A 56-year-old man with alcoholic liver disease presented to our unit
with a 1-day history of hematemesis. On admission, his blood pressure was
100/60 mmHg and pulse rate 102 beats/minute. The initial hematocrit was
29 %. Urgent esophagogastroduodenoscopy (EGD) revealed a large
esophageal tear at the cardia, measuring 15 × 10 mm
([Fig. 1]). A diagnosis of Mallory–Weiss
tear was made.
Fig. 1 A large esophageal tear
at the cardia, seen at the index esophagogastroduodenoscopy (EGD).
Placement of the clips seemed insufficient because of the large
diameter and length of the tear. In order to bring together the edges of the
tear, an endoloop (Endo-Loop MAJ 254; Olympus, Tokyo, Japan) was inserted in
the esophagus by the endoscope (Olympus EVIS EXERA II GIF-H180) in a freehand
manner. After the endoloop snare was correctly placed around the tear, the
snare was anchored with four clips (Quickclip; Olympus) at the margins of the
tear ([Fig. 2 a]).
Fig. 2 An endoloop snare
a anchored at the margins of the tear, and
b tightened.
The loop was then tightened to close the defect ([Fig. 2 b]). The clinical course of the
patient was uneventful, and follow-up EGD performed 4 weeks later revealed
complete healing of the tear with formation of scar tissue ([Fig. 3]).
Fig. 3 Scar formation noticed
at the follow-up esophagogastroduodenoscopy (EGD).
Application of clips and an endoloop in the esophagus has been
described as a method for closure of large mucosal defects after endoscopic
mucosal resection [1], and of esophagomediastinal
fistulas [2]. The closure was completed with a
single-channel endoscope in a sequential two-step maneuver: first, clips were
deployed at the margins of the defect, followed by looping and tightening of
the clips with the endoloop. A total of three patients were reported, with a
100 % technical success.
In our case, the esophagus served as a second working channel,
allowing us to apply both accessories simultaneously with a favorable outcome.
Further studies will be required to prove the feasibility of this approach.
Endoscopy_UCTN_Code_TTT_1AO_2AI
