Esophageal obstruction due to extensive intramural esophageal dissection: diagnosis and treatment using an endoscopic ‘rendezvous’ technique

Abstract

Intramural esophageal dissection is an uncommon condition which usually responds to conservative management. We report an unusual case of extensive dissection resulting in complete esophageal obstruction, and which required endoscopic therapy. Diagnosis was made using two endoscopes: the transoral endoscope was in the false esophageal lumen, while a second endoscope inserted through a pre-existing gastrostomy was in the true esophageal lumen. Endoscopic needle knife incision of the entire mucosal septum resolved the patient's symptoms, and was performed without complication. The literature is reviewed for current knowledge of this condition. We also propose that 'intramural esophageal dissection' should be the preferred name for this condition, which at present is known by many names.

A case of intramural oesophageal dissection secondary to nasogastric tube insertion

“…2,3 There are also instances of the divisive force being the accidental iatrogenic insertion of a foreign body between the layers, with false passage formation along the line of insertion. 4 In cases of spontaneous intramural dissection, the patient typically presents with retrosternal pain and haematemesis. 2,5 There may also be odynophagia and dysphagia, ranging from partial to complete.…”

“…Water-soluble contrast is sufficient to demonstrate the characteristic double-barrelled lumen; endoscopy may demonstrate the haematoma, or even directly visualise the two lumens. 4,5 Treatment is generally conservative, with proton pump inhibitors aiding resolution. 5 There are recent instances of novel endoscopic techniques being used to relieve complex cases, with stents being employed in extensive circumferential dissections, and endoscopic needle-knife incision relieving complete obstruction secondary to total membranous occlusion of the lumen.…”

“…5 There are recent instances of novel endoscopic techniques being used to relieve complex cases, with stents being employed in extensive circumferential dissections, and endoscopic needle-knife incision relieving complete obstruction secondary to total membranous occlusion of the lumen. 3,4 Surgical intervention has almost no role, however.…”

Intramural dissection with mucosal rupture alleviating phlegmonous esophagitis

“…Although esophageal intramural dissection can be managed with conservative methods, such as parenteral nutrition only or a minced diet with proton-pump-inhibitor treatment, the use of endoscopic treatment for esophageal perforation or intramural dissection has been widely accepted in selected patients [1,2,6,8]. So as to evacuate the abscess within the esophageal wall completely and prevent possible mediastinal contamination due to esophageal perforation, we delayed the closure of the dissection orifice, instead of an incision of the dissected septum, and treated this patient successfully with antibiotics.…”

“…The occurrence of 'esophageal' intramural dissection is usually due to iatrogenic causes, such as nasogastric (NG)-tube insertion or endoscopy [1,2]. An underlying etiology or abnormal anatomy, such as inflammation, intramural hematoma, stricture, or diverticula may complicate NG-tube insertion and predispose to this intractable condition [2].…”