1685 Endoscopic Fistulectomy of an Obstructive Esophagogastric Mucosal Bridge

Abstract

INTRODUCTION: Esophageal mucosal bridges are rare complications from many causes including congenital abnormalities, radiotherapy, sclerotherapy, nasoenteric feeding tubes, or Crohn’s disease. Mucosal bridges are made of smooth muscle crossing gastrointestinal lumen and resulting in a double barrel appearance on endoscopy. Pathogenesis may involve mucosal undermining by ulceration followed by healing, re-epithelialization of the mucosal undersurface, and formation of a mucosal tube attached to the non-ulcerated wall. Therefore, chronic, repetitive ulcerations and subsequent healing may lead to bridge formation. Another theory is that inflamed walls of esophagus contacting one another allows granulation tissue to form adhesions resulting in a mucosal bridge. This could explain fistula formation in inflammatory bowel disease. CASE DESCRIPTION/METHODS: A 68-year-old woman presented with a 6-year history of progressive solid food dysphagia and gastroesophageal reflux. Her past surgical history was significant for laparoscopic band surgery complicated by gastric band erosion into the stomach at the gastroesophageal junction that required subsequent gastric band removal and omental flap reinforcement of the gastric perforation nine years prior to presentation. A diagnostic upper endoscopy revealed an esophageal fistula at the gastroesophageal junction and biopsies at the junction showed chronic inflammation without dysplasia. The upper endoscope was advanced to the gastroesophageal junction at 37 cm from the entry site. Proximal to the gastroesophageal junction, two esophageal lumens were seen leading to the gastric lumen due to a thick mucosal bridge causing partial obstruction to the stomach. First, four hemostatic clips were placed at both ends of the stalk before mucosal incision to prevent bleeding. The bridge was grasped with forceps and fistulectomy was performed with a needle knife to incise the mucosal bridge between the clipped portion using electrocautery. On post-operative follow-up at week 6 and 12, the patient had complete resolution of dysphagia and no demonstrated recurrence of mucosal bridge formation. DISCUSSION: This is an unusual case of an esophagogastric fistula from a delayed adverse event of laparoscopic gastric band placement even after band removal and corrective surgery that caused dysphagia. It was successfully treated with endoscopic fistulectomy using hemostatic clips and a needle knife under direct visualization. This method has proven to be effective with no reported recurrences. Watch the video: http://bit.ly/2Y0JNws.