Post written by Radhika Chavan, MD, DNB, from the Department of Gastroenterology and Endoscopy, Ansh Clinic, Ahmedabad, India.

Esophageal duplication cysts are rare congenital anomalies usually managed by surgery. We present cases of 3 patients with symptomatic cysts, each managed using a tailored endoscopic approach.

In the first case, a small mid-esophageal cyst was treated using submucosal tunneling endoscopic resection. The other 2 cases involved large cysts with exophytic components and were managed using hybrid techniques—combining EUS-guided access with endoscopic fenestration. In one case, a guidewire was used for guidance; in the other, a plastic stent facilitated the approach. There were no intraprocedural or postprocedural complications. All patients were asymptomatic at median follow-up of 12 months.

Although they are rare, esophageal duplication cysts are increasingly recognized because of widespread use of cross-sectional imaging. They are usually asymptomatic, and treatment may be unnecessary in such cases. Symptomatic cases are traditionally managed surgically.

Yet, endoscopic management can be offered to those at high surgical risk or those unwilling to undergo surgery. To our knowledge, literature describing specific techniques remains limited. This case series highlights the feasibility and safety of endotherapy for symptomatic and recurrent esophageal duplication cysts. The accompanying video provides a detailed, step-by-step guide that serves as a valuable learning tool for endoscopists globally.

The described hybrid approach combining gastroscopy and EUS enables precise fenestration of cysts, including those with an exophytic component, and can be considered a minimally invasive alternative to surgery for a large cyst.

Endoscopists can take away several practical insights from this case series. First, accurate diagnosis and characterization using EUS is vital in differentiating duplication cysts from other subepithelial lesions. Second, endoscopic therapy should be tailored based on cyst size, location, and morphology. Submucosal tunneling endoscopic resection is suitable for smaller, well-located cysts, but hybrid EUS-guided fenestration offers a safer approach for larger or complex cysts. The use of guidewires or stents not only facilitates localization but also enhances procedural safety by preventing blind entry and guiding the incision.

Third, clipping of cyst edges with esophageal mucosa is essential to prevent recurrence and maintain communication of the cyst with the lumen. Fourth, creating a wide connection between the cyst with the esophageal lumen helps prevent stasis of the secretions within the cyst and is likely to offer a protective effect against malignant transformation. However, further studies with long-term follow-up are needed to confirm efficacy of this method.

This series reflects the evolving role of endoscopy in managing conditions traditionally reserved for surgery. To conclude, advanced endotherapy, including hybrid techniques, offers an effective alternative to surgery for managing esophageal duplication cysts. These procedures enable precise fenestration and reduce adverse events.

Endotherapy of a small esophageal duplication cyst using the submucosal tunneling endoscopic resection (STER) method. A, Radial echoendoscope showing a small cystic lesion (outlined by yellow dotted line) with heteroechoic content seen in the mid esophagus. B, STER was performed and submucosal fibers surrounding the cyst (yellow dotted line) were dissected. C, After a small incision was made on the cyst, a gush of thick yellowish proteinaceous material was seen discharging through it. D, The internal cavity of the cyst became visible (outlined by the black dotted line), along with the entire cyst margin (marked by the yellow dotted line). E, The incision was extended to fully expose the cyst cavity (black dotted line). F, The esophageal incision (red dotted line) was extended to the distal end of the cyst (black dotted line) to create a single lumen.

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