P0523 - Combined Anterograde and Retrograde Endoscopic Management of Complete Esophageal Obstruction in Absence of Fluoroscopic Guidance

Muhammad Hassaan Arif Maan, MD¹, Imran A. Qureshi, MD², Wajiha Khan, MD³, Catherine Choi, MD², Muhammad Mursaleen Ahmad, MBBS⁴, Kaveh Hajifathalian, MD², Weizheng Wang, MD^2
1Rutgers New Jersey Medical School, Bloomfield, NJ; ²Rutgers New Jersey Medical School, Newark, NJ; ³Rutgers New Jersey Medical School, Cartaret, NJ; ⁴Punjab Institute of Medical Sciences, Bloomfield, NJ

Introduction: Head and neck cancers are a relatively common malignancy with radiotherapy as an important component of its management. Esophageal strictures or complete obstruction are major adverse effects of radiotherapy, but can also be caused by acid reflux disease, caustic injury, or Plummer-Vinson syndrome. We describe a case of complete esophageal obstruction, that was successfully managed with combined anterograde and retrograde endoscopic procedure in the absence of fluoroscopic guidance.

Case Description/Methods: We present a case of a 65-year-old gentleman who had received chemo/radiotherapy for tonsillar cancer and had a gastric tube in place for seven years. He wanted to resume oral intake. Endoscopic evaluation from the gastrostomy site with ultrathin scope demonstrated complete esophageal obstruction at the upper esophageal sphincter. [A] At this point, a rendezvous procedure was planned. One endoscopist used an ultrathin scope to intubate the esophagus from the mouth till the obstruction was noted. Another endoscopist dilated the gastrostomy with a dilator balloon and advanced the gastroscope from the gastrostomy site past the lower esophageal sphincter into the esophagus. The ultrathin scope’s light was visualized through the obstructing mucosa by the gastroscope distal to the obstruction. [B] With direct visualization of transillumination across the obstructing mucosa, a needle knife from the gastroscope was used to cut the obstructing tissue. [C] Following this, a biliary stent was passed over a guidewire and placed over the obstruction site. [D, E, F] A gastrostomy tube was also re-placed. The procedure was performed under general anesthesia and was completed without any complications. The patient was discharged home on a clear liquid diet trial. On postoperative follow-up, the patient denied any procedure complications such as fevers or chest pain secondary to iatrogenic esophageal injury. The patient also endorsed ability to progressively tolerate the liquid diet, with some nausea and acidity with tube feeds.

Discussion: Combined anterograde and retrograde endoscopic intervention is a safe procedure for the management of complete esophageal obstructions. Rendezvous endoscopic procedure can be considered in the absence of fluoroscopy if the obstructing mucosa can be transilluminated and directly visualized by both scopes.



Disclosures:


Muhammad Hassaan Arif Maan, MD¹, Imran A. Qureshi, MD², Wajiha Khan, MD³, Catherine Choi, MD², Muhammad Mursaleen Ahmad, MBBS⁴, Kaveh Hajifathalian, MD², Weizheng Wang, MD². P0523 - Combined Anterograde and Retrograde Endoscopic Management of Complete Esophageal Obstruction in Absence of Fluoroscopic Guidance, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.