S1850 Septal Wall Divides Esophagus Into Double Lumen: Successful Endoscopic Septotomy

Abstract

INTRODUCTION: Intraluminal esophageal diverticulum is a rare condition identified by a collection of intraluminal barium with surrounding radiolucent halo on barium swallow. To our knowledge, only seven cases have been reported in the literature. In those cases, management consisted of proton pump inhibitor (PPI) therapy, lifestyle modifications and esophageal dilation. Limited literature exists on the endoscopic management of this condition. Our case highlights the use of endoscopic septotomy and myotomy as minimally invasive techniques in treating symptomatic intraluminal esophageal diverticulum. CASE DESCRIPTION/METHODS: A 27-year-old male with a history of gastroesophageal reflux disease and gastric ulcer presented with progressive dysphagia leading to a 50-lb weight loss over three months. Medical therapy with PPI provided mild symptomatic improvement. Initial upper endoscopy revealed an esophageal stricture with a double lumen. Repeat endoscopy showed true and false lumens divided by a septal wall located at 25 cm from the incisor, with multiple diverticula seen within the false lumen. These endoscopic findings were confirmed by esophagram. Due to persistent symptoms, the patient was referred for further endoscopic evaluation and management. Various endoscopic submucosal dissection knives were used to perform septotomy, guided by yellow and black guidewires placed in the true and false lumens, respectively. A nasogastric tube placed over the yellow guidewire further defined the true lumen. A distal cap attachment was used simultaneously to improve visibility and maintain hemostasis. Septotomy began 25 cm from the incisor and terminated 39 cm from the incisor, for a total length of 14 cm in the mid- to distal esophagus. Intermittent endoscopic mucosal resection was performed with redundant tissue removed via hot snare. One endoclip was deployed at the distal end of the esophagus to prevent mucosal division and achieve hemostasis. At the end of the procedure, a single lumen was visualized endoscopically. DISCUSSION: Endoscopic septotomy and mucosal resection offer a minimally invasive approach to treat intraluminal esophageal diverticulum. The procedure was well-tolerated and follow-up esophagram confirmed a single esophageal lumen. Further reporting and research are needed to determine optimal endoscopic management of this rare condition.