Endoscopic management of refractory post-anastomotic strictures of the neoesophagus. These are our disclosures. Esophageal replacement with colonic interposition has been applied for esophageal cancer treatment since the mid-20th century. It is used in cases of insufficient or failed gastric conduit such as with gastric extension or recurrence of tumor at the conduit. It entails the formation of two anastomosis, namely the proximal esophageal colic and distally the gastro or jejunal colic anastomosis. Anastomotic strictures are a common complication of colonic interposition with a prevalence of 17 to 59 percent. Risk factors include perioperative ischemia and anastomotic leaks. These have historically been treated with endoscopic dilations, however refractory strictures often require surgery. We present a case of refractory anastomotic strictures successfully treated with endoscopic interventions. A 51-year-old male with adenocarcinoma of the esophagus requiring esophagectomy with colonic interposition two years ago presented to us with nausea, vomiting, and dysphagia. An upper endoscopy demonstrated significant narrowing at the proximal anastomosis and despite multiple dilation sessions, his symptoms did not resolve. A barium esophagram demonstrated pooling at the proximal anastomosis as well as a second stricture with complete obstruction at the distal anastomosis. Endoscopic incisional therapy and a lumen-opposing metal stent was used to treat the proximal anastomotic stricture. A through-the-scope esophageal stent over guide wire was used for distal stricture management. We first performed endoscopic incisional therapy of the proximal anastomotic stricture. This modality is best used for short, chronic, non-inflammatory strictures and entails the use of an insulated tip knife for radial incisions followed by circumferential cutting of the stenotic rim. It aims to cause disruption of the fibrotic tissue in order to restore luminal patency and prevent reorganization. We then proceeded to place a 15 millimeter lumen-opposing metal stent not only to provide luminal patency but also to facilitate scope passage for subsequent distal stricture management. The dumbbell shape of the stent provides stability and reduces the risk of migration. Our stent was misdeployed distal to the stricture and required the use of a forceps grasper to adjust its proximal flange above the stricture and ultimately to its correct position. Next we proceeded to dilate the lumen-opposing metal stent with a 15 millimeter through the scope balloon dilator. After dilation the stent was allowed to fully expand over the next 48 hours prior to repeat endoscopy for distal stricture management. On repeat endoscopy for distal and anastomotic stricture management the upper endoscope was able to traverse the previously placed lumen-opposing metal stent with ease. Beyond the proximal stricture the colon conduit was apparent with its tortuous configuration and intervening austral folds. The distal stricture was encountered at approximately 50 centimeters from the incisors. Its position relative to the scope was also confirmed on fluoroscopy. In preparation for stenting the distal and anastomotic stricture a guide wire was passed beyond the narrowing as seen fluoroscopically. Contrast was then injected in order to confirm the guide wire's intraluminal location. The stricture was estimated to be six centimeters in length. An 18 millimeter in diameter and 9.7 centimeter in length fully covered through the scope a esophageal stent was then placed over the guide wire and across the stricture. Correct positioning of the stent during deployment was confirmed fluoroscopically and the stent was deployed under direct endoscopic vision. In order to prevent stent migration an endoscopic helical screw tacking system was used to secure the proximal edge of the stent to the bow. Two tacks were fixated into the deep submucosal layer within the lattices of the entrance stent. A suture cinch was then used to approximate and secure the construct. On follow-up, the patient reported marked improvement of symptoms and is able to tolerate a soft-pureed diet. A repeat esophogram showed passage of contrast into the distal small bowel. He is now scheduled for a repeat endoscopy with proximal stent removal in six weeks. Anastomotic strictures are a common long-term complication of colonic interposition. Although dilation is safe and effective, some strictures may become refractory. Flexible endoscopic incisional therapy and luminal stenting remain a viable option in those with refractory strictures. Long-term perspective data is needed to evaluate the efficacy of these treatment modalities.

endoscopic management

refractory post-anastomotic strictures

neoesophagus

esophageal replacement

colonic interposition