Per-oral endoscopic myotomy for management of helical stenosis of a gastric conduit post-esophagectomy. These are our disclosures. Gastric conduit dysfunction, including delayed gastric emptying, occurs in 15-30% of patients post-esophagectomy. Presenting symptoms include dysphagia, reflux, malnutrition, and recurrent aspiration, leading to significant morbidity and mortality. Most cases are postulated to be due to increased pylorus tone, thus most patients respond to pyloric interventions such as Botox injection, endoscopic balloon dilation, and surgical or endoscopic pyloromyotomy. A minority of patients are refractory to the above interventions, likely due to a secondary mechanism. This includes twisting of the gastric conduit in a way that obstructs outflow. Our case is of a 69-year-old male who underwent Iver-Lewis esophagectomy for esophageal adenocarcinoma. Post-operatively, he had significant mixed dysphagia and regurgitation, requiring complete jejunostomy feeding with ongoing weight loss. Barium swallow showed obstruction at the hiatus and torsion of the gastric conduit proximal to the pylorus. He underwent multiple endoscopic exams, which noted torsional stenosis in the gastric conduit. Over several months, he underwent progressive interventions with minimal symptomatic improvement, including Botox injection to the pylorus, endoscopic balloon dilation, laparoscopic crural revision, and laparotomy with enlargement of the diaphragmatic hiatus and a surgical pyloromyotomy. As torsional stenosis in the gastric conduit is anatomically similar to helical stenosis following laparoscopic sleeve gastrectomy, a similar endoscopic approach was taken. The patient underwent tunneled full-thickness endoscopic myotomy to 3 cm of helical stenosis in the gastric conduit. This is the initial view of the patient's anatomy. The esophageal gastric anastomosis and proximal gastric conduit was widely patent. The helical stenosis could be seen in the gastric antrum with significant resistance when traversed by the gastroscope for a length of about 2 cm. This area of stenosis was about 3 cm proximal to the pylorus, which was also widely patent. An injector needle with saline and methylene blue was used to create a submucosal cushion to facilitate access to the submucosal space. The access site was chosen about 7 cm proximal to the noted helical stenosis. A 2 cm longitudinal mucosotomy was made to enter the submucosal space. A vertical incision was chosen to facilitate clip closure in a difficult location in the gastric body. Methylene blue and saline was used to facilitate submucosal tunneling. Because serial injection could be performed through the knife tip, saline was chosen rather than colloid. Epinephrine was avoided in the injectate to preserve tissue vitality of the submucosal flap. Tunneling was then continued in the submucosal space with serial injection and dissection. A wide submucosal tunnel was created, following the spiral trajectory of the underlying stenosis in the conduit. There was notable twisting of the muscular layer with pinching of the endoscope in the stenotic region. This tunnel was then continued until there was clear entry into a non-stenosed area. When examining from the luminal side, the area of twisting corresponded with the previously noted helical stenosis. Myotomy was started in this area of helical stenosis. It was performed proximal to distal similar to other per-oral endoscopic myotomy techniques given the tight stenosis. Cautious myotomy was performed in progressive, thin layers to avoid serosal perforation or transection of large penetrating vessels. Full thickness myotomy was completed with serosal exposure and there was notable release of the twisted stenotic area. Finally, the mucosotomy was closed with through-the-sculpt clips. This is the final view of the gastric conduit. Following full thickness myotomy, there was improvement in resistance to endoscope passage through the area of helical stenosis. At the patient's 2-month follow-up, he was eating 3-4 solid meals per day, he had weaned off of J-tube feeds, and was gaining weight. His post-procedure barium swallow on the right-hand side demonstrated improved flow through the previous area of helical stenosis. With advances in third space endoscopy, surgery is no longer the only option for refractory stenosis in carefully selected patients. In the rare case of severe gastric conduit dysfunction due to helical stenosis, endoscopic myotomy may be a safe and effective treatment.

endoscopic myotomy

gastric conduit dysfunction

helical stenosis

post-esophagectomy

submucosal tunnel