Jasmine Sinha, MD, MPH, A. Aziz Aadam, MD; Northwestern University Feinberg School of Medicine, Chicago, IL
Introduction: Formation of severe submucosal fibrosis in esophageal anastomotic stricture may preclude successful esophageal dilation and require additional endoscopic therapy. Furthermore, due to submucosal fibrosis and pressure fluctuations in the esophagus, diverticulum formation may occur after repeated dilation. Endoscopic incisional therapy (EIT) is a therapeutic option for refractory anastomotic esophageal stricture and peri-anastomotic diverticulum formation.
Methods: A 68-year-old man with esophageal adenocarcinoma status post esophagectomy presented with dysphagia. Endoscopy revealed a 6mm stricture at the esophagogastric anastomosis, about 22cm from the incisors. Despite weekly dilations with a 45 French bougie dilator and steroid injections, repeat endoscopy revealed a persistent 9mm stricture at the anastomosis. EIT was used to perform a stricturoplasty. Using an insulated-tip knife, a small incision was made along the esophageal lumen over a segment of thickened mucosa with suspected submucosal fibrosis. Exposure of the submucosa revealed significant underlying fibrosis. Two additional incisions, approximately 2mm in depth, were made to the apparent extent of fibrosis. The knife was then traced with radial motion, parallel to the esophageal lumen, to dissect the submucosal fibrosis until the endoscope could pass. Following stricturoplasty, this segment was dilated to 15mm to allow for radial disruption of the stricture. The patient developed recurrent dysphagia 3 months later. Esophagram revealed a peri-anastomotic diverticulum with pooling of contrast. Endoscopy confirmed a diverticulum with a thick septum and so the decision was made proceed with a diverticulum septotomy. After marking the base of the septum with snare tip, a scissor-type knife was used to dissect the proximal end of the septum, exposing a thick layer of submucosal fibrosis. Additional dissection was carried out to the base of the septum to create a single continuous lumen with the esophagus. Follow up endoscopy 6 months later revealed a widely patent anastomosis and no recurrence of the peri-anastomotic diverticulum. The patient denied any further dysphagia. Discussion: EIT is an effective therapy for esophageal stricture refractory to endoscopic dilation and steroid injection using the method described here. In addition, peri-anastomotic diverticulum should be considered as a potential etiology of dysphagia symptoms and can be treated with diverticular septotomy.
Disclosures: Jasmine Sinha indicated no relevant financial relationships. A. Aziz Aadam: Boston Scientific – Consultant. Cook Medical – Consultant. Steris Endoscopy – Consultant.