Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos)

Abstract

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire-guided cannulation. The ZD was treated with flexible endoscopic clip-assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation.

Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy

“…Iatrogenic causes are endotracheal intubation [1], gastrointestinal endoscopy [2], nasogastric tube insertion [3]. Lately, as laparoscopy or robot-assisted total gastrectomy is performed through an intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™; Covidien, Mansfield, MA, USA), anesthesiologists are required to insert the OrVil™ transorally [4].…”

Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP) (with videos)

“…Diagnostic and therapeutic esophagogastroduodenoscopy (EGD) plays an important role in investigating the dysphagia and in managing the underlying stenosis. We translate endoscopic retrograde cholangiopancreatography (ERCP) techniques and skills in approaching pancreaticobiliary obstruction in the management of severe and complete PES [2]. We select and report three cases of severe or complete PES in which flexible endoscopic therapy was successfully provided by using fluoroscopy, ERCP wire guides, endoscopic balloons, and by performing pharyngo-esophageal puncture (PEP).…”

87-Year-Old Woman With Painful Swallowing

“…10 The mechanism of dissection appears to be an initial inciting traumatic break in the mucosa, which subsequently leads to a full separation of the mucosal or submucosal layers from the deeper muscular layers as a result of increased intraesophageal pressure. 10 Dissections have been reported to occur as a result of foreign body ingestion 7 or a food bolus or soon after esophageal instrumentation, including endoscopy, 12 nasogastric tube placements, 8 and transesophageal echocardiography. 13 Esophageal hematoma is another possible triggering event, and this may be why patients receiving anticoagulation therapy are at higher risk of developing spontaneous intramural bleeding.…”