Severe Esophageal Stricture Research Articles

Risk of severe esophageal stricture among childhood cancer survivors – A population-based case-cohort study within the Adult Life after Childhood Cancer in Scandinavia (ALiCCS)

PurposeDue to limited data on treatment-related risk factors associated with esophageal stricture in childhood cancer survivors, this study aimed to assess such factors in long-term survivors. MethodsA case-cohort study was conducted involving 36 cases of five-year childhood cancer survivors with esophageal stricture and a sub-cohort of 540 survivors diagnosed with cancer in 1970–2007 as identified within the Nordic ‘Adult Life after Childhood Cancer in Scandinavia’ program. Individualized treatment details were retrieved from medical records. Radiation doses to each body region and average dose to the esophagus were reconstructed for patients that received radiotherapy. We used a modified Cox proportional hazard model to evaluate associations between esophageal stricture and risk factors by calculating incidence rate ratio (IRR), with 95 % confidence intervals (CIs). ResultsAn increased rate of esophageal stricture was found in survivors who received total body irradiation (IRR=13.7, 95 %CI 4.6–41.1), chest- and neck-directed radiotherapy (IRR=23.5, 95 %CI 8.5−64.7) and doses of ≥12 Gy to the esophagus (IRR=26.8, 95 % CI=9.0–80.3) compared to non-irradiated survivors. Treatment with chemotherapy was also associated with esophageal stricture (IRR=8.4, 95 % CI=2.9–24.4). Notably, leukemia survivors faced an elevated rate (IRR=3.8, 95 % CI 1.8–8.1) compared with survivors of CNS and other solid tumors. ConclusionsOur findings indicate an increased risk of esophageal stricture among childhood cancer survivors, with both neck- and chest-directed radiotherapy and chemotherapy as important risk factors.

Esophageal ganglioneuromatosis; a rare cause of intractable esophageal stenosis: a case report

BackgroundGanglioneuromatosis is a rare type of benign neurogenic tumor that usually affects the sites of the major sympathetic ganglia in the retroperitoneum and the posterior mediastinum. Affection of the gastrointestinal tract is rare, and involvement of the esophagus is exceptional. To the best of our knowledge, only 4 cases of esophageal ganglioneuromatosis in adults were reported in the literature. No cases have been reported in the pediatric age group.Case presentationAn 11-year-old boy presented with dysphagia due to severe esophageal stenosis caused by esophageal ganglioneuromatosis.ConclusionsDespite its rarity, the present case implies that ganglioneuromatosis should be considered in children with idiopathic esophageal stenosis.

Sporadic gastrinoma with refractory benign esophageal stricture: A case report

BACKGROUND Gastrinoma is characterized by an excessive release of gastrin, leading to hypersecretion of gastric acid, subsequently resulting in recurrent peptic ulcers, chronic diarrhea, and even esophageal strictures. This case report aims to improve awareness and facilitate early diagnosis and treatment of gastrinoma by presenting a rare case of gastrinoma with refractory benign esophageal stricture (RBES). Additionally, it highlights the persistent challenges that gastroenterologists encounter in managing RBES. CASE SUMMARY This case demonstrates a patient with gastrinoma who developed RBES and complete esophageal obstruction despite management with maximal acid suppressive therapy, multiple endoscopic bougie dilations and endoscopic incisional therapy (EIT). CONCLUSION It is essential to diagnose gastrinoma as early as possible, as inadequately controlled acid secretion over an extended period increases the risk of developing severe esophageal strictures. In patients with esophageal strictures causing complete luminal obstruction, blind reopening EIT presents challenges and carries a high risk of perforation.

Endoscopic treatment of an esophageal perforation in eosinophilic esophagitis by insertion of a self-expanding metal stent.

We present the case of a 29-year-old patient with multiple allergies, mild asthma and rhinoconjunctivitis who reported a history of esophageal impactions after ingestion of solid foods. These episodes resolved spontaneously at home and by self-induced vomiting and never required endoscopic removal. The patient presented to the emergency department due to a sensation of food impaction lasting more than 12 hours after eating meat the night before, which did not subside with the intake of liquids or self-induced vomiting. Endoscopic evaluation was requested for foreign body extraction. A meat bolus impacted in the distal esophagus was easily removed using a Roth basket, revealing a severe esophageal stricture that prevented passage of the endoscope into the gastric cavity. Furthermore, in the same area where the foreign body was previously located, a deep esophageal tear was seen. Given the high suspicion of perforation, the patient was examined, and thoracic and cervical crepitation was observed. It was decided to immediately insert, with only endoscopic control, a partially covered Ultraflex® esophageal stent measuring 18 mm in diameter and 15 cm in length. After insertion, clinical improvement and cessation of crepitation were observed.

Feasibility of a Percutaneous and Non-Fluoroscopic Procedure for Transcatheter Mitral Valve Edge-to-Edge Repair.

Transcatheter edge-to-edge repair (TEER) of the mitral valve has emerged as an alternative treatment for mitral regurgitation (MR). However, the high radiation exposure during the process has been associated with multiple adverse effects for medical staff. In this study, we assessed the feasibility and safety of TEER performed solely under the echocardiographic (echo) guidance. Between April 2021 to August 2021, we retrospectively collected characteristics of 23 patients with MR who underwent TEER under echocardiographic guidance exclusively. Follow-up evaluations were performed at 1- , 3-months and 1-year post procedure. All 23 patients (mean age, 66.1 12.1 years; 65.2% males) successfully underwent echo-guided TEER, with 22 patients under transesophageal echo (TEE) guidance and 1 patient under transthoracic echo (TTE) guidance for severe esophageal stenosis. Of the patients, 60.9% received 1 implant and 39.1% received 2 implants. The median total procedural time was 130 (interquartile range, IQR: 90-150) min and the device procedure time was 73 (IQR: 58-100) min. The median length of stay was 6 (IQR: 5-9) days. At 3-months follow-up, 63.6% of patients had an MR 1+ and 90.9% had an MR 2+ (p 0.001 vs. baseline). Improvement in functional status was observed, with 40.9% of patients classified as New York Heart Association (NYHA) functional class I and 45.5% as NYHA functional class II (p 0.001 compared to baseline) at 3-months. At 1-year follow-up, 90.4% maintained MR reduction with MR 2+ (p 0.001 vs. baseline). Single leaflet device attachment (SLDA) occurred in one patient (4.3%) 1-week post procedure. This retrospective, single-center, and pilot study demonstrates the feasibility, safety, and low complication rates of TEER guided solely by echocardiography. Our findings support the systematic use of echocardiography as the sole guidance modality for TEER, highlighting its potential as an alternative to fluoroscopy-guided procedures. Further multicenter and comparative studies are warranted to confirm these results and provide a more comprehensive evaluation of this approach.

Severe Esophageal Stricture Caused by Esophageal Candidiasis in a Non-HIV Patient

Severe Esophageal Stricture Caused by Esophageal Candidiasis in a Non-HIV Patient

S2785 Navigating the Narrow Path: Chronic Benign, Severe Esophageal Strictures in a Patient With Acquired Immune Deficiency Syndrome

S2785 Navigating the Narrow Path: Chronic Benign, Severe Esophageal Strictures in a Patient With Acquired Immune Deficiency Syndrome

Successful small-diameter endoscopic hemostasis using a self-assembling peptide matrix for Mallory-Weiss syndrome in a patient with a severe esophageal stricture

Successful small-diameter endoscopic hemostasis using a self-assembling peptide matrix for Mallory-Weiss syndrome in a patient with a severe esophageal stricture

TBX1 copy number variant of unknown significance presenting as severe esophageal stricture and recurrent candidiasis

IntroductionTBX1 Is involved in pharyngeal pouch development affecting thymus, parathyroid, craniofacial, and cardiac outflow tract development. TBX1 deletions present with phenotype of Di George syndrome. We present the case of a patient with esophageal stricture and candidiasis showing a novel TBX1 gene triplication VUS. Case descriptionA 27-year-old male was hospitalized for hematemesis and progressive dysphagia. The physical exam was remarkable for short stature, underweight, dental hypoplasia, alopecia and occipital vitiligo. Calcium and lymphocyte numbers were normal. Severe esophageal strictures precluded upper endoscopy. He received IV fluconazole for two weeks to continue oral antifungal indefinitely. Since infancy he has had multiple candida infections in nails and oral mucosa requiring fluconazole, and medical history of asthma and atopic dermatitis. No history of cardiac abnormalities. At 14 years old he started with progressive dysphagia. Barium swallow and endoscopies showed severe acute and chronic esophagitis and thoracic esophageal strictures with severe stenosis. Patient's sister has history of candida infections, hypocalcemia due to hypoparathyroidism, and hypothyroidism. There is consanguinity among paternal grandparents. Invitae PID panel showed VUS with TBX1 gene triplication, not previously reported. Familial genetic testing was requested for her sister to support the diagnosis of DiGeorge Syndrome. DiscussionTBX1 gene deletions present a spectrum clinical phenotype including thymic hypoplasia, hypocalcemia, and congenital heart defects. TBX1 duplication and gain of function TBX1 heterozygous mutation led to protein dysfunction and a similar phenotype caused by loss-of-function mutations or deletions. TBX1 triplication could plausibly lead to dysfunctional protein expression, which requires confirmation. TBX1 is a negative regulator of thymic epithelial cell differentiation and proliferation, which could affect immune regulation and explain patient's chronic candida infections. Feeding difficulties and esophageal dysmotility have been reported in Di George syndrome. Sibling's hypocalcemia due to hypoparathyroidism could be explained by TBX1 dysfunction. APECED was considered in differential diagnosis due to chronic mucocutaneous candidiasis and sister's endocrinopathies, nevertheless, no AIRE or STAT1 mutations identified. Genetic analysis and familiar VUS have the potential to identify the cause of PIDs. TBX1 transcript and protein expression analysis will contribute to confirming the diagnostic impression.

Prevention of Esophageal Stricture after Endoscopic Submucosal Dissection with an Autologous Esophageal Epithelial Cell Suspension: An Animal Study.

Severe esophageal stricture decreases patient's quality of life after circumferential endoscopic submucosal dissection (ESD). We aimed to evaluate the efficacy of autologous esophageal epithelial cell suspensions in preventing esophageal stricture after circumferential ESD. Twelve male mini-pigs underwent circumferential ESD and were randomized into four groups: G1 (control), G2 (esophageal stent), G3 (autologous esophageal epithelial cell suspension), and G4 (autologous esophageal epithelial cell suspension combined with esophageal stent). Post-ESD status was observed in each group, and endoscopy was performed weekly. Esophageal stents were removed 3 weeks after ESD. The esophageal stricture rates and histologic characteristics were assessed 4 weeks after ESD. G1 showed the greatest weight loss (p < 0.05). Dysphagia scores were not significantly different among the groups. The esophageal mucosal stricture rates were 77.7 ± 2.9%, 74.2 ± 1.9%, 69.2 ± 3.8% and 65.9 ± 1.9% in G1-4, respectively; with the highest in G1 (G1 vs. G3, p = 0.005; G1 vs. G4, p = 0.001). The regenerated epithelium lengths were 4.408 ± 1.980 mm, 8.319 ± 0.857 mm, 11.801 ± 2.455 mm and 12.353 ± 1.111 mm in G1-4, respectively. The lowest degree of re-epithelialization was observed in G1, followed by G2, with the highest degrees in G3 and G4 (G1 vs. G3, p = 0.001; G1 vs. G4, p = 0.000). The maximum wound fibrosis thicknesses were 2.546 ± 0.389 mm, 2.136 ± 0.231 mm, 1.126 ± 0.211 mm and 1.131 ± 0.438 mm in G1-4, respectively, with higher degrees in G1 and G2 than in G3 and G4 (G1 vs. G3, p = 0.001; G1 vs. G4, p = 0.001). Autologous esophageal epithelial cell suspensions can promote re-epithelialization and reduce fibrosis, thus decreasing esophageal stricture severity after ESD.

Early duodenal cancer successfully treated by endoscopic submucosal dissection with an ultra-thin endoscope in spite of severe esophageal stricture.

Early duodenal cancer successfully treated by endoscopic submucosal dissection with an ultra-thin endoscope in spite of severe esophageal stricture.

Esophageal Stricture Recalcitrant to Repeated Dilation in Complex Rheumatological Disease

We report a case of severe refractory esophageal strictures in the setting of rheumatological disease found to be secondary to isolated esophageal autoimmune bullous disease. She had a history of Sjogren syndrome and esophageal strictures with many previous dilations. After rheumatological workup, she was diagnosed with mixed connective tissue disease. Biopsy showed complement and immunoglobulin G deposition in the basement membrane consistent with bullous lupus or bullous pemphigoid. She had no cutaneous bullae and was diagnosed with isolated esophageal bullous disease. She required multiple dilatations over several months of treatment and was started on mycophenolate mofetil with clinical improvement.

S2852 Dislodged Esophageal Stent Extracted via PEG Tube Site: An Uncommon Solution for a Real Life Problem

Introduction: Esophageal stents have been used for management of refractory benign strictures and has risk of stent migration even with endoscopic suturing or clipping techniques. With esophageal stricture present, the retrieval of the migrated stent becomes a dilemma. We present one such case that required retrieval of the migrated stent through a pre-existing percutaneous endoscopic gastrostomy (PEG) tube site. Case Description/Methods: A 62-year-old man with history of supraglottic small cell carcinoma treated with chemo-radiation therapy developed a severe benign esophageal stricture. He had multiple esophageal dilations and steroid injections which failed and eventually treated by esophageal stent placement with stent fixation via endoscopic suturing. He presented with food impaction and esophagogastroduodenoscopy (EGD) found a severe distal esophageal stricture which could only be traversed with a pediatric gastroscope. The previously placed 20mmx80mm fully covered self-expanding metal stent (FCSEMS) had migrated into the stomach (Figure 1a). Exhaustive attempts at endoscopic retrieval past the esophageal stricture was unsuccessful. He had a pre-existing 20Fr PEG tube and the PEG tract was gradually dilated to 15mm. An adult gastroscope was passed through the PEG site and a raptor forceps was used to grab and extract the forceps successfully (Figure 1b-c). A new 24Fr PEG tube was placed. Mild oozing was seen in the tract, otherwise patient tolerated the procedure well. He was referred to discuss surgical options for further treatment of his esophageal stricture. (Figure) Discussion: Esophageal stents are being increasingly utilized in the management of not only malignant strictures, but also benign esophageal disease such as recurrent esophageal strictures, anastomotic leaks, perforations and fistulae. Stent migration may occur frequently in benign disease with risk factors being use of FCSEMS, distal location and previous migration. An unretrieved stent may cause small bowel obstruction. Anchoring stents with endoscopic suturing, and clips may reduce the risk of migration. If unable to be removed endoscopically then a surgical approach will be needed. Luckily, the presence of a mature gastrostomy tract provided an alternate extraction route for our patient. Risks associated with this modality include bleeding, gastrostomy site disruption, gastric perforation and peritonitis. Increased physician awareness of endoscopic options in such a case may obviate the need for surgical intervention.Figure 1.: Endoscopic image of dislodged esophageal stent in stomach (a). Endoscopic image of adult gastroscope passed through PEG site dilated with CRE balloon (b). Image of dislodged esophageal stent retrieved via dilated PEG site (c).

S2312 Esophageal Stricture Secondary to Mycophenolate Mofetil-Induced Injury

Introduction: Immunosuppressant medications like mycophenolate mofetil (MMF) have recently garnered more attention in the literature due to gastrointestinal toxicity. There are increasing case reports of transplant patients on MMF who develop inflammation or ulcers throughout the GI tract. It is theorized that the inflammation is due to MMF toxicity from metabolite formation. Although there has been increasing evidence of MMF induced injury to the GI tract, there are few reports of esophageal involvement, which is presented below. Case Description/Methods: This case involves a 40 year-old patient with Type I diabetes mellitus complicated by gastroparesis, renal and pancreatic transplants on immunosuppression with MMF, who developed progressively worsening dysphagia, weight loss, nausea, and vomiting. The patient initially presented to an outside gastroenterologist due to complaints of nausea and hematemesis. An EGD was completed with evidence of ulcerative esophagitis with biopsies negative for bacterial, fungal and viral stains. He was started on a proton pump inhibitor (PPI) for treatment of presumed reflux esophagitis. After no improvement with several months of therapy, he presented to our gastroenterology clinic for evaluation. Upon questioning, he specifically complained of progressive difficulty with swallowing after starting MMF. The patient underwent EGD and showed a severe distal esophageal stricture, which was not able to be traversed with the regular upper endoscope (Figure). Biopsies were taken and revealed acute erosive esophagitis. Immunohistochemical staining was negative for HSV and CMV. Given our high suspicion for MMF-induced esophageal injury, his medication was changed to liquid formulation. The patient underwent repeat serial endoscopies with dilation every 2 weeks for the next 2 months. After transitioning to liquid formulation, each subsequent endoscopy showed improvement in the ulcerated stricture. The patient was last dilated to 45 French in which he reported marked improvement of his dysphagia. Discussion: This case demonstrates a patient who developed a severe esophageal stricture from MMF induced injury with resolution of symptoms after multiple dilations and transition to a liquid formulation of MMF. Though the exact physiologic mechanisms are not well understood, gastroenterologists should be suspicious in patients on mycophenolate who present with dysphagia and stricture that is not explained by infection, malignancy, reflux, or other medications.Figure 1.: A. Initial non-traversable esophageal stricture B. Esophageal stricture status post multiple dilations C. Improving ulcerative stricture after switching to liquid formulation of MMF and multiple dilations.

S3639 Nitromethane Ingestion Resulting in Severe Esophageal and Pyloric Stenosis: A Case Report

S3639 Nitromethane Ingestion Resulting in Severe Esophageal and Pyloric Stenosis: A Case Report

S2301 Dysphagia: An Unusual Primary Presentation of Non-Small Cell Lung Cancer

Introduction: Respiratory symptoms predominate in patients with lung malignancies. Dysphagia as a presenting symptom is rare with only about 1%-2% of patients presenting with dysphagia as their cardinal symptom. We describe a rare case of a 56-year-old male presenting with only dysphagia in the setting of extrinsic esophageal compression secondary to non-small cell lung cancer. Case Description/Methods: A 56-year-old male with past medical history of hypertension, chronic obstructive pulmonary disease, and chronic tobacco use presented to the emergency department with complaint of persistent emesis for the past 3 months. The patient described the emesis as occurring minutes after eating a meal. He also admitted to loss of appetite, unintentional weight loss, and dysphagia to solids. On admission, the patient was normotensive and tachycardic to a heart rate of 108. CT chest was performed and revealed an 8.0 x 7.5 cm right mediastinal mass with obliteration of the right main pulmonary artery and right main bronchus along with multiple irregular and nodular opacities in the right lung and left lower lobe concerning for metastases. Pulmonology was consulted and performed a bronchoscopy which showed a large obstructing endobronchial lesion of the right mainstem bronchus; biopsies of the lesion were sent. The patient was diagnosed with metastatic non-small cell lung cancer. The patient’s hospital course was complicated by intractable emesis and development of shock. Repeat CT was performed and was remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax. Gastroenterology was consulted for concerns of esophageal perforation vs. invasion. Esophagogastroduodenoscopy was performed and showed severe extrinsic stenosis 30-32 cm from the incisors. The area of stenosis measured 2 cm in length and was dilated. A 23mm x 120mm EndoMAXX fully covered stent was placed at the 26 cm to 38 cm region of the esophagus. Following stabilization, the patient was able to tolerate mechanical soft diet and thin liquids (Figure). Discussion: Dysphagia associated with lung cancer can occur via 3 mechanisms: mediastinal extrinsic esophageal compression, upper esophageal compression by lymph nodes, and radiation induced esophageal stenosis. Patients may experience decreased quality of life due to poor oral intake, malnutrition, and increased risk for infection. Lung malignancy associated dysphagia can be improved by both surgical and non-surgical interventions such as dilatation or esophageal stenting.Figure 1.: (A) Initial CT Chest findings of a right 8.0 x 7.5 cm mediastinal mass (B) Repeat CT Chest remarkable for a moderate volume pneumomediastinum and a small to moderate size right pneumothorax and (C) EGD imaging of a 23mm x 120mm EndoMAXX fully covered stent placed at the area of severe esophageal stenosis.

S2353 Esophageal Hyperkeratosis Complicated by Recurrent Dysphagia

Introduction: Esophageal hyperkeratosis (EH) is a rare condition characterized by keratinization of the esophageal epithelium. The pathophysiology is poorly understood, and risk factors remain unclear. We present a case of severe long segment EH leading to severe esophageal stenosis. Case Description/Methods: A 70-year-old male with a long history of gastroesophageal reflux disorder (GERD) presented to the ED with acute food impaction. Prior to his presentation, he reported worsening dysphagia and ongoing heartburn for several months. He had been lost to follow-up and was not on any antacids at the time of presentation. Emergent upper endoscopy (EGD) was performed to remove the food impaction. Additional findings on EGD showed esophagitis, esophageal stenosis of 13cm in length (7mm in diameter), and white plaques. Esophageal biopsies were negative for eosinophils but confirmed candida and were suggestive of esophageal hyperkeratosis. Dilation was deferred until the esophagitis was treated with PPI and itraconazole. Repeat EGD one month later showed ongoing stenosis, healed esophagitis, as well as significantly thickened esophageal mucosa extending 13 cm proximally from the GE junction (Figure A, B). Balloon dilation of the stenotic lesion was performed. Repeat biopsies confirmed esophageal hyperkeratotic squamous epithelium with parakeratosis and no dysplasia (Figure C). Due to the severity of his stenosis, he subsequently underwent multiple EGDs with balloon dilations over the next several months to obtain a maximum esophageal lumen diameter of 19mm. Dilation of his esophagus was particularly difficult due to the length of hyperkeratosis, degree of stenosis, and loss of elasticity of his esophageal mucosa. Tearing of the tissue and bleeding were common even with small interval increases during each dilation session. In addition, healing of the tissue between sessions often led to a restricturing of his esophagus. He is currently symptom-free on pantoprazole 40mg twice a day, a soft diet, and undergoing surveillance endoscopies every 6 months with balloon dilations. Discussion: Esophageal hyperkeratosis is a rare disorder with thickening of the stratum corneum and occurs in 2% of esophageal biopsies. While the prevalence and pathophysiology are unclear, it is thought to be associated with GERD, vitamin A deficiency, zinc deficiency, and a low fiber/low residue diet. There is also some evidence to suggest it may be associated with an increased risk of squamous cell carcinoma.Figure 1.: 1: a and b) EGD of middle and lower esophagus showing irregular mucosa with furrowing and white exudate, pre-dilation. 1c) Magnification 400x. Histopathology demonstrates esophageal squamous mucosa with dyskeratosis and extensive hyperkeratosis (black arrow).

S2313 Esophageal Stricture Recalcitrant to Repeated Dilation in Complex Rheumatological and Bullous Disease

Introduction: Many rheumatological diseases have been well characterized to affect the esophagus. Esophageal involvement in autoimmune bullous disease is rare and almost always occurs with severe cutaneous symptoms. We report a case of severe esophageal strictures recalcitrant to repeated dilatation in a patient with complex rheumatological disease and isolated esophageal bullous disease. Case Description/Methods: A 50-year-old female presented with complete inability to tolerate oral intake for several weeks. Past history included Sjogren's syndrome and esophageal strictures with many previous dilatations. Physical exam findings were relevant for poor skin turgor, dry mucous membranes, and skin hyperpigmentation on her hands and forearms. Laboratory studies showed hypokalemia, hypoalbuminemia, and anemia. The patient was admitted. Her esophagram and esophagogastroduodenoscopy (EGD) showed a proximal esophageal stricture which was dilated using a push style dilator to 14mm. The stricture recurred, requiring repeated dilatation and placement of a percutaneous gastrojejunostomy. Once oral intake was tolerated, she was discharged with outpatient follow-up. Outpatient rheumatological workup showed antibodies to ANA, RNP, SSA, CCP, and Smith indicating mixed connective tissue disease with features of systemic lupus erythematosus, rheumatoid arthritis, and scleroderma. She required multiple dilatations over several months and was started on mycophenolate mofetil with some clinical improvement. The dysphagia recurred 2 months later and EGD showed and esophageal stricture measuring 7mm requiring a neonatal upper gastroscope to facilitate balloon dilatation. Biopsies examined for immunofluorescence showed continuous linear deposition along the basement membrane zone for IgG and C3, consistent with atypical esophageal bullous systemic lupus erythematosus or atypical esophageal bullous pemphigoid. The patient declined systemic steroids. Her mycophenolate mofetil dose was increased and she received weekly dilatations to prevent Koebnerization and allow time for medical therapy effect. After 3 months of treatment, she had symptom improvement (Figure). Discussion: In patients with systemic immune mediated disorders including rheumatological disease, bullous diseases can be considered as a cause of esophageal stricture. Bullous disease with esophageal involvement can be difficult to treat, especially in this patient who declined corticosteroids. A combination approach using both immune suppression and dilatation was effective.Figure 1.: a. Pre- dilatation during repeated dilation treatments. Diameter 8mm. b. Post- dilatation. Diameter 11mm. c. Immunofluorescence showing IgG deposition along the basement membrane.

S2834 Gastro-Cutaneous Fistula Closure Using Novel Tack Suture System

Introduction: Gastro-cutaneous fistulas that develop at prior gastrostomy sites are usually successfully closed by the use of endoscopic suturing or the over-the-scope clips (OTSC). However, the endoscopic suturing device and the OTSC device measure approximately 16 mm and 14 mm, respectively, resulting in them not able to pass through narrow esophageal strictures. The endoscopic tack suture system is a novel technique that includes a through the scope suture-based device that was recently designed for the closure of large and irregular defects in the gastrointestinal tract. Even more advantageous is the ability for the tack suture system to be passed through the working channel of a standard gastroscope. Case Description/Methods: A 61-year-old male with past medical history of head and neck cancer presented with persistent gastro-cutaneous fistula drainage following gastrostomy tube removal. On endoscopic evaluation, a benign appearing esophageal stenosis in the upper esophagus required downgrading the scope from a therapeutic scope to a gastroscope. A gastric fistula was noted in the gastric body, but the exact site of the fistula was unclear as there were 2 defects side by side (Figure A). Both defects were treated with APC and the entire area was closed with a single tack suture system with 4 tacks drilled in healthy tissue surrounding the defect (Figure B). Following tack placement, a single suture was used to cinch down and close the defect (Figure C). On follow up the patient had no further fistula drainage. Discussion: Our case presents the use of a novel tack suturing system to close a persistent gastro-cutaneous fistula in the setting of an esophageal stricture. Commonly used defect closing devices such as the OTSC and endoscopic suturing device can be too large to navigate severe esophageal strictures. The endoscopic tack suture system has the ability to aid in the closure of fistulas, perforations, anastomotic leaks and submucosal dissections. While preclinical data reported no adverse events, possibilities include wound dehiscence, delayed perforation, and bleeding if the tacking system is improperly placed. Mahmoud et al. conducted the first and only multi-center study describing the feasibility and safety of the endoscopic tack suturing device in the clinical setting and found successful closure of defects in approximately 90% of cases. This novel tack suture system is a useful tool in cases that are confined to the parameters of a standard gastroscope.Figure 1.: A: Gastric fistula. B: Fistula following APC with 4 tacks drilled in healthy tissue surrounding the defect. C. Cinching of single suture with closure of gastric fistula.

432. A CASE OF ADVANCED ESOPHAGEAL CARCINOSARCOMA DIAGNOSED LATE DUE TO SEVERE STENOSIS AFTER CHEMORADIOTHERAPY

Abstract Radiochemotherapy (CRT) is one of the curative treatment options next to surgery in the treatment of esophageal squamous cell carcinoma. However, CRT may cause esophageal stenosis or obstruction during the healing process. Therefore, in such cases, follow up of early recurrence detection becomes an issue for those patients. We report a case of severe stenosis after CRT, in which recurrence could not detected until advanced cancer developed on the anal side of stenosis. The case is a 73-year-old male. He was diagnosed with upper thoracic esophageal cancer (T4N2M0StageIVa) and had undergone radical chemoradiotherapy 5 years ago. The treatment effect achieved a complete response, but the primary tumor site caused severe esophageal stenosis. Therefore, biannual CT follow up had been done instead of endoscopic follow up. During follow-up, CT revealed a new neoplastic lesion in the lower thoracic esophagus, and endoscopy inserted through a gastrostomy revealed a bulky tumor on the anorectal side of the stenotic lesion. Biopsy revealed carcinosarcoma and robot-assisted thoracoscopic esophagectomy was performed. Malignant neoplasms can be developed not only the same site of primary tumor after CRT. Especially in case of carcinosarcoma, detection would be delayed because of rapid growing. But when the severe esophageal stenosis occurred after CRT, the examination of anal side become difficult. Therefore, it is necessary to observe by frequent CT or PET examination, or endoscopy from gastrostomy for early detection of recurrence or newly malignant neoplasm.