OTSC combined with jejunal mucosal ESD for closure of jejunal dilated blind pouch and anastomotic metal stent placement in the treatment of post-oesophagojejunostomy stricture: a case report (with video).

RATIONALE: Anastomotic stricture after oesophagojejunostomy occurs in 5%-15% of cases, and those complicated by jejunal dilated blind pouch are clinically rare. Traditional single treatments cannot address both lesions simultaneously. The combination of over-the-scope clip (OTSC), endoscopic submucosal dissection (ESD), and covered metal stent provides a potential minimally invasive approach for such complex postoperative complications. PATIENT CONCERNS: A 66-year-old male with a 5-year history of total gastrectomy for cardiac cancer developed progressive dysphagia 3 months after surgery for lower esophageal squamous cell carcinoma. He had difficulty with semiliquid food, accompanied by acid reflux and nocturnal cough, with an approximately 10-kg weight loss that severely impacted his eating function and quality of life. He worried about symptom progression and reoperation trauma. DIAGNOSES: Definitive diagnoses included benign oesophagojejunostomy anastomotic stricture, jejunal dilated blind pouch distal to the anastomosis, and histories of lower esophageal squamous cell carcinoma surgery and cardiac cancer total gastrectomy. Pathology excluded tumor recurrence. Computed tomography (CT) and endoscopy confirmed a 2.4cm-long strictured segment (0.7 cm diameter) as measured on axial CT imaging at the level of the aortic arch using electronic calipers and a 3.0 cm × 2.5 cm jejunal blind pouch (maximum dimensions on axial CT slice). INTERVENTIONS: A two-step endoscopic procedure was performed: 1) Jejunal blind pouch closure: ESD resected mucosal tissue to reduce volume, followed by OTSC placement to close the orifice; 2) Anastomotic covered metal stent placement: After balloon dilation of the stricture to 1.5 cm, a 2.0 cm × 8.0 cm covered metal stent was implanted. Perioperative management included anti-infection, nutritional support, and acid suppression therapy. OUTCOMES: The patient tolerated liquid food on postoperative day 1 and semiliquid food on day 3. One month later, he ate soft food normally with a 3-kg weight gain, and reexamination showed well-positioned stent and closed blind pouch. At 3-month follow-up, the stent was removed without restenosis or blind pouch recurrence. At 9-month follow-up, the patient remained asymptomatic with no recurrent dysphagia, and his self-reported weight had further increased to 70.3 kg (total gain 10.3 kg from baseline). No serious complications occurred within 9 months, and his quality of life improved significantly. LESSONS: For "stricture + blind pouch" cases, treating the blind pouch first avoids reflux affecting stent efficacy. ESD pretreatment enhances OTSC closure safety, covered stents dilate strictures, and refined perioperative management reduces complications. This case represents preliminary experience suggesting the regimen's potential feasibility in carefully selected patients. However, the evidence level remains limited, and long-term efficacy and safety require validation through prospective, multi-center studies with larger sample sizes.