Supplementary Material for: Pan-Esophageal Submucosal Dissection following Transesophageal Echocardiography

A 73-year-old female underwent open mitral valve replacement with transesophageal echocardiography (TEE) guidance. She developed upper gastrointestinal bleeding postoperatively and was found on upper endoscopy to have a bleeding site at the gastric cardia with the appearance of focal trauma and a possible puncture site. A submucosal bluish protrusion was seen throughout the esophagus with a mucosal flap at the proximal esophagus. As a unifying diagnosis, it was suspected that the intraoperative TEE probe caused a submucosal dissection with point of entry at the proximal esophagus, running the entire length of the esophagus and exiting at the gastric cardia, giving rise to a clinical upper gastrointestinal bleed. Closure of the esophageal defect was achieved using an endoclip. A CT scan showed focal pneumomediastinum along the proximal esophagus, confirming the hypothesis. We report the first case to our knowledge of iatrogenic pan-esophageal submucosal dissection, which, in this case, presented as a clinical bleed from the exit point trauma to the gastric cardia mucosa caused by a TEE probe. Endoscopic management of the gastric injury as well as the esophageal defect led to resolution of the bleeding and avoidance of mediastinitis, respectively, allowing for an excellent recovery.1例73岁女性患者在经食管超声心动图（transesophageal echocardiography，TEE）引导下接受开放式二尖瓣置换术。术后患者出现上消化道出血，经上消化道内镜检查发现胃贲门处存在出血灶，表现为局灶性创伤，疑似穿刺位点。食管全程可见黏膜下蓝色隆起，食管近端可见黏膜瓣形成。综合诊断推断，术中使用的TEE探头引发了全食管黏膜下剥离：剥离起点位于食管近端，沿食管全程走行，最终出口位于胃贲门处，进而导致临床可见的上消化道出血。通过内镜夹子成功闭合食管缺损。CT扫描显示食管近端局灶性纵隔气肿，证实了上述推测。据我们所知，本文报告的是首例医源性全食管黏膜下剥离病例，本例中该病症表现为TEE探头造成胃贲门黏膜出口处创伤，进而引发临床出血。针对胃部损伤及食管缺损的内镜治疗分别实现了止血及预防纵隔炎的效果，助力患者获得良好康复。