We present the case of a 51-year-old man with dysphagia to solids and occasional retrosternal
chest pain. Computed tomography of the chest revealed an esophageal mass, which on
endoscopy was just distal to the gastroesophageal junction. An esophagram found a
delay in the passage of contrast as a result. An endoscopic ultrasound (EUS) demonstrated
an anechoic/hypoechoic third layer cyst, with internal debris and a redundancy of
layers, consistent with a large duplication cyst. Although definitive management is
surgical excision, simple endoscopic fenestration has been described [1]
[2]; however, there remains a concern about recurrence in the long term. We offered
the patient a novel endoscopic approach aimed at complete excision of the luminal
cyst wall, reducing any long-term recurrence ([Video 1]).
Video 1 Endoscopic management of a large duplication cyst.
The cyst was punctured using a 19-gauge EUS needle. Saline with methylene blue was
injected into the cyst to increase its size and stain the internal cyst wall blue,
making an endoscopic excision safer. An electrosurgical knife was used to create an
initial incision along the lateral margin, and endoscopic submucosal dissection (ESD)
was performed until we identified the cyst roof, which was stained blue. The knife
was used to perforate the cyst, resulting in an immediate flow of methylene blue-stained
cyst fluid. The entire roof was then resected en bloc in a circumferential manner
using an insulated-tip knife. With the internal cavity completely exposed, the lining
was irrigated and inspected. The edges of the cyst were clipped circumferentially
to prevent both delayed bleeding and premature closure.
This is the first description of an ESD technique for treatment of a duplication cyst.
Pre-injecting the cyst seems to make dissection easier and safer. The result is a
complete unroofing and marsupialization of the cyst cavity. This may be a potentially
superior approach for the treatment of duplication cysts and may help to reduce the
risk of recurrence.
Endoscopy_UCTN_Code_TTT_1AO_2AN
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
