Finding the esophagus. These are our disclosures. We present the case of a 77-year-old male with a medical history of laryngeal carcinoma who presented for management of post-laryngectomy stenosis of the neopharynx. His laryngeal cancer was diagnosed approximately two years prior to presentation, where he completed definitive chemoradiation therapy. His post-treatment course was complicated by posterior glottic, subglottic, esophageal stenosis and chronic aspiration. Our patient has undergone multiple esophageal dilations for esophageal stenosis, and due to aspiration, the patient has been PEG-dependent. On previous evaluations, the patient stated he desired to eat by mouth and subsequently underwent total laryngectomy with a thigh flap reconstruction. However, his post-op course was complicated by an esophagram showing markedly delayed passage of contrast through his neopharynx with obstruction at the level of the upper esophagus just distal to the pharyngeal stent. For this, GI was consulted for further evaluation of esophageal stenosis. A gastroscope was advanced into the oropharynx, where a previously placed salivary bypass stent was seen, which could not be traversed. We therefore exchanged the gastroscope for a small calibroscope and cannulated the bypass stent. We made several attempts to pass a guide wire through the lumen, but we were unsuccessful in doing so. We subsequently removed the previously placed PEG tube, the ostomy was dilated, and a gastroscope was advanced through the gastrostomy into the stomach, then into the esophagus in a retrograde fashion. Here we see the gastroscope inside of the esophagus in a retrograde fashion, and we also see the previously placed guide wire from the anterograde approach, coiled inside of a lumen. As the esophagus was cannulated more proximally, a severe stricture was encountered, as denoted here by the red arrow. A guide wire was passed through the stricture under fluoroscopic guidance, and the guide wire was observed from the oropharynx. At this point, we removed the salivary bypass stent, and using two endoscopes, one through the oral cavity and one in a retrograde fashion, we advanced the guide wire in a retrograde approach, as denoted here by the red arrow. In this clip, the red arrow denotes the blind end lumen where the salivary stent was placed, and the true esophagus, as denoted by the blue arrow. An IT2 knife was passed through the gastroscope in the oropharynx, and the septum between the false lumen and native esophagus was dissected. After dissecting the septum, the anterograde and retrograde scopes achieved mutual visualization of the true esophageal lumen. A 10mm lumen-opposing metal stent was advanced in a retrograde fashion through the endoscope cannulating the gastrostomy site, and was placed across the pharyngeal esophageal communication. The lumen-opposing metal stent was then dilated to 10mm using a controlled radial expansion balloon. The patient tolerated the procedure well, and was started on a clear liquid diet for three days prior to advancing his diet to a low-residue diet. He was safely discharged and followed up in the outpatient setting with his multidisciplinary care team. In conclusion, clear endoscopic and fluoroscopic guidance is paramount during esophageal dilations to prevent creation of false tracts. Covered metal stents can be successfully used to recreate continuity in the esophagus even after complete obliteration of the esophageal lumen. A percutaneous gastrostomy can be used to facilitate retrograde access to the esophagus in cases with limited anterograde access.

laryngeal carcinoma

chemoradiation therapy

esophageal dilations

esophageal stenosis

chronic aspiration