Knife-assisted incision for restoring esophageal lumen after surgical exclusion

Abstract

Figures

Initial appearance of the esophageal lumen.

Incision of the fibrosis with L-type dissector (Finemedix, Daegu, Korea) to separate staples.

Final view: the staple line site was traversed by a standard gastroscope.

Full text

Surgical repair with esophageal exclusion is a life-saving surgery for patients with mediastinitis following mid-esophageal perforation 1 . This is followed by either spontaneous recanalization of the organ or subsequent surgery to restore lumen patency 2 .

We present the case of a patient who underwent endoscopic restoration of the esophageal lumen after unsuccessful spontaneous recanalization following esophageal exclusion.

A 41-year-old man, with known achalasia, underwent pneumatic endoscopic dilation at another center, resulting in a 6 cm longitudinal laceration of the lateral esophageal wall. The patient developed mediastinitis and was treated by surgical repair of the laceration and esophageal exclusion with proximal staple line division.

At 4 months post-surgery, the patient continued to experience dysphagia with a liquid diet. Postoperative esophagograms revealed poor contrast passage across the staple lines. The patient was referred to our unit for endoscopic recanalization ( Video 1 ). Endoscopically, we found a moderate stenosis (caliber 6 mm) at the staple line site ( Fig. 1 ).

Endoscopic esophageal lumen recanalization after surgical exclusion.Video 1

Initial appearance of the esophageal lumen.

Initially, we placed a guidewire in the stapled lumen and performed dilation with Savary–Gilliard bougies up to 9 mm. Then, we extensively incised the fibrosis between the residual lumen and the stapled lumen using an L-type dissector (Finemedix, Daegu, Korea) ( Fig. 2 ). Finally protruding staple sutures were removed by cold forceps.

Incision of the fibrosis with L-type dissector (Finemedix, Daegu, Korea) to separate staples.

As a result, a well-patent esophageal lumen, traversable with a standard gastroscope (caliber 9.8 mm), was achieved ( Fig. 3 ). No leaks were detected on the intraprocedural esophagogram.

Final view: the staple line site was traversed by a standard gastroscope.

On the first postoperative day, an X-ray with contrast medium showed smooth contrast passage throughout the esophagus. The patient was discharged after resuming a soft diet. At the 3-month follow-up, he reported having no dysphagia.

To the best of our knowledge, this is the first report of endoscopic recanalization after surgical esophageal exclusion and describes a potential treatment option for similar complex cases.

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