Paroreal endoscopic two-way tunneling and lumen restoration for complete esophageal obstruction. There are no relevant disclosures for the authors. Complete esophageal obstruction more than 3 cm length is a challenge for endoscopic and surgical interventions. Paroreal tunneling for restoration of esophagus utilizing the third space techniques can establish continuity in such cases. A 52-year-old gentleman presented with aphasia after undergoing laryngectomy for recurrent carcinoma larynx post radiation. He had a pharyngocutaneous fistula in the postoperative period. Feeding was being done through gastrostomy tube. Apergy endoscopy at another hospital showed a blind end in upper esophagus. He was referred to us for further management. Endoscopy by us showed that there was complete luminal obstruction in the post cricoid region. The options of treatment including paroreal endoscopic two-way tunneling and lumen restoration was discussed with the patient and he chose this procedure. The procedure was done under general anesthesia. One endoscopist did endoscopy through the paroreal route and the finding was confirmed. The second endoscopist was on the gastric side. The gastrostomy was removed and the tract dilated using a CRE balloon. The endoscope was then passed through the tract into stomach and then across the GE junction. It was advanced into the proximal esophagus where the lumen was found to have been completely obstructed. Both the scopes were placed close to the obstruction and on fluoroscopy the defect was found to be more than 3 cm. Both the endoscopes were removed and transparent cap attached to the tip. The retrograde scope was advanced and a mucosal incision was made 5 cm proximal to the obstruction at 7 o'clock position. The mucosal incision was advanced and dissection was made on either side. There was intense scarring and the dissection was made to have a tunnel approximately 6 cm towards the stricture. The scope was then passed antigrade way and a submucosal bleb was seen close to the obstruction. A mucosal incision was made on the antigrade aspect at 5 o'clock position in the same plane as the previous tunnel. The mucosal incision was then extended and the submucosal tunnel was advanced. Careful dissection was made and during this process one of the light source was switched off and transillumination was seen. The dissection was carried out so that the other channel was reached through the antigrade manner and once the tunnel were connected together, a guide wire was placed from the antigrade route into the esophagus and this was monitored by fluoroscopy and the scope placed in the retrograde manner. Over the guide wire, a self-expanding metallic stent 10 cm length was placed across the stricture. The proximal end of the stent was seen distal to the trichopharynx. After placing the stent, a contrast study was done through the stent by instilling dye. The contrast dye was seen flowing through the stent into the esophagus without any obstruction. After the procedure, the patient was started on orifice which was enhanced to semisolids and then patient was discharged. The self-expanding metallic stent was removed after 6 weeks. After the removal of the stent, endoscopy showed there was no luminal obstruction, however there was some scarring. The patient underwent 4 sessions of dilatation on follow-up. No interventions were done in the last 1 year. To conclude complete esophageal obstruction, a rare complication after laryngectomy is a real therapeutic challenge. Endoscopic 2-way tunneling with lumen restoration by SEMS placement is an option when obstructed segment is more than 3 cm. After lumen restoration, patients would require follow-up dilatation.

esophageal obstruction

laryngectomy

endoscopic tunneling

self-expanding stent

third space techniques