Kissing scopes: treatment of complete esophageal obstruction using combined antegrade/retrograde approach

A 75-year-old woman with a history of laryngeal cancer status post-chemoradiation, tracheostomy, and percutaneous endoscopic gastrostomy presented with dysphagia, weight loss, and inability to tolerate excess respiratory secretions. Esophagogastroduodenoscopy (EGD) 2 months prior was reported incomplete due to large Zenker’s diverticulum, and the procedure was aborted. Unsuccessful attempts were made to administer oral contrast to perform an esophagram.

During the procedure, the lumen was not identified despite multiple attempts. The patientʼs percutaneous endoscopic gastrostomy tube was removed externally and a pediatric gastroscope was inserted through the stoma and advanced up into the esophagus, but continuity with the upper portion was not achieved via needle knife from below. The gastrostomy tract was dilated with a balloon and a standard gastroscope was advanced through the stoma and up the esophagus ([Fig. 1]). A needle knife was used to make a cut from below under indirect endoscopic visualization from the scope at the mouth. Dilation with a balloon dilator was performed and the stricture was stented with a 19 × 70-mm fully covered metal stent inserted from below and bridged with a secondary stent of the same size ([Fig. 2]).

Fig. 1 Achieving continuity: light seen from scope advanced through the percutaneous endoscopic gastrostomy site.

Fig. 2 Esophageal stent placed across newly opened esophageal stricture.

Video 1 Kissing scopes: complete esophageal obstruction treated using a combined antegrade/retrograde approach.

The patient returned 1 month later for evaluation and stent removal, and two overlapping stents were found. The gastroscope was able to traverse the previously created fistula tract without difficulty without evidence of stenosis. The stents were removed with a rat-toothed forceps. Contrast was injected at the proximal esophagus with no extravasation noted on fluoroscopy and the procedure was terminated. After stent removal, the patient felt well and was started on a clear liquid diet and discharged.

Variations of this technique have been performed [1] [2] [3]. However, this case demonstrates the use of two scopes with a combined antegrade/retrograde approach, needle knife cutting, and fully covered metal stent placement during the same setting for resolution of esophageal stenosis.

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Competing interests

Michel Kahaleh is a consultant for Concordia Lab and Obalon Technologies Inc. He has done research for Fuji, Pentax, Gore, Aspire, GI Dynamics, Cook, Apollo, NinePoint Medical, and Merit. He has done research and consulting for Boston Scientific. The other authors declare they have no conflict of interest.

• References

• 1 Bueno R, Swanson SJ, Jaklitsch MT. et al. Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction. Gastrointest Endosc 2001; 54: 368-372
• 2 Moyer MT, Stack BC, Mathew A. Successful recovery of esophageal patency in 2 patients with complete obstruction by using combined antegrade retrograde dilation procedure, needle knife, and EUS needle. Gastrointest Endosc 2006; 64: 789-792
• 3 Schembre D, Dever JB, Glenn M. et al. Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus. Endoscopy 2011; 43: 434-437

Publication History

Article published online:
13 July 2020