1. Perbtani Yaseen, Alejandro L Suarez, Mihir S Wagh. Endoscopic techniques for complete esophageal obstruction. Endoscopy International Open 2016; 04: E136–E142.
2. Vitali F, Nägel A, Pfeifer L, et al. Endoscopic recanalization of complete esophageal obstruction. Surg Endosc. 2021 Jun;35(6):3184-3188.
3. Bertolini R, Meyenberger C, Putora PM, et al. Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique. World J Gastroenterol. 2016 Feb 21;22(7):2366-72.