Antegrade and retrograde endoscopic approach in the establishment of a neo-esophagus: a novel technique

Background: Although total obstruction or secondary atresia of the esophagus is extremely rare, high-grade strictures are not uncommon. The retrograde approach was previously described to achieve dilation when the conventional antegrade method fails. Setting: Gastroenterology laboratory in a tertiary referral center. Patient: A 30-year-old man with congenital T-cell immunodeficiency had complete esophageal obstruction after a severe episode of cryptococcal meningitis that required prolonged nasogastric intubation. For the next 3 years, he had daily episodes of regurgitations and several hospitalizations for aspiration pneumonia. A barium study revealed a dilated megaesophagus, with no contrast reaching to the stomach. Intervention: Initially, a new track was created by using access from above and below the obstruction. This was followed by placement of a self-expandable silicone stent after allowing sufficient time for the new track to mature. Main Outcome Measurements: Restoration of esophageal continuity, which allowed resolution of the patient's aspiration pneumonia and resumption of oral feeding. Conclusions: Complete esophageal obstruction after prolonged nasogastric intubation is a rare but serious complication. A novel endoscopic approach can be used to restore esophageal continuity, minimize complications, and avoid major reconstructive surgeries.