Endoscopic incisional therapy for giant bridge pseudopolyposis of the esophagus in a patient with upper gastrointestinal Crohn's disease. Esophageal Crohn's disease has a prevalence of 0.2 to 1.8%. Its clinical, endoscopic, and histopathologic features are nonspecific. Endoscopic manifestations are variable, ranging from erosions to stricturing or fistulizing disease. Pseudopolyps are non-neoplastic mucosal lesions that develop following cycles of inflammation and healing. They are classified as giant when their size is greater than 1.5 cm, filiform when they are slender, finger-like projections of the mucosa, and bridged when they are long and filiform, connecting opposing walls of the lumen. Esophageal involvement is rare, described in just a few case reports. Treatment includes both standard medical therapy and endoscopic intervention. An endoscopic approach is reserved for symptomatic disease causing bleeding, anemia, dysphagia, or protein-losing enteropathy. The underlying principle of endoscopic incisional therapy is to restore adequate luminal patency. For strictures, this technique involves the radial incision and cutting of tissue parallel to the craniocaudal axis of the esophagus. Various electrocauter-enhanced needle knives, which are more common, or mechanical scissor-type knives are available. This method has established technical feasibility, safety, and efficacy for short, benign esophageal strictures which are refractory to dilation. There has also been reported success in the rare cases of esophageal webs and septa. We present a case of a 38-year-old male with ileocolonic and stricturing esophageal Crohn's disease. He was referred for assessment of a 16-year history of solid food dysphagia and weight loss with strict adherence to a pureed diet. Medical management and serial bougie dilation were unsuccessful. Initially, a diagnostic EGD was performed. We first encountered a tight proximal esophageal stricture, 20 cm from the incisors. CRE balloon dilation was required for the passage of a regular gastroscope with a 9.2 mm diameter. Distal to the stricture, we observed many giant, bridged pseudopolyps of varying lengths and sizes. These formed a complex, web-like tract, likely explaining the patient's refractory dysphagia. We were able to carefully negotiate the gastroscope through this column and towards the gastroesophageal junction. The stomach and duodenum, which are not shown in this video, had no evidence of upper GI Crohn's disease. After discussion with the patient and his family, we proposed a novel application of endoscopic incisional therapy in the treatment of a symptomatic esophageal Crohn's disease with giant, bridged pseudopolyposis. After wire-guided bougie dilation up to 33 French, we were able to pass a regular gastroscope into the distal esophagus. We began our approach at the proximal end of the affected segment. An insulated tip, or an IT-type ESD knife was used in conjunction with an electrosurgical unit. Our ESU was set to endoclit Q mode with effect 2, duration 3, and interval 4. Incision was performed at the midline of the pseudopolyp bridge in a radial fashion towards the esophageal lumen. This maneuver allowed us to dissect and release the mucosal bridge, ultimately resulting in remnant filiform-type pseudopolyps on the opposing esophageal walls. We sequentially repeated these incisions on each accessible bridge as we advanced distally towards the gastroesophageal junction. By cutting these obstructive lesions one by one, we were gradually able to achieve dramatic improvement in luminal patency. We then resected the remnant pseudopolyp tissue using a 15mm snare. Select specimens were collected for histopathologic evaluation. Post-procedure examination revealed satisfactory eradication of the web-like tract. Early clinical response was achieved as the patient was able to advance his diet to solids for the first time in many years. Pathology was consistent with pseudopolyposis as it revealed chronic inflammation and fibrosis of the lamina propria. Interval EGD for endoscopic incisional therapy site assessment and consideration of repeat dilation was arranged. We again came across the narrow proximal esophageal stricture which was only traversable with an ultra-slim gastroscope. As indicated by a white star, we encountered multiple false lumens with retained debris distal to the stricture. We felt that the septum-like structures which formed these false lumens were likely representative of long-segment bridge pseudopolyps. Notably, the distal esophagus appeared patent and well-healed from the prior endoscopic incisional therapy. To facilitate additional clinical improvement and prevent further debris accumulation, we arranged repeat endoscopic incisional therapy for false lumen takedown. Standard endoscopic equipment could not be used as we were only able to pass the ultra-slim gastroscope through the proximal stricture. We therefore cut the distal tip of a 5.5 French miniature ERCP sphinctrotome to fabricate a needle knife that would fit through the 2.2mm working channel of this endoscope. Here we note the absence of an insulated tip thus increasing the risk of perforation during this procedure. First, a guide wire was inserted into the scope and through the proximal end of the false lumen. The scope was then reinserted beside the wire. Guide wire placement was confirmed at the distal end of the false lumen. We began our first incision and cut at the proximal rim of the septum-like structure. This was again performed towards the center of the true esophageal lumen. This maneuver was repeated as we advanced the needle knife craniocaudally along the wire, gradually resulting in complete longitudinal dissection of the bridge and eradication of the false lumen. The guide wire was sequentially placed through the other false lumens. Needle knife endoscopic incisional therapy was then repeated in a similar fashion for the remaining bridge pseudopolyps. Post-procedure, there was no evidence of contrast extravasation under fluoroscopy. Bougie dilation was performed up to 36 French. The passage of a regular gastroscope confirmed luminal patency and no evidence of mucosal injury. Barium swallow on the left from 2018 reveals the patient's distal esophageal abnormalities suggestive of long-standing esophageal Crohn's disease. On the right, fluoroscopic image post-procedure suggests successful treatment without evidence of contrast extravasation. A high index of suspicion is required for the diagnosis and early treatment of complex esophageal Crohn's disease. Early multidisciplinary discussion between IBD specialists and therapeutic endoscopists is warranted for challenging and or atypical cases. Endoscopic incisional therapy has the potential to play an important role in the endoscopic management of advanced IBD phenotypes. Endoscopic incisional therapy appears to be safe, technically feasible, and effective in the management of complex esophageal Crohn's disease with bridge pseudopolyposis. Long-term follow-up is required for the assessment of recurrence and treatment durability. Additional prospective study is warranted for procedural standardization and optimizing instrument selection.

endoscopic incisional therapy

esophageal Crohn's disease

giant bridged pseudopolyps

dysphagia

luminal patency