Double lumen esophagus due to false submucosal path induced by nasogastric tube: endoscopic treatment with marsupialization

A 39-year-old man with a medical history of vertebrobasilar stroke 1 year previously, associated with tobacco and cocaine use, presented with dysphagia. During his hospitalization, the patient developed swallowing disorders. An attempt to insert a nasogastric tube (NGT) was unsuccessful owing to unusual resistance. A percutaneous endoscopic gastrostomy was therefore performed. During upper gastrointestinal endoscopy (UGE), a false submucosal path, secondary to NGT impaction was observed, with upper and lower orifices located at 33 cm and 38 cm, respectively, from the dental arches ([Fig. 1]). Enteral nutrition and proton pump inhibitors were initiated but no endoscopic surveillance was proposed.

Fig. 1 False submucosal path induced by the nasogastric tube. a Upper orifice (33 cm from the dental arch). b Lower orifice (38 cm from the dental arch).

One year later, when the patient restarted oral intake, he started describing episodes of dysphagia, especially with solid food. A UGE was performed and esophageal duplication was observed, corresponding to a chronicization of the false submucosal path, which partially obstructed the esophagus, especially by inducing food impaction ([Fig. 2]). A guidewire (Jagwire; Boston Scientific, Marlborough, Massachusetts, USA) was advanced from the upper toward the lower orifice to confirm the permeability of the false path ([Fig. 3]). Then, an antegrade complete incision of the submucosal flap was performed, initially using an ITknife nano (Olympus, Tokyo, Japan) to secure the cut. However, the knife was quickly switched to a 2 mm Dualknife (Olympus) because of difficulties in current application. The incision was carried out from the proximal to the distal orifice, following the guidewire, without any complication ([Video 1]). Immediately following this marsupialization approach, the patient had no further dysphagia.

Fig. 2 One year later: chronicization of the false submucosal path. a Upper orifice (33 cm from the dental arch). b Lower orifice (38 cm from the dental arch).

Fig. 3 Guidewire in the false path. a Upper orifice (33 cm from the dental arch). b Lower orifice (38 cm from the dental arch).

Video 1 Endoscopic treatment with marsupialization for double lumen esophagus caused by nasogastric tube. a Proximal orifice. b Distal orifice.

At follow-up 6 months later, the patient reported gastroesophageal reflux without dysphagia. Endoscopy revealed ulcerated esophagitis and a pseudodiverticulum just above the esophagogastric junction, corresponding to the inferior site of NGT impaction, but without significant stenosis.

In conclusion, the double lumen esophagus secondary to NGT impaction is a rare complication, with only two other cases found in the literature [1] [2]. We describe here the first case of successful endoscopic treatment by marsupialization.

Endoscopy_UCTN_Code_CPL_1AH_2AG

• References

• 1 Yang CW, Yen HH, Su WW. et al. Esophageal submucosal tunnel: a rare complication of nasogastric tube placement. Dis Esophagus 2016; 29: 690
• 2 Tashiro M, Matsuda K, Ueda R. Double lumen esophagus: a rare complication of nasogastric tube?. Dig Endosc 2014; 26: 680