Himesh Zaver, MD, Juan E. Corral, MD, Dawn Francis, MD, Michael Wallace, MD, MPH; Mayo Clinic, Jacksonville, FL
Introduction: Complete esophageal obstruction can occur in the setting of both benign and malignant pathology, including radiation. Treatment is predicated on addressing the suspected pathology and esophageal dilation. Various endoscopic and surgical approaches such as “Per-Oral Endoscopic Tunneling for Restoration of the Esophagus” (POETRE) exist as therapy for complete esophageal obstruction. We describe an alternative approach for esophageal recanalization, “Per Oral Savary Tip Endoscopic Recanalization” (POSTER) of the esophagus.
Methods: A 78-year-old man was referred to our tertiary care center for management of a radiation-induced esophageal obstruction. Past medical history was significant for squamous cell carcinoma of the right true vocal cord diagnosed six months prior, treated with chemotherapy and radiation. Two months following treatment the patient endorsed progressive dysphagia. Subsequent esophagogastroduodenoscopy (EGD), revealed a benign appearing intrinsic esophageal stenosis with complete obstruction located 16-18 cm from the patient’s incisors. Careful examination revealed closure of the native esophageal lumen with a thin membrane of connective tissue and mucosa fused together. Using the flexible tip of a 2mm wire guide the thin webs of tissue were bluntly dissected, allowing direct visualization of the distal esophagus. The stricture measured approximately 3 cm in length. Using an 8-9-10 mm dilator the stricture was dilated to 10 mm. Following dilation, using a 10-12 mm Through-the-Scope (TTS) balloon dilator the esophageal stenosis was further dilated under direct vision to a maximum diameter of 12 mm. In a follow-up endoscopy 5 weeks later, the stricture was dilated to a maximum diameter of 16.5 mm using a 15-16.5-18 mm TTS balloon dilator. At post procedure follow up the patient endorsed that he was maintaining his weight, tolerating solid meals and denied any episodes of aspiration or respiratory distress. Discussion: Radiation induced esophagitis can cause complete obstruction. This may lead to disabling symptoms and invasive interventions such as POETRE to secure enteral nutrition. Compared to POETRE, “Per Oral Savary Tip Endoscopic Recanalization” (POSTER) of the esophagus is a less invasive alternative to restore esophageal patency in patients with short-segment obstructions caused by radiation. POSTER is an inexpensive and safe way to alleviate dysphagia, and should be considered in patients with benign thin strictures causing complete esophageal obstructions.
Lateral (A) and anterior (B) fluoroscopy contrast at the level C5-C6 supportive of esophageal stenosis.
Closure of the esophageal lumen with a thin membrane of connective tissue and mucosa.
Endoscopic image of obstructive stricture following blunt dissection with soft-tipped guidewire.
Disclosures: Himesh Zaver indicated no relevant financial relationships. Juan Corral indicated no relevant financial relationships. Dawn Francis indicated no relevant financial relationships. Michael Wallace: Fujifilm, Boston Scientific, Olympus, Medtronic, Ninepoint Medical, Cosmo/Aries Pharmaceutical – Grant/Research Support. GI Supply (2018), Endokey, Endostart, Boston Scientific, Microtek – Consultant, On Behalf of Mayo Clinic. Virgo Inc, Cosmo/Aries Pharmaceuticals, Anx Robotica (2019), Covidien, GI Supply – Consultant. Virgo Inc. – Stockholder/Ownership Interest (excluding diversified mutual funds).