Per-oral endoscopic tunneling for restoration of the esophagus: a novel endoscopic submucosal dissection technique for therapy of complete esophageal obstruction.

BACKGROUND AND AIMS: Total aphagia from complete esophageal obstruction (CEO) can be seen in patients with head-neck or thoracic malignancies undergoing chemoradiation or surgery. Combined antegrade and retrograde endoscopy (via gastrostomy tube [G-tube] tract) is often performed for esophageal reconstruction but is limited by the length of the obstructed esophagus. We describe per-oral endoscopic tunneling for restoration of the esophagus (POETRE) for patients with longer segments of esophageal obstruction. The aim of this study was to assess the efficacy and safety of POETRE for CEO. METHODS: All patients with CEO undergoing endoscopy with POETRE from October 2013 to September 2015 were enrolled in this single-center prospective study. Clinical, endoscopic, and radiologic records were maintained as required for clinical care and for the study. Dysphagia score was recorded before and after POETRE. Adverse events were assessed based on the American Society for Gastrointestinal Endoscopy criteria. RESULTS: Four patients (3 men; mean age, 72.3 years) underwent POETRE for CEO ≥3 cm in length. Esophageal reconstruction was technically successful in all patients (100%). Antegrade submucosal tunneling was performed in 2 of 4 patients (50%), and retrograde tunneling was performed in the other 2 patients, all with simultaneous dual endoscope and fluoroscopic guidance. The mean dysphagia score of 4 before the procedure improved to 2.5 after POETRE during follow-up (mean, 27.8 weeks). All patients required subsequent serial endoscopic dilations as needed after POETRE. One adverse event (pneumonia) was seen (25%). CONCLUSIONS: We present a novel ESD technique, POETRE, for therapy of complete esophageal obstruction. This approach is specifically useful for lumen restoration in patients with longer segments of esophageal obstruction. (Clinical trial registration number: NCT00968552.).