A multistep approach for managing a complex esophageal perforation

Background and Aims: 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. Methods: 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 mid-esophageal 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 Ryles 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. Results: 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. Conclusions: 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.