Extensive spontaneous submucosal dissection of the esophagus: long-term sequential endoscopic observation and treatment

Intramural Esophageal Hematoma Mimicking Acute Coronary Syndrome: Complication of Warfarin Use in a Mechanical Heart Valve Patient

A 59-year-old female with a history of mitral valve replacement presented to emergency department, complaining of sudden-onset retrosternal chest pain since 4 hours ago. Electrocardiogram, laboratory tests, and computed tomography (CT) angiography of aorta were performed and ruled out aortic dissection and cardiovascular events. However, new complaint of odynophagia, dysphagia, and incidental findings in CT angiography proposed esophageal pathologies. After initial workup including upper gastrointestinal endoscopy, intramural esophageal hematoma was diagnosed. Laboratory tests revealed significant reduction in the hemoglobin level. Management of warfarin-induced major bleeding in a patient whom anticoagulation was necessary for the prevention of mechanical heart valve thrombosis was challenging. The patient recovered fully with conservative treatment and was discharged on hospital day 14 with low molecular weight heparin. We described a case of intramural esophageal hematoma as a rare condition that could be misdiagnosed as a cardiovascular emergent disease and would be worsened by antiplatelet and anticoagulation therapy. Accordingly, it is important to differentiate intramural esophageal hematoma from cardiac ischemic events. Another challenge was correction of coagulation in the presence of mechanical mitral valve. Fortunately, we had a favorable outcome following conservative management.

A miniseries of spontaneous intramural esophageal hematoma in hemodialysis patients: a rare cause of dysphagia

Intramural esophageal hematoma (IEH) is an uncommon clinical condition, with a prognosis that is essentially benign. In most cases, a predisposing factor may be seen, with the most common being the history of esophagic instrumentation, food impactions, and thrombocytopenia. We report a miniseries of 3 patients on hemodialysis, who developed IEH. All 3 of them presented with sudden onset and progressively worsening dysphagia and hematemesis. Diagnosis of IEH was established by upper gastrointestinal endoscopy. All patients were managed conservatively, and symptoms of dysphagia and chest pain improved within 6-8 days. Good resolution of hematoma was noted by repeat endoscopy within 2-3 weeks. The reported case of IEH in hemodialysis patients is rare and needs to be identified early when patients present with dysphagia, as anticoagulation during hemodialysis would possibly worsen the clinical condition, the course of which is otherwise benign.

Transanal endoscopic microsurgery

The aim of oncologic surgery is radical cancer treatment with preservation of function and quality of life. Almost 30 years ago, transanal endoscopic microsurgery (TEM) revolutionised the technique and outcomes of transanal surgery, first becoming the standard of treatment for large rectal adenomas, then offering a possibly curative treatment for early rectal cancer, and finally generating discussion on its potential role in combination with neoadjuvant therapies for the treatment of more invasive cancer. TEM afforded the advantage of combining a less invasive transanal approach with low recurrence rates thanks to enhanced visualization of the surgical field, which allows more precise dissection. We describe the current indications, the preoperative work-up, the surgical technique (with the aid of a video), postoperative management and results obtained in an over 20-year-long experience. Designed as an accurate means to allow excision of benign rectal neoplasms with a very low morbidity rate, TEM today is indicated as a curative treatment of malignant neoplasms that are histologically confirmed as pT1 sm1 carcinomas. T1 sm2-3 and T2 lesions should at present be included in prospective trials. Accurate preoperative staging is essential for optimal selection of patients. Patients with clear indication for TEM should be referred to specialized medical centres experienced with the technique.

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

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.

Treatment of Barrett's esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy

BACKGROUND

Endoscopic therapies for early neoplasia in Barrett's esophagus may be a viable alternative to esophagectomy.

OBJECTIVE

Our purpose was to compare endoscopic therapy and esophagectomy.

DESIGN

Retrospective review from a single institution.

SETTING

A medium-sized tertiary referral center.

PATIENTS AND INTERVENTIONS

All patients with Barrett's esophagus and dysplasia or intramucosal carcinoma treated by photodynamic therapy (PDT), EMR, or argon plasma coagulation (APC) or esophagectomy with curative intent from May 1998 until November 2005.

MAIN OUTCOME MEASUREMENTS

Survival, progression to cancer, eradication of dysplasia and Barrett's esophagus, major and minor complications, and costs were compared.

RESULTS

Sixty-two patients who underwent endoscopic therapy (2 APC alone, 18 EMR + APC, 20 PDT + APC, and 22 EMR + PDT + APC) and 32 patients who underwent esophagectomy met the inclusion criteria. The 30-day mortality rate included 1 patient in the endotherapy group (2%) and none in the surgical group (P = .49). No deaths from esophageal cancer occurred in either group. Cancer developed in 6% of endotherapy patients and in none in the surgical cohort (P < .05). Major and minor complications occurred in 8% and 31% of endotherapy patients, respectively, and 13% and 63% of surgery patients (P = .50, P < .001). Median cost to date was $40,079 for endotherapy and $66,060 for esophagectomy (P < .001).

LIMITATIONS

Retrospective study, relatively short follow-up, small numbers.

CONCLUSIONS

Both endotherapy and esophagectomy can effectively treat high-grade dysplasia and intramucosal carcinoma associated with Barrett's esophagus. Endotherapy is associated with a higher risk of tumor progression, although this is uncommon. Esophagectomy incurs higher initial costs and results in more frequent minor complications but is usually curative.

Spontaneous intramural esophageal hematoma: case report and review

Intramural esophageal hematoma is a rare form of esophageal injury. The presenting symptoms are nonspecific. Esophagogastroscopy and computed tomography scan are usually needed to establish the diagnosis of intramural esophageal hematoma. Presented here is a patient with spontaneous intramural esophageal hematoma who was successfully treated with conservative measures.

Perforación intramural espontánea del esófago

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.