Successful endoscopic mucosal incision and enucleation of an implanted press‐through package sheet in the esophageal wall

A 94-year-old woman with dementia was admitted to our hospital because of hematemesis and melena. We performed an endoscopic examination and found an elevated submucosal tumor-like lesion in the thoracic esophagus revealing a trace of a press-through package (PTP) sheet on top of it (Fig. 1a,b). Computed tomography (CT) examination revealed a PTP sheet in the thoracic esophagus near the aortic arch without free air in the mediastinum (Fig. 2). Her son stated that she might have swallowed the PTP sheet approximately six months ago. Surgical therapy poses a large risk on a very elderly patient,1, 2 so we decided to try to remove the PTP sheet with an endoscope.3 Two days later, endoscopic treatment was performed under general anesthesia. First, a longitudinal incision was made with HookKnife (Olympus, Tokyo, Japan) on the oral side of the covering mucosa. Then, a horizontal incision was made from the prior incision to the right and left, while touching the tip of the knife on the PTP sheet (Fig. 1c,d). We did not use local injection because firm fibrosis around the PTP sheet could not make room for local injection. Finally, hinged double doors of the mucosa were made in front of the PTP sheet. The edge of the PTP sheet was grasped with biopsy forceps and pulled easily into a soft large hood (D-206-05, Olympus) attached to the tip of the endoscope. It was pulled out of the esophagus, accompanied by the endoscope. No perforation was detected on both CT and endoscopic examination (Fig. 1e,f). The patient resumed food consumption on the ninth day after the enucleation with no difficulties thereafter and was discharged three days later. This is the first report of an implanted PTP sheet in the esophageal wall. Moreover, it was enucleated successfully using an endoscope.

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Endoscopic findings of the thoracic esophagus. (a) Distant view of the submucosal tumor-like protrusion on admission. (b) A part of the press-through package (PTP) sheet was seen on top of it. (c) The mucosa covering the oral part of the PTP sheet was cut with knife. (d) The PTP sheet was pulled into a soft large hood and removed. (e, f) Excavation site on the sixth day after the treatment without perforation. No apparent diverticulum was found in the esophagus on endoscopic and computed tomography examination.

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Computed tomography findings of thoracic slice on admission. A press-through package (PTP) sheet (arrows) was seen in the esophagus near the aortic arch. Appropriate Window Level and Window Width reveals a clear image of the PTP sheet (arrowheads). No free air was seen in the mediastinum.

Authors declare no conflict of interest for this article.

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