A 74-year-old woman presented with dysphagia. Upper endoscopy revealed eosinophilic esophagitis (EoE) and two squamous lesions: a 15-mm lesion in the upper esophagus with low-grade dysplasia (LGD) and a 30-mm lesion in the mid–lower esophagus with high-grade dysplasia (HGD). We prioritized endoscopic resection before initiating steroid therapy.
After multidisciplinary discussion, we elected to resect the smaller lesion first to minimize the risk of complications. Endoscopic mucosal resection yielded an 18-mm specimen with confirmed LGD and R0 margins. No complications occurred.
We then performed endoscopic submucosal dissection (ESD) of the distal lesion, obtaining a 35 × 30 mm specimen, HGD, R0, without immediate adverse events.
Twenty-four hours later, the patient developed dyspnea and oxygen saturation dropped to 70%. A CT scan revealed mediastinitis with a large esophageal perforation. Thoracic surgeons performed mediastinal washout and placed three drains.
During endoscopy, we observed that the esophagus had become detached from the stomach along one-third of its circumference over a length of 7 cm, while the resected area showed no perforation; the breach had occurred laterally.
We elected to reconnect the esophagus and stomach using a VAC-stent system. The patient stabilized, and after three days the stent was replaced. Remarkably, the previously open segment had reapproximated.
Six days later, we placed a fully covered 12-cm metal stent, which was kept in place for one month. The patient recovered well and was discharged after one month.
A follow-up gastroscopy two months later revealed a stricture at the mucosectomy site in the upper esophagus, with fragile mucosa along all the organ, but no recurrent lesions. Five months later, the patient is eating normally and remains on PPI therapy. Re-evaluation and management of the underlying EoE are pending.
Only a few cases of ESD in patients with EoE have been reported in the literature, and perforation appears to be a common complication in this setting. In our patient, the perforation site was unusual, underscoring both the technical challenges of resection and the difficulty in predicting complications in these patients. Nonetheless, the rapid mucosal healing achieved with VAC therapy was remarkable. We believe that in such cases a careful choice between ESD and mucosal resection is essential, and that VAC therapy may represent a valuable option when severe complications occur in these patients.