Oesophageal Crohn's disease: a novel approach to managing iatrogenic perforation of an oesophageal Crohn's stricture.

The prevalence of oesophageal Crohn's disease (CD) is 0.3–2%.1 Management is with corticosteroids, 5-aminosalicylic acids, immunomodulators or biologics as for active CD elsewhere plus acid suppression with proton pump inhibitors or H2-receptor antagonists.1 Strictures are additionally treated with repeated dilatations.1 Surgery for strictures is reserved as a final option, because of the associated risk of operative morbidity as well as local recurrence.2 Spontaneous perforation and local fistula formation are reported, typically requiring surgery. We report a case of perforated oesophageal CD, which we managed with a novel approach. A 40-year-old man with extensive CD presented with dysphagia. He previously had right hemicolectomy and small bowel resection, with resulting strictures requiring dilatation at surgical anastomosis sites. His CD was refractory to medical management, and required autologous stem-cell transplantation previously. Gastroscopy revealed a 2 cm fibrotic stricture in the mid-oesophagus at 25 cm. Through-the-scope (TTS) balloon dilation had been performed 3-times previously to this stricture without complication. On this presentation, the stricture was not traversable (Olympus GIF-H260, 10 mm diameter) and TTS balloon dilation at 12 mm was performed (Boston Scientific CRE-wireguided). On extubation, inflammation and a full thickness mucosal tear were noted. He was transferred to our centre where Gastrografin swallow confirmed perforation (Fig. 1A). He was managed with intravenous co-amoxiclav and total parenteral nutrition. In view of the risk of poor healing, all treatment options were considered including oesophageal resection. A removable covered self-expanding metal stent (Niti-S, 18 mm/80 mm, Pyramed) was deployed with radiological control. He represented 6-weeks later; Gastrografin swallow confirmed distal stent migration, and proximal stricture recurrence but no contrast leak (Fig. 1B). Endoscopic stent removal and stricturotomy using electrocautery via a sphincterotome were completed under anaesthesia without complication.