Reverse NOTES: Esophageal Canalization

Introduction: Traditional natural orifice translumenal endoscopic surgery (NOTES) involves entry through a pre-existing orifice such as the mouth, anus or vagina. A surgically created “orifice” such as a gastrostomy can also be used as an access site, performing a reverse NOTES surgery. This video describes such reverse access to treat a complete esophageal occlusion following radiation.
Methods: A 55-year-old female with a history of tonsillar cancer developed complete dysphagia and odynophagia after completing chemoradiation. Esophagoscopy and esophagogram demonstrated complete occlusion at the level of the pyriform sinus. Biopsy of the stricture was negative for neoplasia. Initially a 5mm trocar was placed in the right upper quadrant to obtain insufflation. Using visualization through this port, the pre-existing gastrostomy tube was removed and a 12mm trocar was placed into the stomach. The endoscope was introduced through this trocar and was carried retrograde up the esophagus to the level of the stricture. An operating laryngoscope visualized the stricture from above. Using simultaneous visualization from above and below the stricture, the stricture was incised and a guidewire passed through the gastroscope. After passing the guidewire up through the mouth the stricture was serially dilated up to 36 French. The stricture was then temporarily stented. The patient’s gastrostomy tube was replaced at the termination of the procedure.
Results: The patient was extubated at the termination of the case and noted immediate improvement in dysphagia. She returned in two weeks for stent removal and repeated dilation. Inspection at that time demonstrated no mucosal lesions or tears.
Conclusions: Using a pre-existing gastrostomy provides access to the gastrointestinal tract for reverse NOTES procedures. Using a simultaneous antegrade and retrograde approach allows treatment of an esophageal stricture safely. Direct trocar placement into the stomach may allow future procedures to proceed with access to gastrointestinal tract which may not be otherwise available.

Session: Podium Video Presentation

Program Number: V028

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