Shetty Shiran, Sujay Prabhath Dronamraju, Musunuri Balaji, M C S Praveen, Mahajan Abhay, Mishra Santanu
Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
VideoGIE. 2025 Mar 21;10(8):387-391. doi: 10.1016/j.vgie.2025.03.029. eCollection 2025 Aug.
Esophageal perforation in adults is associated with significant morbidity and mortality, with optimal treatment approaches remaining debated. Outcomes are linked to timely diagnosis and appropriate interventions. Common therapeutic options, such as esophageal clips, stents, and suturing, may be ineffective for large perforations. We aimed to show the need for a multistep approach in dealing with difficult perforations.
An 85-year-old male presented with chest pain and dyspnea, following an endoscopic procedure. He was hemodynamically stable but had leukocytosis (14,400/μL). CT thorax confirmed esophageal perforation with right-sided hydropneumothorax. Due to poor performance status, surgery was deferred. Endoscopy revealed a 4-cm midesophageal perforation. A fully covered self-expandable metal stent (SEMS) was initially placed. However, the perforation persisted after SEMS removal. To address the defect, endoluminal vacuum therapy (ENDOVAC) was attempted using a modified ENDOVAC with sponge attached to a Ryle's tube and connected to a negative pressure wound therapy device. The sponge was replaced every 3 days, with adjustments to match the defect size. Despite 4 ENDOVAC sessions and defect reduction, complete closure was not achieved. Definitive closure was achieved using a through-the-scope tack-and-suture device. Tacks were placed 5 to 10 mm from the defect margins, securing healthy tissue, and deployed using a push catheter in a zig-zag pattern for optimal coverage. Sutures were tightened sequentially to eliminate slack and ensure closure.
Postprocedure, an oral gastrograffin study confirmed no leaks, and then he was resumed on oral feeds. Follow-up chest x-ray showed resolution of hydropneumothorax, with no complaints or adverse events reported.
This case demonstrates the successful management of a complex esophageal perforation using a multistep endoscopic intervention approach. Failure of defect closure using clips required use of a covered metal stent, endoscopic vacuum therapy, along with tack-and-suture device to achieve complete closure of defect.
成人食管穿孔与显著的发病率和死亡率相关，最佳治疗方法仍存在争议。治疗结果与及时诊断和适当干预有关。常见的治疗选择，如食管夹、支架和缝合，对于大穿孔可能无效。我们旨在表明处理困难穿孔需要多步骤方法。
一名85岁男性在内镜检查后出现胸痛和呼吸困难。他血流动力学稳定，但有白细胞增多症（14,400/μL）。胸部CT证实食管穿孔伴右侧液气胸。由于身体状况不佳，手术推迟。内镜检查发现食管中段有一个4厘米的穿孔。最初放置了一个全覆膜自膨式金属支架（SEMS）。然而，在移除SEMS后穿孔仍然存在。为了处理缺损，尝试使用改良的带有附着在鼻胃管上的海绵并连接到负压伤口治疗装置的腔内负压治疗（ENDOVAC）。海绵每3天更换一次，并根据缺损大小进行调整。尽管进行了4次ENDOVAC治疗且缺损有所缩小，但仍未实现完全闭合。使用经内镜钉合缝合装置实现了最终闭合。钉子放置在距缺损边缘5至10毫米处，固定健康组织，并使用推送导管以之字形模式展开以实现最佳覆盖。缝线依次收紧以消除松弛并确保闭合。
术后，口服泛影葡胺检查证实无渗漏，然后恢复经口进食。随访胸部X线显示液气胸消失，未报告任何不适或不良事件。
本病例展示了使用多步骤内镜干预方法成功处理复杂食管穿孔。使用夹子未能闭合缺损，需要使用覆膜金属支架、内镜负压治疗以及钉合缝合装置来实现缺损的完全闭合。
