S5249 Use of Electrohydraulic Lithotripsy for Endoscopic Reconstruction of Disconnected Esophagus by the Double Scope Retrograde Technique. Think Beyond the Stones!

Introduction: Esophageal strictures, often caused by GERD, infections, or caustic ingestion, can lead to progressive dysphagia. Complete esophageal obstruction is rare, particularly in benign cases, and may occur mainly following radiation therapy. We report a unique case of disconnected esophagus due to a post-radiation stricture, successfully treated with retrograde endoscopic reconstruction by double scope technique using electrohydraulic lithotripsy (EHL) device to create the tract between the lumens. To our knowledge, this is the first reported case utilizing EHL for this indication. Case Description: A 65-year-old man with a history of tonsillar cancer treated with chemoradiation in 2024 developed progressive dysphagia and poor oral intake, necessitating PEG tube placement. Endoscopy revealed complete esophageal disconnection due to a benign radiation-induced stricture. A guide wire could not pass through the stricture. Reconstruction was achieved via retrograde endoscopic access through the gastrocutaneous fistula. An initial puncture was made using an EHL probe under direct endoscopic and fluoroscopic guidance using the alignment of the 2 scopes and the transillumination sign, followed by retrograde guidewire passage. A tract was then created using a triangular knife in Endo Cut and soft coagulation mode in an antegrade fashion, then the fistula was dilated to 7 mm with a Through the Scope (TTS) dilator antegradely. A 14 mm × 70 mm fully covered esophageal stent was deployed under fluoroscopic guidance, successfully restoring esophageal continuity. The patient was able to start oral intake immediately post-procedure. Discussion: EHL is a well-established technique for fragmenting stones in the pancreatic and hepatobiliary systems, utilizing electrohydraulic shock waves generated by electric discharge in saline solution. However, its application outside the biliary and pancreatic tracts remains limited in Gastroenterology. While previous case reports have described its use in managing gallstone ileus, the use of EHL for recanalizing a completely obstructed esophageal lumen has not been previously documented. This case represents a novel application of EHL in managing complete esophageal disconnection, highlighting its potential as a minimally invasive option in select cases of complex esophageal strictures.