Endoscopy Video Forum

V3 - Solving the Maze: Restoring the Oesophageal Lumen After Defective Mucosal Healing of a Stented Circumferential Intramural Esophageal Dissection

Monday, October 8
5:04 PM - 5:11 PM
Location: Terrace Ballroom 1 (level 400)

Category: Endoscopy Video Forum
Danial Daneshvar, MD1, Youssef El Douaihy, MD1, Najib Nassani, MD2, Vera Zarakat, MD1, Iskandar Barakat, MD1, Sherif Andrawes, MD1
1Staten Island University Hospital, Staten Island, NY; 2University of Illinois, Chicago, IL

Abstract Body: We are presenting today a case of 22 years old man who presented to us for dysphagia, chest pain, persistent vomiting, anorexia and significant weight loss. All these symptoms started after recent marijuana use. A CT scan of the chest was performed in emergency department and it showed a double lumen oesophagus which was confirmed in the barium oesophagogram. EGD was performed which showed a false and true lumen and a septum in between, confirming the diagnosis of oesophageal submucosal dissection. 

An endoscopic overstitching device was used in order to close the tunnel as well as clips but the tissue was too friable, so it failed. Biopsies were taken to rule out any underlying disease but they were unrevealing. 

A fully covered metallic oesophageal stent was then placed to cover the dissected area. But the patient did not tolerate the stent and we have to take it out because of the odynophagia. 

After literature research, we planed to do conservative management including NPO diet, TPN and PPI twice daily. It was effective for almost one week but then the patient came back with dysphagia. 

A week later we placed a second fully covered metallic oesophageal stent that was shorten in length and less radial force in an attempted to have better tolerability of the stent by the patient.

Patient was able to tolerate oral intake. He came back in 4 weeks to remove the stent. He lost the follow up after.

4 months later he came back with dysphagia and vomiting. A repeat EGD showed a stricture proximal to the site of the previously placed oesophageal stent. The stricture was too tight and we had to dilate and open it with using a needle knife. 

Beyond the stricture multiple oesophageal dissection were noted in addition to old non-healing dissection. Using endoscopic submucosal dissection technique, the loose intraluminal mucosal tissue was dissected and removed en bloc. 

His symptoms improved and he was able to tolerate oral diet. A follow up endoscopy showed re-establishment of the oesophageal lumen with a patent single lumen in the oesophagus. 

We present a complicated case of submucosal superficial tearing of oesophagus secondary to sever cannabinoid hyperemesis syndrome that failed the conventional treatment modalities of overstitching , suturing, clipping and stenting.  We propose in the right setting ESD can be used to as a technique to clear the luminal interference caused by redundant dissected mucosal lining and re-establish luminal patency.


Disclosures:
Danial Daneshvar indicated no relevant financial relationships.
Youssef El Douaihy indicated no relevant financial relationships.
Najib Nassani indicated no relevant financial relationships.
Vera Zarakat indicated no relevant financial relationships.
Iskandar Barakat indicated no relevant financial relationships.
Sherif Andrawes indicated no relevant financial relationships.

Youssef El Douaihy

Fellow
Staten Island University Hospital
Staten Island, NY

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