Babich Jay P, Diehl David L, Entrup Michael H
Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA 17822, USA.
Surg Laparosc Endosc Percutan Tech. 2012 Aug;22(4):e232-5. doi: 10.1097/SLE.0b013e318257c9e5.
Complete esophageal obstruction is a challenging problem that is not amendable to standard dilation techniques. Multiple endoscopic techniques as well as radical surgical procedures have been developed with the goal of restoring a patent esophageal lumen. In patients with complete esophageal obstruction, an antegrade-retrograde technique has been described, but this generally depends on the ability to transilluminate across the stricture. Successful transillumination allows for safe direct puncture across the stricture, followed by dilation. In long-segment strictures (greater than 2-3 cm), transillumination may not be possible. We report a case of a 63 year-old woman who developed a complete esophageal obstruction from radiation therapy (RT) for hypopharyngeal squamous cell carcinoma. She did have enteral access via a percutaneous endoscopic gastrostomy (PEG) tube which had been placed prior to beginning RT. A combined antegrade (through the mouth) and retrograde (through PEG site) approach was done, but transillumination across the stricture failed. Fluoroscopy demonstrated a 4 cm long stricture. The creation of a submucosal tunnel from the retrograde direction decreased the stricture length to 15 mm and transillumination was achieved. This allowed safe puncture of the stricture, placement of a guidewire, then successful dilation. The patient can now tolerate soft foods and maintain her weight. Submucosal tunneling can be used to achieve transillumination for the combined antegrade-retrograde approach to complete esophageal obstruction.
完全性食管梗阻是一个具有挑战性的问题，无法通过标准的扩张技术解决。为了恢复食管腔通畅，已经开发了多种内镜技术以及根治性手术方法。对于完全性食管梗阻患者，已经描述了一种顺行-逆行技术，但这通常取决于能否透过狭窄部位进行透照。成功的透照允许安全地直接穿刺穿过狭窄部位，随后进行扩张。对于长段狭窄（大于2-3厘米），可能无法进行透照。我们报告了一例63岁女性患者，她因下咽鳞状细胞癌接受放射治疗（RT）后出现完全性食管梗阻。在开始放疗之前，她确实通过经皮内镜下胃造口术（PEG）管建立了肠内通路。采用了联合顺行（经口腔）和逆行（经PEG部位）的方法，但穿过狭窄部位的透照失败。荧光透视显示有一个4厘米长的狭窄。从逆行方向创建黏膜下隧道将狭窄长度缩短至15毫米，并实现了透照。这允许安全地穿刺狭窄部位，放置导丝，然后成功进行扩张。患者现在能够耐受软食并维持体重。黏膜下隧道可用于实现透照，以采用联合顺行-逆行方法治疗完全性食管梗阻。
