Tanaka Ippei, Inoue Haruhiro, Ushikubo Kei, Yamamoto Kazuki, Nishikawa Yohei, Owada Kaori, Tanabe Mayo, Onimaru Manabu, Otsuka Koji
Digestive Diseases Center, Showa University Koto Toyosu Hospital, 5-1-38,Toyosu, Koto-ku, Tokyo, 135-8577, Japan.
Clin J Gastroenterol. 2025 Jul 12. doi: 10.1007/s12328-025-02182-3.
Chronic esophageal achalasia can lead to significant morphological changes in the esophagus, posing challenges during endoscopic examinations. Here, we report a case of iatrogenic esophageal perforation in an elderly patient with achalasia. An 80-year-old woman presented with severe dysphagia and marked weight loss, indicating chronic malnutrition. She had a 50-year history of achalasia, previously treated with a Heller-Dor operation. Endoscopic evaluation was performed to assess the esophageal condition; however, during the procedure, an iatrogenic perforation occurred. The patient underwent urgent management under general anesthesia. Two drainage tubes were placed at the base of the right thoracic cavity. Saline infusion via the perforation site enabled endoscopic lavage of the thoracic cavity. The perforation was initially closed with the thread-and-clip technique. After 30 days, the perforation site had developed into a fistula approximately 1 cm in size. Attempts to close it using argon plasma coagulation ablation and over-the-scope clip were unsuccessful. It was presumed that the significant accumulation of fluid in the esophagus due to achalasia was hindering fistula closure. Consequently, peroral endoscopic myotomy was performed, ultimately leading to the closure of the fistula. Despite requiring prolonged hospitalization for recovery and nutritional rehabilitation, the patient was eventually discharged in stable condition, able to consume meals without difficulty. This case underscores the high risk of esophageal perforation during endoscopy in elderly patients with advanced achalasia and subsequent malnutrition. Furthermore, it highlights the potential for successful management of severe complications like esophageal perforation through advanced endoscopic techniques, thereby avoiding the need for surgical intervention.
慢性食管贲门失弛缓症可导致食管出现显著的形态学改变，给内镜检查带来挑战。在此，我们报告一例老年贲门失弛缓症患者发生医源性食管穿孔的病例。一名80岁女性因严重吞咽困难和明显体重减轻就诊，提示存在慢性营养不良。她有50年的贲门失弛缓症病史，此前接受过Heller-Dor手术。为评估食管状况进行了内镜检查；然而，在检查过程中发生了医源性穿孔。患者在全身麻醉下接受了紧急处理。在右胸腔底部放置了两根引流管。通过穿孔部位注入生理盐水，对胸腔进行内镜冲洗。穿孔最初采用丝线夹闭技术进行封闭。30天后，穿孔部位形成了一个约1厘米大小的瘘管。尝试使用氩等离子体凝固消融和套扎器封闭瘘管均未成功。推测由于贲门失弛缓症导致食管内大量积液阻碍了瘘管的闭合。因此，进行了经口内镜下肌切开术，最终实现了瘘管的闭合。尽管患者需要长时间住院进行康复和营养恢复，但最终出院时病情稳定，能够顺利进食。该病例强调了老年晚期贲门失弛缓症患者在内镜检查时发生食管穿孔及随后出现营养不良的高风险。此外，它还凸显了通过先进的内镜技术成功处理食管穿孔等严重并发症的可能性，从而避免了手术干预的必要性。
