Endoscopic ultrasound-guided esophagoenterostomy for a completely obstructed surgical anastomosis.

Endoscopic ultrasound (EUS) has the potential to safely guide the creation of gastrointestinal anastomoses [1]. Different methods have been studied in animal models [2] and more recently EUS-guided gastroenterostomy with a lumen-apposing stent has been described in two small patient series [3,4]. A 58-year-old woman with junctional adenocarcinomawho had undergone total gastrectomywith distal esophagectomy in October 2014 was referred to us with grade 4 dysphagia in January 2015. Endoscopy revealed a completely obstructed esophagojejunal anastomosis, the position of which was confirmed by imaging (●" Fig.1). Initial access to the jejunum was accomplished under EUS guidance with a flexible 19G needle (Expect; Boston Scientific, Spencer, Indiana, USA) (●" Fig.2). Once the tip of the needle had been advanced beyond the anastomosis, contrast agent was injected to confirm that the needle was correctly located in the jejunum. A 0.025-inch guidewire was advanced through the needle and looped in the intestinal lumen. An over-the-wire exchange with a therapeutic forwardviewing endoscope was performed and the anastomotic tract was dilated over the guidewire, first with a 7-Fr biliary dilation catheter, then up to 6mm using a biliary balloon. Finally, a fully-covered biliary self-expanding metal stent (SEMS) was inserted and left in place for 1week to prevent anastomotic leakage and to consolidate the passage (●" Fig.3a). The biliary stent was subsequently replaced with a fully-covered “yo-yo” stent (NAGI stent; Taewoong, Seoul, Korea) with a 16-mm diameter (●" Fig.3b). However, because of pain, this stent was removed after only 1 week and over three consecutive sessions the neoanastomosis was progressively dilated with balloons up to 20mm (●" Fig.3c;●" Video 1). This is the first reported case of EUS-guided treatment of a completely obstructed esophagoenteric anastomosis located in the mediastinum. EUS helped to achieve safe access to the jejunum by avoiding inadvertent puncture of the surrounding