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a technically challenging problem, the combined antegrade and retrograde dilation (CARD) procedure provides an endoscopic treatment option for these obstructions [1–3], and the addition of an endoscopic ultrasound (EUS) needle increases the speed and convenience of the procedure [4–5]. Here we describe use of this technique for the successful treatment of a long cervical esophageal occlusion by using flexible endoscopes and a fully covered removable stent. A 61-year-old man presented to another institution with complete esophageal obstruction, 8 months after treatment for a T2N2B tonsillar squamous cell carcinoma. He required a gastrostomy tube for nutrition and was unable to swallow his own secretions. A conventional CARD procedure was attempted but unsuccessful due to the size of the obstruction. Subsequently, the patient self-referred to our center for the CARD–EUS needle procedure. A 6-mm upper endoscope (GIFXP160; Olympus, Hamburg, Germany) was introduced through the gastrostomy and advanced retrograde to the distal aspect of the occlusion, which was located in the cervical esophagus (●" Fig. 1a). A 9-mm flexible upper endoscope (GIFQ180; Olympus) was advanced perorally to the proximal aspect of the stricture where C-arm fluoroscopy in the anteroposterior and lateral positions was used to align the endoscopes (●" Fig. 1b). A 19guage EUS needle was advanced through the antegrade endoscope and used to traverse the 3.2-cm obstruction under fluoroscopic guidance until visualized by the retrograde endoscope (●" Fig. 1c). A hydrophilic 0.035-inch guide wire was then used to pass a 6-Fr biliary dilation catheter. Wire-guided balloon dilators were used to dilate the stricture to 11mm at three stations with good effect (●" Fig. 1 d,e). A 7-cm × 18-mm fully covered removable stent was placed, taking care to open the proximal aspect of the occlusion without introducing the stent into the oropharynx, which proved difficult (●" Fig. 1f). The duration of the procedure was 80minutes. The stent was removed at 9 weeks, whereupon the patient was taught to perform periodic self-dilationwith aMaloney rigid esophageal dilator, with good results.

endoscopy

Successful treatment of cervical esophageal obstruction using combined antegrade and retrograde dilation with an endoscopic ultrasound needle and fully covered stent