Endoscopic nasomediastinal drainage followed by clip application for treatment of delayed esophageal perforation with mediastinitis

Treatment of esophageal perforation with mediastinal abscess by nasomediastinal drainage placement

Although endoscopic submucosal dissection has been increasingly performed for managing superficial esophageal carcinomas, the risk of post-operative esophageal stenosis remains. Endoscopic balloon dilation for esophageal stenosis is the most common cause of esophageal perforation. Esophageal perforation complicated with mediastinal abscess and sepsis has a high mortality rate. The standard treatment for esophageal perforation is closure. However, the late diagnosis of a case necessitates that treatment of mediastinitis be prioritized over closure of the perforation. We report the case of a 70-year-old man with post-endoscopic submucosal dissection stenosis who underwent endoscopic balloon dilation. Six days after the 16th endoscopic balloon dilation, the patient came to our hospital with a complaint of chest discomfort. Upon assessment, an esophageal perforation and a mediastinal abscess became evident. Because the patient's systemic condition remained stable, instead of performing surgery, we treated the patient conservatively by placing a nasomediastinal drain. After daily rinsing, the mediastinal abscess eventually regressed on the 15th hospital day. The esophageal perforation also closed spontaneously after removing the drainage tube. Nasomediastinal drainage placement appears to be effective in treating an esophageal perforation with a mediastinal abscess.

An Endoscopic Nasomediastinal Approach to a Mediastinal Abscess Developing after Zenker's Diverticulectomy

Zenker's diverticulum is the most frequent symptomatic diverticulum of the esophagus, but the prevalence is <0.1%. The optimal treatment is surgery. Here, we present a nasomediastinal drainage approach to treatment of a mediastinal abscess, developing in the late postoperative period and attributable to leakage from the staple line.

Role of endoscopic clipping in the treatment of oesophageal perforations

With advances in endoscopic technologies, endoscopic clips have been used widely and successfully in the treatment of various types of oesophageal perforations, anastomosis leakages and fistulas. Our aim was to summarize the experience with two types of clips: The through-the-scope (TTS) clip and the over-the-scope clip (OTSC). We summarized the results of oesophageal perforation closure with endoscopic clips. We processed the data from 38 articles and 127 patients using PubMed search. Based on evidence thus far, it can be stated that both clips can be used in the treatment of early (< 24 h), iatrogenic, spontaneous oesophageal perforations in the case of limited injury or contamination. TTS clips are efficacious in the treatment of 10 mm lesions, while bigger (< 20 mm) lesions can be treated successfully with OTSC clips, whose effectiveness is similar to that of surgical treatment. However, the clinical success rate is significantly lower in the case of fistulas and in the treatment of anastomosis insufficiency. Tough prospective randomized multicentre trials, which produce the largest amount of evidence, are still missing. Based on experience so far, endoscopic clips represent a possible therapeutic alternative to surgery in the treatment of oesophageal perforations under well-defined conditions.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks

Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.

A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip

Boerhaave syndrome is a spontaneous perforation of the oesophagus secondary to forceful emesis. Surgery has been advocated in delayed presentations of Boerhaave's syndrome with mediastinitis. The over-the-scope clip (OTSC) by OVESCO^® (Tubingen, Germany) has been used in the endoscopic management of gastrointestinal bleeds, fistulae and anastamotic leaks. We describe the successful endoscopic use of the OTSC in a delayed presentation of Boerhaave syndrome with mediastinitis. A 69-year-old gentleman underwent a computerised tomography scan, which demonstrated a lower oesophageal perforation and mediastinitis 7 days after admission, having presented with forceful emesis and chest discomfort. During endoscopy the defect was visualized and successfully closed using the OTSC. This resulted in a favourable outcome and is a technique not previously described in the literature to manage this condition.

Acute Mediastinitis Associated with Foreign Body Erosion from the Hypopharynx and Esophagus

Objective. Mediastinitis secondary to hypopharyngeal and esophageal foreign bodies is a rare but lethal complication. So far, no literature on a large scale has been reported. This investigation reviewed cases of mediastinitis associated with foreign body ingestion during the past 40 years.

Study Design. Case series with chart review.

Setting. Second Xiangya Hospital, Central South University.

Subjects and Methods. Of 2981 patients with hypopharyngeal and esophageal foreign body impaction included between 1969 and 2010, 93 had complications of acute mediastinitis. Four patients were dead within 4 hours after admission. The rest of the 89 patients underwent surgical drainage. Thirteen underwent primary repair (7 cases with suture, 6 cases with omentum onlay graft), and 9 patients underwent endoscopic stent placement at the same time.

Results. The mean (SD) time between ingestion and initial treatment of patients who developed mediastinitis was 7.72 (1.93) days, compared with 1.92 (1.41) days for those who did not ( P < .05). Morbidity was 3.1% and mortality was 30.1% (28/93), but the mortality of every decade has decreased from 38.7% in the 1970s to 8.3% today. Nine cases with local stent were all recovered.

Conclusions. Delay in initiating treatment and intrathoracic esophageal foreign bodies are the main risk factors of mediastinitis secondary to foreign body ingestion. Computed tomography plays an important role in diagnosis and guiding treatments. In conjunction with aggressive surgical debridement and drainage, endoscopic stent placement could be the optimal management for most patients.

Medical management of iatrogenic esophageal perforations

OPINION STATEMENT

Esophageal perforation is an uncommon, potentially disastrous occurrence with high mortality rates even when managed with surgery. Over the past few decades, several case series have shown that nonoperative management is a feasible option in some patients, although the criteria for selecting such patients are neither firmly established nor accepted by all those who manage these critical patients. The decision to manage a patient without surgery should be made collaboratively with a surgeon. No single criterion, with the possible exception of sepsis and shock, mandates surgical management. Randomized, prospective studies comparing surgical and nonsurgical therapy have not been performed. Factors that can affect the decision to proceed nonoperatively include the perforation's site and size, the patient's underlying comorbidities, and the patient's hemodynamic status on presentation. Healthy patients with small, contained perforations who present without sepsis tend to be the best candidates for nonoperative management. Intravenous antibiotics and cessation of oral intake should be instituted immediately, even before confirming the diagnosis. Mediastinal fluid collections and pleural effusions often coexist with esophageal perforations and must be managed concomitantly. Percutaneously placed drains are an important adjunct to therapy when collections are identified. Endoscopic stenting has been introduced as a means to seal the perforation. After embarking on a nonoperative course, patients still may deteriorate and require surgery, so close follow-up is warranted for every patient. When proper nonoperative management strategies are followed, outcomes have been shown to be at least equivalent to those of surgical management in most series. In this review, the principles of patient selection and medical therapy for iatrogenic esophageal perforations are discussed.

Gastrointestinal perforations: role of endoscopic closure

PURPOSE OF REVIEW

Understanding the role of endoscopic closure techniques helps in expanding the endoscopist's role in the management of gastrointestinal neoplasia and explore new frontiers of minimally invasive endoluminal surgery.

RECENT FINDINGS

This article covers recent advances in endoscopic closure of various gastrointestinal perforations, with a special focus on devices, experimental evidence and clinical outcomes of endoscopic closure of gastrointestinal perforations.

SUMMARY

Endoscopic closure techniques help the endoscopist to walk on thin ice and save himself and the patient in the case of mishap.

Treatment of Boerhaave's Syndrome

Boerhaave's syndrome is the spontaneous transmural rupture of the esophagus. A high degree of clinical suspicion is a prerequisite for its prompt diagnosis, and early therapeutic intervention reduces its associated morbidity and mortality. Factors that influence the outcome are location and extent of perforation and the timing of medical or surgical treatment. Boerhaave's syndrome is the most lethal perforation of the gastrointestinal tract. Delay in intervention relates directly to increased mortality. Despite advances in surgical techniques and endoscopic therapies, this disorder still has high morbidity and mortality rates. The outcome of patients with this disorder is dependent upon the prompt and accurate diagnosis. Initial stabilization of the patient with intravenous fluids and antibiotics is of key importance, with subsequent decisive therapy initiated using either a conservative medical or endoscopic or surgical approach. Boerhaave's syndrome often occurs in otherwise-relatively healthy patients. This postemetic perforation of the esophagus can result in a devastating injury that usually is exacerbated by delayed diagnosis. This article will focus on its clinical presentations and review its potentially applicable therapies.

A case of Sengstaken-Blakemore tube-induced esophageal rupture repaired by endoscopic clipping

A 57-year-old man was admitted to another hospital for hematemesis due to heavy drinking. A Sengstaken-Blakemore tube was inserted and the patient was transferred to our hospital. The patient's ensuing movements inadvertently caused an esophageal rupture 2.5 cm in size. Since the patient's condition was stable, treatment via endoscopic repair using metallic clips was chosen over emergency surgery. Two hemoclips were fixed at the ends of the ruptured area; by employing an endoscopic detachable snare, the ruptured area was carefully repaired with 10 metallic clips. As a result, the esophageal rupture could be successfully repaired by endoscopic procedure rather than performing surgery.

Management of Esophageal Perforation in Adults

Perforation of esophagus in the adult is a very morbid condition with high morbidity and mortality. The ideal treatment is controversial. The main causes for esophageal perforation in adults are iatrogenic, traumatic, spontaneous and foreign bodies. The morbidity and mortality rate is directly related to the delay in diagnosis and initiation of optimum treatment. The reported mortality from treated esophageal perforation is 10% to 25%, when therapy is initiated within 24 hours of perforation, but it could rise up to 40% to 60% when the treatment is delayed beyond 48 hours. Primary closure of the perforation site and wide drainage of the mediastinum is recommended if perforation is detected in less than 24 hours. Treatment option for delayed or missed rupture of esophagus is not very clear and is controversial. Recently a substantial number of patients with esophageal perforation are being managed by nonoperative measures. Patients with small perforations and minimal extraesophageal involvement may be better managed by nonoperative treatment Major prognostic factors determining mortality are the etiology and site of the injury, the presence of underlying esophageal pathology, the delay in diagnosis and the method of treatment. For optimum outcome for management of esophageal perforations in adults a multidisciplinary approach is needed.

Endoscopic repair of gastrogastric fistula after Roux-en-Y gastric bypass: a less-invasive approach

BACKGROUND

Gastrogastric fistulas (GGFs) are a well-known complication of Roux-en-Y gastric bypass. Surgical repair of such fistulas is technically difficult, with significant associated morbidity. The aim of the present study was to evaluate the efficacy of endoscopic GGF closure at a university hospital in the United States.

METHODS

Patients with Roux-en-Y gastric bypass and confirmed GGFs on esophagogastroduodenoscopy or barium study. Endoscopic repair was performed with the EndoCinch suturing system (group 1) or clips (group 2). All patients were followed up in the outpatient clinic or interviewed by telephone at 1, 6, and 18 months after the procedure, then as indicated by symptoms.

RESULTS

A total of 95 patients were included in the present series (group 1, n = 71, 75%; group 2, n = 24, 25%). The mean GGF size was significantly larger in group 1 than in group 2 (14.5 +/- 8.7 versus 7.7 +/- 6, P = .01). An average of 2.2 sutures or 3 clips (range 2-7) was used. Complete initial GGF closure was achieved in 90 patients (95%), with reopening in 59 (65%) an average of 177 +/- 202 days. The average follow-up was 395 +/- 49 days, with 22 patients lost to follow-up. Two significant complications were reported (bleeding and an esophageal tear). None of the GGFs with an initial size >20 mm remained closed during the follow-up period compared with 10 (32%) of the 31 fistulas <or=10 mm in diameter remained closed.

CONCLUSION

Peroral endoscopic repair of postbariatric GGFs is technically feasible and safe but with limited durability. The fistula size predicted for long-term outcomes, with the best results seen in fistulas <or=10 mm in diameter.

Natural Orifice Trans-Luminal Endoscopic Surgery in the esophagus

As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.

Role of endosonography in drainage of fluid collections and other NOTES procedures

Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.

Endoscopic closure of gastrointestinal leaks

Surgery has been the mainstay of therapy in patients with gastrointestinal perforations. This paradigm started to shift with the development of techniques for endoscopic closure of gastrointestinal perforations. A detailed review of the literature on this subject, along with a commentary on practical aspects in the management of patients with gastrointestinal leaks, is provided here.

Successful endoscopic hemoclipping of an esophageal perforation

We describe a case of esophageal perforation that resulted from a fishbone. A 71-year-old man had had a fishbone impacted in the lower esophagus for 2 days. At presentation, the bone was dislodged at endoscopy; one round opening in a deep ulceration was detected when the fishbone was removed. The perforation was closed by endoscopic hemoclipping, after the removal of the fishbone. A thoracic computed tomography revealed air around the esophagus, aorta and bronchus and the presence of a pleural effusion. These findings suggested mediastinal emphysema and mediastinitis due to the esophageal perforation after the removal of the fishbone. Esophagography revealed a focal esophageal defect and linear contrast leakage at the distal esophagus. The mediastinal emphysema and pleural effusion successfully resolved after the endoscopic hemoclip application and conservative management of the perforation.

Endoscopic clips for closing esophageal perforations: case report and pooled analysis

BACKGROUND

Acute and chronic esophageal perforations have traditionally been treated with surgery or a conservative approach. Recently, endoscopic repair has been reported in some case reports.

OBJECTIVE

To describe a case of a chronic esophagoperitoneal fistula successfully closed by endoscopic clips after several failed reoperations and stent placement. To perform a pooled analysis of the reports describing such closures.

DESIGN

Case report and pooled analysis.

SETTING

Tertiary-care hospitals.

PATIENTS

Our patient presented with mature perforation in the distal esophagus caused by laparoscopic band gastroplasty. Patients for pooled analysis identified by a MEDLINE search (1966 to January 2007) performed for all the English language articles that reported esophageal perforation/fistulae and endoscopic clips.

INTERVENTIONS

Endoscopic clip application after ablation of epithelialized edges in our patient. Pooled analyses for demographic and perforation variables, along with predictors for closure time after clipping, were performed.

MAIN OUTCOME MEASUREMENTS

Closure of esophageal perforations.

RESULTS

The fistula in our patient closed in 3 weeks after endoscopic clipping. The literature review identified a total of 11 articles that describe 17 patients (acute 7, intermediate 4, and chronic 6). The most common cause was iatrogenic (65%), and the size of the perforation ranged from 3 to 25 mm. The median healing time after clipping was 18 days (interquartile range 6-26). Both univariable and multivariable analyses identified only the duration of perforation as a significant predictor of closure time, P values .003 and .02, respectively.

LIMITATIONS

Small sample size, nonrandomized sample.

CONCLUSIONS

Endoclips may be effective for closing both acute and chronic esophageal perforations. The duration of the perforation is a significant factor for predicting closure time.

Treatment of large, oesophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage

A bevont fémstentek benignus nyelőcső-stenosisban és -perforatioban való alkalmazása, a stent okozta szöveti reakció és a stent eltávolítás nehézségei miatt, kezdeti stádiumban van. A szerzők nyelőcső-perforatioban egy újabb, bevont fémstent terápiás hatását és eltávolítására kidolgozott módszerük hatékonyságát vizsgálták 3 beteg kapcsán. Három beteg közül kettőnél corrosiv nyelőcsőstenosis tágításakor perforatio lépett fel. Emiatt az egyiknél mediastinalis drenázs és jejunostomia, másiknál primér sutura és drenázs történt. Ezt követően mindkettőben septicus állapot, mediastinitis alakult ki. Ennek hátterében egyiknél perforatio mellett mediastinalis drén okozta nyelőcsőfistula, a másiknál nyelőcsővarrat-elégtelenség állt. A nyelőcső falának defektusát 8, illetve 10 nappal a perforatio, műtét után bevont fémstenttel hidalták át. A harmadik beteg inoperabilis nyelőcsőtumora okozta stenosisának tágítása, stentelési kísérlete során nyelőcsőruptura lépett fel, melyet két órán belül bevont fémstenttel zárta. Parenteralis táplálást, széles spectrumú antibioticus kezelést alkalmaztak. Három nap múlva ellenőrizve mindhárom stent tölcsére tökéletesen zárt. Nasogastricus szonda-, majd per os táplálásra tértek át. Átmeneti mediastinalis drenázs után a stenteket 35, illetve 74 nappal a stentimplantatio után endoscoposan távolították el. Ez idő alatt a nyelőcsőfal-defectusok, a perforatios nyílások záródtak. A stent felső szélénél jelentkező stenosist mindkét betegnél tágították. A 3. betegnél a tumoros nyelőcsőruptura korai, végleges stentelése után szövődmény nem lépett fel. Itt drenázsra nem volt szükség. Nagy nyelőcső-perforatio – kísérő septicus állapot, mediastinitis esetén is – sikeresen gyógyítható bevont, eltávolítható fémstenttel és megfelelő mediastinalis drenázzsal.

Endoscopic closure of cervical esophageal perforation caused by traumatic insertion of a mucosectomy cap

Cap-assisted endoscopic mucosal resection enables nonsurgical removal of superficial esophageal lesions. Perforation at the resection site is a rare but known complication of this technique. We report a case in which traumatic insertion of the mucosectomy cap led to perforation of the cervical esophagus. This complication has not been previously reported. The perforation was successfully closed by the endoscopic placement of clips.

Endoscopic management of gastrointestinal leaks

Endoscopic closure of gastrointestinal perforations, fistulas, and anastomotic dehiscence is technically feasible. Endoluminal closure of the instrumental perforations of the gastrointestinal tract can be accomplished immediately after the recognition of perforation, while avoiding the delay of arranging surgery and the trauma associated with thoracotomy or laparotomy. In addition, endoscopic closure should be considered in patients with anastomotic dehiscence and chronic fistulas as this may avoid the risk associated with reoperation. The outcome of closure depends on the technical expertise in the proper selection and use of various endoluminal closure options. Training of the endoscopists in the use of this novel technology will enhance the quality of care of our patients.

Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach

BACKGROUND

Gastric leaks represent an important source of morbidity and mortality associated with Roux-en-Y gastric bypass. These leaks, once managed acutely, can become chronic and represent a difficult clinical challenge. Surgical options to address a chronic gastric leak are technically challenging and often unsuccessful. We present a novel peroral endoscopic treatment for patients with chronic gastric leaks after Roux-en-Y gastric bypass.

DESIGN

Case series.

INTERVENTIONS

Repair of chronic gastric leaks after Roux-en-Y gastric bypass by using a combination of argon plasma coagulation, hemoclips, fibrin glue, Polyflex stent placement, and distal gastrojejunal stenosis dilation. The goal was to achieve durable fistula closure and avoid surgery.

MAIN OUTCOME MEASUREMENTS

Durable fistula closure as assessed by an upper-GI series and clinical evaluation.

RESULTS

Gastric leak closure was achieved in all 3 patients, with complete resolution of symptoms. Polyflex stent migration into the Roux limb occurred in 1 patient, and this was retrieved endoscopically. There were no other significant complications.

CONCLUSIONS

Peroral endoscopic repair of gastric leaks is technically feasible. This procedure may offer a less invasive alternative to traditional surgical revision.

A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model

BACKGROUND

Surgical closure of a colon perforation is accompanied by the risks of general anesthesia and prolonged recovery from surgery because of ileus and other sequelae. Very little is known about the effectiveness of endoluminal repair of colon perforations with clips, which eliminates incisions of the abdominal wall and provides a less invasive alternative to surgical closure. The aim of this study is to evaluate the feasibility and the safety of endoscopic closure of colonic perforations with endoclips in a porcine model.

METHODS

Approximately 1.5- to 2-cm colon perforations created with a needle knife in 4 50-kg, female pigs that were under general anesthesia were closed with endoclips. After 24 hours of recovery, the animals were allowed to eat. All the animals received intravenous antibiotics and were carefully monitored for signs of sepsis. After a follow-up of 1 week, the pigs were euthanized for postmortem examination. The fifth pig was euthanized immediately after closure of a 5-cm colon perforation with clips to evaluate the extent of transmural closure with endoclips.

RESULTS

The animals recovered well, without any clinical features of sepsis or peritonitis. Postmortem examination did not reveal fecal peritonitis, and there was no evidence of pericolonic abscess formation at the site of perforation. The perforation site showed signs of healing without any evidence of transmural dehiscence. Histopathology demonstrated granulation tissue bridging the site of perforation. In the fifth pig, euthanized immediately after closure of the perforation, nice mucosal apposition was seen, while the muscular and serosal coats remained dehisced.

CONCLUSIONS

Endoscopic closure of small iatrogenic colon perforations with clips results in mucosal and submucosal healing and prevents fecal soiling of peritoneal cavity.

Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series

BACKGROUND

Mediastinal abscesses after esophageal perforation or postoperative leakage nearly always require surgical intervention.

METHODS

Patients with paraesophageal abscesses were treated with EUS-guided or endoscopic mediastinal puncture if the abscess was >2 cm and sepsis was present. Abscess cavities were entered with a 9.5-mm endoscope after balloon dilation to allow irrigation and drainage. Debris was removed with a Dormia basket. Concomitant pleural effusions were treated with transthoracic drains. Patients received intravenous antibiotics and enteral/parenteral nutrition.

RESULTS

Twenty patients fulfilled the entry criteria. Simple drainage was sufficient in 4 cases, and puncture was impossible in one case. Of the 15 treated patients (age 39-76 years, 5 women) the etiology of perforation was Boerhaave's syndrome (n = 8), anastomotic leak (n = 3), and iatrogenic perforation (n = 4). Debridement was successful in all cases and required a median of 5 daily sessions (range 3-10). All patients became apyrexial, with a C-reactive protein < 5 mg/L within a median of 4 days (range 2-8 days). Esophageal defects were closed with endoclips (n = 7), fibrin glue (n = 4), metal stents (n = 1), or spontaneously healed (n = 3). One patient died from a massive pulmonary embolism one day after successful debridement (mortality 7%). No other complications were seen. Median follow-up was 12 months (range 3-40 months).

CONCLUSIONS

Nonoperative endoscopic transesophageal debridement of mediastinal abscesses appears safe and effective.

Esophageal emergencies: things that will wake you from a sound sleep

Esophageal emergencies are a common problem facing practicing gastroenterologists and it is important to know what therapies are indicated for different situations. Patients ingesting caustic agents should be monitored intensively for signs of perforation and ultimately for signs of stricture development. Foreign bodies impacted in the esophagus should be removed promptly to prevent perforation. Although esophageal perforations are generally managed surgically, conservative management of localized perforations has become more common especially with improved antibiotics and the use of nonsurgical interventional drainage techniques. In either elected course the gastroenterologist should work closely with the surgical team.

Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae

BACKGROUND AND AIMS

Esophageal perforation is associated with high morbidity and mortality. Surgery and drainage are considered primary management. Conservative management is an option in a select group. Conservative treatment requires drainage, control of infection, nutritional support, and considerable patience.

METHODS

We describe 3 cases in which endoscopic metallic clips were placed to close mature perforations with associated fistulae. All 3 patients underwent mucosal approximation of the defects under direct endoscopic visualization.

RESULTS

A review of the literature revealed only 4 other reports of the use of endoclipping for esophageal perforation, one diagnosed immediately, a second within 24 hours, a third diagnosed after 2 days and endoclipped after prolonged mediastinal drainage, and a fourth believed to be chronic. The cases presented here represent well-established, mature defects.

CONCLUSIONS

Endoscopic treatment of mature esophageal perforation with metallic clips can be performed to promote closure. In combination with other conservative medical efforts, this method can be used safely and effectively for selected patients.