First report of in-tissue esophagogastric transit migration of an over-the-scope clip

A 33-year-old male underwent emergent upper endoscopy because of acute food impaction. Esophagogastroduodenoscopy (EGD) proved highly suggestive of underlying eosinophilic esophagitis (EoE), yielding a presumptive EoE endoscopic reference score (EREFS) of 7 with extensive distal food impaction [1]. After endoscopic disimpaction using various maneuvers, finally including the push technique, a circumscript deeper esophageal wall injury occurred just above the Z line (Fig. 1A). This was treated by the intraprocedural deployment of an 11/6t over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) and the patient’s subsequent clinical course was uncomplicated (Fig. 1B). After histopathological confirmation of EoE, topical treatment was initiated with an orodispersible budesonide tablet (1 mg b.i.d.), recently marketed in Europe, and the patient was scheduled for repeat EGD 6 weeks later [2]. With improving EoE, as reflected by a reduction in the EREFS to 2, the OTSC was no longer detectable in the distal esophagus. Notably, the Z line above which the clip had initially been deployed proved well demarcated circumferentially, thus implying true in-tissue migration instead of the clip having merely been pulled into the stomach (Fig. 1C). A retroflexed view in the stomach showed the OTSC still in situ and attached to the mucosa with ample of granulation tissue, giving rise to a typical OTSC-related pseudopolyp (Fig. 1D).

Figure 1 (A) Deeper, although not clear-cut transmural defect just above the Z line during endoscopic disimpaction of an eosinophilic esophagitis (EoE)-related food bolus. (B) Successful deployment of an over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany); note also endoscopic signs of EoE corresponding to an endoscopic reference score of 7. (C) Illustration of a fully preserved Z line above which the OTSC was initially deployed. (D) Scope inversion within the stomach excluded OTSC detachment but rather suggested in-tissue esophagogastric migration, with the OTSC still attached to the mucosa

OTSC applications have gained much momentum in recent years and provide a powerful backup strategy in modern endoscopy, mostly for the management of transmural luminal defects and/or gastrointestinal bleeding, with limited potential for clinically relevant complications [3]. Although no distinct clinical and/or endoscopic complication whatsoever arose in this individual patient, this well-documented illustration of in-tissue esophagogastric transit migration is altogether novel, most likely related to constant stomach-directed peristaltic forces, and may add to our knowledge of in vivo biomechanical interactions and the behavior of OTSC clips.