Endoscopy 2016; 48(10): 951
DOI: 10.1055/s-0042-110489
Letters to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Lumen restoration of long esophageal strictures. Should we shift towards endoscopic submucosal dissection?

Georgios Mavrogenis
,
Tom G. Moreels
,
Jean-Baptiste Chevaux
,
Maximilien Thoma
,
Pierre Deprez
,
Hubert Piessevaux
Further Information

Publication History

submitted 29 April 2016

accepted after revision 25 May 2016

Publication Date:
26 September 2016 (online)

We read with interest the article by Gonzalez et al. [1] on the management of complete esophageal strictures secondary to radiation, caustic ingestion, and iatrogenic esophageal stripping. In three of the nine patients, the stricture was long (> 5 cm), including one case with esophageal obstruction of the entire esophagus. In this latter case, the authors successfully applied a multimodal approach, including an initial partial recanalization with the help of a catheter loaded over a guidewire, surgical reconstruction of the upper esophageal sphincter, and in a third session, placement of a metal stent. Shorter strictures were managed with similar techniques, as well as with puncture using a 19-gauge endoscopic ultrasound fine-needle aspiration needle, under fluoroscopic guidance and transillumination.

We would like to suggest a safer, faster, and easier method of esophageal recanalization by the use of endoscopic submucosal dissection (ESD) techniques. The main advantage of this method is that direct visualization is maintained throughout the procedure, minimizing the risk of inadvertent esophageal perforation and puncture of nearby critical structures.

To date, at least four cases have been reported in the literature [2] [3] [4], including a case of complete postradiation esophageal recanalization, involving the entire esophagus and hypopharynx, in a single session [2]. Despite the length of the stricture, dissection of the fibrotic tissue was feasible. In particular, the submucosal tissue that separated the muscle layers was dissected, after expansion with a gelatin plasma substitute, using a 1.5-mm Dual Knife (Olympus, Tokyo, Japan) with spray coagulation (VIO 300D; Erbe Elektromedizin GmbH, Tübingen, Germany). An endoscopic rendezvous was only required for dissection of the upper esophageal sphincter and hypopharynx, as the axis of dissection was not evident without transillumination. During 2 years of follow-up, the patient has undergone balloon dilation up to 15 mm every 3 months, and tolerates mixed meals.

In conclusion, we believe that esophageal restoration by means of ESD is an emerging modality that overcomes the limitations of esophageal tunneling with standard techniques.

 
  • References

  • 1 Gonzalez JM, Vanbiervliet G, Gasmi M et al. Efficacy of the endoscopic rendezvous technique for the reconstruction of complete esophageal disruptions. Endoscopy 2016; 48: 179-183
  • 2 Mavrogenis G, Moreels TG, Chevaux JB et al. Recanalization of a complete postradiation esophageal obstruction with endoscopic submucosal dissection techniques. Gastrointest Endosc 2015; 81: 1476
  • 3 Wagh MS, Yang D, Chavalitdhamrong D et al. Per-oral endoscopic tunneling for restoration of the esophagus (POETRE). Gastrointest Endosc 2014; 80: 330
  • 4 Perbtani Y, Suarez AL, Wagh MS. Emerging techniques and efficacy of endoscopic esophageal reconstruction and lumen restoration for complete esophageal obstruction. Endosc Int Open 2016; 4: E136-E142