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Combined Antegrade and Retrograde Endoscopy with Radiofrequency Ablation and Dilatation for Complex Esophageal Obstruction

Barnes-Jewish Hospital, Saint Louis, MO

INTRODUCTION: Symptomatic obstruction of the esophagus can result from a variety of benign[3] and malignant[2] lesions. Endoscopic dilatation of the obstruction can provide relief of symptoms in many patients. However, in a small subset of patients, antegrade passage of a guidewire across the obstruction is not possible. Here we report a case where retrograde endoscopy via a gastrostomy failed to identify a lumen through the obstruction. A radiofrequency probe was used to bore through the obstruction and allow for safe dilation.

CASE PRESENTATION: A 72 year old patient presented with complete obstruction of the esophagus secondary to squamous cell carcinoma. The patient experienced dysphonia after her radiation therapy that has persisted. A blind pouch was encountered behind the larynx. The gastrostomy lumen was dilated to accommodate a pediatric esophagoscope which demonstrated a very smooth, blunt tunnel ending in the cervical esophagus. Using fluoroscopy, the obstruction was estimated at 9-10 mm in length. Multiple images at various angles were obtained to confirm that the tips of both scopes were collinear. A radiofrequency probe was introduced into the distal esophagus via the gastrostomy, and was used with fluoroscopic guidance to tunnel a hole through the obstruction. A guidewire was passed through the tunnel. Sequential dilatation was performed and the scope was able to be passed through the obstruction. A Dobbhoff tube was placed through the nose and out the gastrostomy site and was anchored to the new gastrostomy tube to insure that the lumen would remain patent. On post-operative day one the patient was noted to have mild stridor. She was treated with a seven day steroid taper and racemic epinephrine nebulizers. A swallow study was performed, which was negative for any pooling or extravasation at the site of dilatation. The patient was discharged four days later able to swallow thin liquids and manage her own secretions.

DISCUSSIONS: The use of radiofrequency ablation represents a new technique to manage complex esophageal obstruction. This technique allows for the development of a tunnel through the obstruction to allow for subsequent passage of a guidewire. The risk of perforation is kept to a minimum as the subsequent passage of dilating devices is safely done over a guidewire. In our reported case, the patient experienced stridor pre-operatively that worsened after use of the ablation procedure. It seems unlikely that the radiofrequency probe would cause any damage to neighboring structures based on it’s physics of energy dissipation, which decreases proportionally to the fourth power. It is more likely that the direct radiation of the larynx led to nerve damage and paralysis.

CONCLUSION: Here we extend the capability of endoscopy to treat complex obstructions by using radiofrequency ablation to safely bore a path through the stricture under fluoroscopic guidance. This technique has the advantage of avoiding any delay in treatment that is encountered when a complete obstruction is encountered on upper endoscopy, as the physician can move directly to a combined antegrade and retrograde procedure.

DISCLOSURE: R.C. Fields, None.

REFERENCES

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2. Christie NA, Buenaventura PO, Fernando HC, Nguyen NT, Weigel TL, Ferson PF, Luketich JD (2001 ) Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up. Ann Thor Surg71 :1797 –801.
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