Re-canalization of completely obstructed gastrointestinal lumens with an endoscopic rendezvous technique. Authors Kotaro Oka, Shannon Morales, Ashley Varadaya, Sophia Yuen, Gregory Haber. A 73-year-old man with squamous cell carcinoma of the left piriform sinus developed dysphagia during radiation treatment one and a half years ago. Dysphagia progressed and eventually a PEG tube was placed for nutrition. Seven months prior to presentation, he underwent laryngoscopy and a balloon dilation of the esophageal inlet to 10 millimeters. Dysphagia progressed and he is now unable to tolerate secretions. Examination with a regular endoscope reveals a very stenosed proximal esophagus. The XP scope was passed into the esophagus revealing a completely obstructed esophageal lumen. Another XP scope was passed through the PEG tube site into the distal esophagus. Here the proximal scope is used to transilluminate the septum. On fluoroscopy, we can see that the scopes are still about one centimeter apart from each other. The scopes are repositioned to improve transillumination and to more closely approximate the scopes on fluoroscopy. While traditional methods of re-canalization involve a EUS needle through which a wire is passed, the lumen of this esophagus was too narrow to accommodate a large scope and the XP scope would not accommodate an EUS needle. Snare tip cautery is used to create a tract through the septum. The snare catheter is driven through the newly created tract. Here the snare tip can be seen from the upper esophagus. The handle of the snare was removed, the snare was removed, and a wire was passed through the catheter into the upper esophagus. The wire is captured with a snare in the upper esophagus. The lower scope is withdrawn, leaving the wire in place. A small catheter is used to initially increase the diameter of the tract. Then 5mm and 7mm savory dilators are used to further dilate the tract. A 10mm fully covered metal stent is placed across the tract. Here, we can see light being transmitted through the stent. Endoscopic methods. The scope tips were brought into close approximation using fluoroscopy and transillumination. Transillumination revealed a thin septum. Snare-tip cautery was used to create a track through the septum. A guide wire was placed in advance from the proximal scope through the tract and snared with a distal scope. Savory dilation was performed to 5mm and 7mm. A 10mm fully covered metal stent was placed across the tract to maintain patency. Case 2. A completely occluded pouch anal anastomosis. A 30-year-old man with ulcerative colitis, status post total proctocolectomy with ileal pouch anal anastomosis complicated by a leak, status post revision of the anastomosis three years ago, presented with tenesmus. Subsequent flexible sigmoidoscopy revealed a complete occlusion of the pouch anal anastomosis. A complete occlusion was seen at the anastomosis. Another scope was passed via the ileostomy into the pouch. Using fluoroscopy and transillumination, the scopes were maneuvered into close approximation with each other, identifying a thin septum. Despite probing with a catheter and a wire, an opening could not be found in the septum. Using a needle life from the scope above the septum, a communication was created between the pouch and the anus. A wire was advanced through the needle and was captured with a snare from the lower scope. Here the wire can be seen from the scope below the septum. Over the wire, balloon dilations to a maximum diameter of 8 mm were performed. The balloon can be seen with the lower scope traversing the anastomosis. We then placed a fully covered 14mm self-expanding metal stent from the lower scope through the anastomosis into the pouch. Here, the stent can be seen traversing the anastomosis into the view of the upper scope. To pull the stent further down, an XP scope was passed via the anus. Rat-toothed forceps were used to pull the stent further down into the distal rectum. Here we see the stent in good position with the distal end in the distal rectum. The endoscopes were brought into close approximation using fluoroscopy and transillumination. A needle knife deployed from the proximal scope was used to create a communication between the pouch and the anus. A wire was passed through the needle and snared with the distal scope. Balloon dilations to 8mm were performed over the guide wire. A 14mm covered metal stent was placed across the anastomosis. An XB scope was avast via the anus and rat-toothed forceps were used to pull the stent further down into the rectum. Clinical Implications Thin septums that obstruct GI lumens can be recannulated endoscopically. Fluoroscopy and transillumination can be used to verify close approximation between two endoscopes. Transillumination can be used to verify a thin septum before recannulation. This allows for over-the-wire dilation and stenting. Conclusions Completely obstructed gastrointestinal lumens with thin septums can be recannulized endoscopically using a rendezvous technique. Fluoroscopy and transillumination can be used to closely approximate upstream and downstream endoscopes and to verify a thin septum before recannulation. Stereotype cautery can be used to create a tract when larger diameter tools, such as a needle knife, will not fit through a smaller endoscope. The tract created allows for dilation and stenting.

endoscopic rendezvous technique

obstructed gastrointestinal lumens

esophageal dilation

metal stent placement

ulcerative colitis