Spontaneous circumferential intramural esophageal dissection complicated with esophageal perforation and esophageal-pleural fistula: a case report and literature review

A case of a death caused by an atrial-oesophageal-thoracic fistula after radiofrequency ablation of atrial fibrillation

The report is about a 49-year-old man with rheumatic heart disease and atrial fibrillation. He underwent mitral valve replacement, tricuspid valvuloplasty, and atrial fibrillation radiofrequency ablation in the hospital. He vomited blood on the 2nd postoperative day, and the bleeding gradually worsened thereafter. He had to have repeated drainage of large amounts of blood from his right thoracic cavity and digestive tract. He died suddenly after undergoing an oesophageal endoscopy on the 24th postoperative day. The autopsy revealed an atrial-oesophageal-thoracic fistula. By excluding the possibility of the fistula being caused by complications from nasoenteric feeding, tracheal intubation, and a foreign body ingestion, we determined that the atrial-oesophageal-thoracic fistula was a complication after radiofrequency ablation according to the finding of coagulation necrosis of the myocardial cells at the left atrium fistula. In addition, we also performed an elemental analysis on the radiofrequency ablation area and other cardiac tissues by scanning electron microscopy-energy dispersive spectroscopy (SEM-EDS) and found five metal elements, Cr, Cu, Zn, Mn, and Ti, which specifically existed in the radiofrequency ablation area. This finding has the potential to serve as new evidence for radiofrequency ablation and is a worthy direction of research.

Intramural esophageal dissection with eosinophilic esophagitis

Intramural esophageal dissection (IED), like esophageal perforation, is a rare complication of eosinophilic esophagitis (EoE). A 44-year-old woman who had experienced EoE for 8 years complained of food impaction, severe neck pain, and odynophagia as well as consulted the emergency unit. She was diagnosed with IED with mediastinal emphysema by enhanced computed tomography. After admission, she was treated conservatively with noninvasive treatment, including fasting, intravenous feeding, and antibiotics. Only nine cases of IED with EoE have been previously reported. All were male, and our patient was the first female patient from Asia. Urgent endoscopy was conducted in eight cases, of which three were worse after endoscopy, and in one case, total esophagectomy was conducted due to subsequent esophageal perforation. We did not perform urgent endoscopy on our patient because of a potentially increased risk of esophageal perforation through the procedure. When patients with EoE complain of severe retrosternal pain, odynophagia, or dysphagia, IED should be considered in addition to food impaction.

Rare spontaneous extensive annular intramural esophageal dissection with endoscopic treatment: A case report

BACKGROUND

Intramural esophageal dissection (IED) is a rare disease that should be considered in patients with chest pain, dysphagia, and hematemesis. Although it occurs most frequently in older adult women with impaired coagulation or as a sequela of endoscopy, the incidence of spontaneous IED without an obvious causative agent has risen gradually.

CASE SUMMARY

This report describes a case of extensive annular IED in a 75-year-old male patient who presented with dysphagia for the past month. Esophageal barium meal radiography revealed slow passage of diluted iohexol through the esophagus after swallowing, prominent luminal dilation, obstruction of the lower segment with only a small amount of contrast medium entering the gastric cavity, and no obvious extravasation. Gastroscopy revealed smooth esophageal mucosa; several esophageal mucosal bridges and webbed mucosa were observed approximately 22 cm from the incisor. The mucosal surface was occasionally rough and uneven, and the length of the esophageal mucosal defect exceeded 10 cm. The anatomy was considered to be annular because the mucosal bridge connecting the proximal and distal tube was not attached to the surrounding myotubes. The final diagnosis was spontaneous extensive annular IED. We treated the patient successfully using endoscopic esophagotomy, which completely relieved the symptoms without complications.

CONCLUSION

Spontaneous annular IED can be treated successfully by endoscopic resection of the mucosal septum between the true and false lumen.

Circumferential intramural esophageal dissection with large mucosal defect

Intramural esophageal dissection (IED) is an uncommon entity characterized by mucosal rupture creating a false lumen. It usually develops following endoscopy or in old patients with bleeding tendencies and spontaneous presentation possesses diagnostic dilemma. Managing partial IED is simpler than circumferential IED. Due to rarity of presentation, management is not standardized. We report circumferential IED in a young patient and challenges faced during diagnosis and management.

Management of Patients With Circumferential Intramural Esophageal Dissection

A novel minimally invasive endoscopic drainage technique using a double-tube system improves the feasibility and safety of conservative treatment in spontaneous esophageal intramural dissection (EID). Two patients with spontaneous EID underwent double-tube system placement through esophagogastroduodenoscopy. One tube was inserted into the submucosal layer with continuous suction, and another nasoduodenal tube was simultaneously inserted for enteral nutritional support. Given the ease of placement and the success of this simple double-tube system method, this technique may provide a new, low-risk, and cost-effective treatment modality for patients with EID.

First successful treatment of a circumferential intramural esophageal dissection with perforation in a patient with eosinophilic esophagitis using a partially covered self-expandable metal stent

Intramural esophageal dissection (IED) is a rare disease characterized by a partial (PIED) or circumferential (CIED) mucosal rupture. Whereas PIED responds well to nonoperative treatment, complicated courses have been reported necessitating surgery, up to the point of esophagectomy despite complex endoscopic interventions, in CIED. We report the first case of an iatrogenic CIED with perforation in a young patient with underlying eosinophilic esophagitis treated successfully by endoscopy alone, using a partially covered self-expandable metal stent.