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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
0013-726X
1438-8812
Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

10.1055/a-2387-4762
E-Videos-2023-11-4618-EV
E-Videos
Endoscopic ultrasound-guided esophagojejunostomy of a complete anastomotic stricture
http://orcid.org/0009-0004-7094-6368
Lu Hui
Zhang Tianyu Dr.
Zhang Ling
http://orcid.org/0009-0006-6038-5338
Wang Dong MD
1 66281 Department of Gastroenterology, Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital, Shanghai, China
Correspondence Dong Wang, MD Ruijin Hospital, Shanghai Jiao Tong University School of MedicineNo. 197, Ruijin Second RoadShanghai 200001Chinac44l81h96@sjtu.edu.cn
04 9 2024
12 2024
1 9 2024
56 Suppl 1 E747E748
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc A 76-year-old man, diagnosed with anastomotic fistula after radical total gastrectomy and esophagojejunostomy (Roux-en-Y) due to gastric adenocarcinoma, was managed with thoracotomy and fistula repair. At 8 weeks after surgery, the patient was referred to our hospital because of progressive aphagia and persistent vomiting. Esophagography and gastroscopy revealed complete obstruction at the esophagojejunal anastomosis ( Fig. 1 ). The first attempt at endoscopic ultrasound (EUS)-guided rendezvous directly through the stricture was unsuccessful.

Fig. 1 Complete esophagojejunal anastomotic stricture. a Esophagogram shows obvious dilation of the esophageal lumen and complete obliteration at the lower esophagus. b Gastroscopic view of scar tissue.

Therefore, we attempted bypass recanalization to create a new esophagojejunostomy under EUS guidance ( Video 1 ). A forward-viewing echoendoscope was placed near the stricture and jejunal peristalsis was demonstrated on the EUS image. A 19G needle was used to puncture the esophageal wall and enter the jejunal lumen ( Fig. 2 a ). Contrast was instilled and fluoroscopy of the distal jejunum confirmed successful puncture. A guidewire was then passed through the needle into the efferent loop ( Fig. 2 b ). To avoid electrocautery risk to the thoracic aorta, a 6Fr and an 8.5Fr bougie were used separately to dilate a passage between the esophagus and jejunum ( Fig. 2 c ). Considering the diameter and maneuverability of the passage, we chose a biliary fully covered self-expanding metallic stent (FCSEMS, 10 × 80 mm) to deploy through the passage ( Fig. 2 d, e ). Instilled contrast was seen flowing into the distal jejunum without leakage ( Fig. 2 f ).

Endoscopic ultrasound-guided recanalization to bypass complete stricture of esophagojejunal anastomosis.

Video 1

Fig. 2 Recanalization to bypass the stricture using a biliary fully covered self-expanding metallic stent (FCSEMS) to create a new esophagojejunostomy. a A 19G needle was used to puncture the esophagus and enter the jejunal lumen. b A guidewire was passed into the efferent jejunal lumen under esophagography. c Bougies were used to dilate the passage. d A biliary FCSEMS was deployed along the guidewire through the passage. e Final gastroscopic view of the stent. f Contrast instilled into the stent flowed into the distal jejunal lumen without leakage.

After 2 days, the patient was able to eat soft food without vomiting or pain. After 3 months, fluoroscopy showed smooth flow through the anastomosis, and the biliary FCSEMS was then replaced by an esophageal FCSEMS (20 × 80 mm). After 4 months, the esophageal stent was finally removed, leaving an ideal passage between esophagus and jejunum ( Fig. 3 ). No complications were seen during the follow-up.

Fig. 3 Stricture after EUS-guided bypass recanalization: a–c after 1 month, d after 4 months. a Fluoroscopy shows smooth flow through the new anastomosis. b Gastroscopic view of a clear and open passage after removal of the biliary FCSEMS. c Placement of the esophageal FCSEMS. d Ideal passage between the esophagus and jejunum after stent removal.

To the best of our knowledge, this is the first case report of EUS-guided recanalization bypassing the stricture of a complete esophageal stenosis. It may be a promising recanalization method to treat esophageal stenosis when conventional approaches fail.

Endoscopy_UCTN_Code_TTT_1AQ_2AF

Conflict of Interest The authors declare that they have no conflict of interest.
