LAUSR

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). 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 [1–3]. 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.