Authors D. PERSYN (1), D. DE WULF (2), R. BISSCHOPS (2) / [1] UZ Leuven, Leuven, Belgium, Gastro-enterology, [2] UZ Leuven, Leuven, Belgium, gastro-enterology We describe the case of a 64-year-old female with a history of alcoholic hepatic steatosis and vitamin B12 deficiency with the presence of tissue transglutaminase antibodies. An upper gastro-intestinal endoscopy was performed to rule out celiac disease with an unexpected finding of a well differentiated esophageal squamous cell carcinoma. The lesion was located in the mid-esophagus (extending 20-25 cm from the incisors, gastroesophageal junction at 38cm) and had an endoscopic type V1-V2 intrapapillary capillary loops pattern (IPCL). Staging showed limited disease (cT1N0M0). She underwent an endoscopic submucosal dissection (ESD) in march 2019. Postoperative pathology report showed a high-grade squamous intraepithelial lesion. During follow up dysphagia developed, caused by a postoperative refractory stricture which was managed with sequential endoscopic balloon dilation. During follow-up two metachronic lesions more distally in the esophagus (28cm from the incisors) with aberrant IPCL pattern type V1 were identified. In march 2020 a second ESD for these lesions was performed. Prior to ESD, during the same session a balloon dilatation of the post ESD stricture was also performed. ESD was successfully conducted using carbon dioxide insufflation with en bloc resection of the suspect lesion (27x15 mm). A few hours after the procedure, the patient developed dyspnea and associated upper abdominal pain. A chest X-ray showed the presence of a pneumoperitoneum. Urgent endoscopy revealed a linear mucosal laceration and perforation of 2cm in the lesser curvature of the gastric upper body. The perforation site was endoscopically closed using six hemoclips. There was no perforation or injury to the muscular layer at the ESD site. Intravenous broad-spectrum antibiotics were started and she resumed oral feeding gradually. The patient was discharged six days after the ESD procedure without any sequelae. The final pathology report showed a high-grade squamous intraepithelial lesion. Discussion: ESD is an organ preserving treatment for patients with gastro-intestinal neoplasms and very low risk for lymph node metastasis. The most common adverse events of esophageal ESD include perforation (0 - 10,7%), bleeding (0 - 22,8%) and stricture formation (1). In this case we demonstrated an exceptionally rare complication of insufflation induced-barotrauma in the stomach during ESD in the esophagus, despite the use of CO2. We assume this perforation was caused by the esophageal stricture proximal to the ESD site. Tight apposition of the endoscope most likely caused air trapping in the stomach impeding air to escape through the esophagus. The perforation at the high lesser curvature of the stomach is an inherent point of weakness together with the left side of the distal esophagus. The preference for this location is related to reduced elasticity, fewer mucosal folds and the presence of a junction between the semicircular and oblique muscle fibers (2,3). As illustrated by this case, esophageal ESD can cause high intra-esophageal and intragastric pressure with suction in the esophagus not effectively reducing gas and pressure in the stomach. General anesthesia also plays a role by reducing the contractile force of the gastric muscles (increased trapping of gastric gas) and the impossibility of the patient to belch. Literature: 1. Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, et al. Endoscopic submucosal dissection: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy. 2015;47(09):829-854. 2. Merchea A, Cullinane DC, Sawyer MD, et al. Esophagogastroduodenoscopy- associated gastrointestinal perforations: a single-center experience. Surgery 2010;148:876–82. 3. Fung AM, Chan FS, Wong IY, Law S. Synchronous perforations of the oesophagus and stomach by air insufflation: an uncommon complication of endoscopic dilation. BMJ Case Reports. Published online October 31, 2016: bcr2016216375.
