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Qureshi A, Mansuri U, Roknsharifi M, Ghobrial Y, Asgeri A, Asgeri M. Endoscopic Management of Boerhaave Syndrome: Are Outcomes Better Than Surgery? A Case Report and Review of Literature. J Community Hosp Intern Med Perspect 2024; 14:104-108. [PMID: 38966501 PMCID: PMC11221440 DOI: 10.55729/2000-9666.1324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 07/06/2024] Open
Abstract
Boerhaave syndrome (BS) is a rare clinical diagnosis associated with a high morbidity and mortality rate. Diagnosis of this condition is usually delayed which can lead to a very poor outcome. The timing of presentation and time to management plays a very important role in the prognosis and selection of the management method. With the advances seen in therapeutic endoscopy, many authors have been exploring the possibility of shifting the focus of management from surgery to interventional endoscopy. We present a case report of a patient presenting with BS that was successfully managed endoscopically. We also reviewed the literature on how surgical management compares to endoscopic management and attempted to establish general recommendations from available literature on management of BS.
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Affiliation(s)
- Ammar Qureshi
- Department of Medicine, University of California-Riverside,
USA
| | - Uvesh Mansuri
- Department of Medicine, Medstar Union Memorial Hospital,
USA
| | | | - Youssef Ghobrial
- Department of Medicine, Sunrise GME Consortium Gastroenterology Fellowship Program,
USA
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Estorninho J, Pimentel R, Gravito-Soares M, Gravito-Soares E, Amaro P, Figueiredo P. Successful Endoscopic Closure of Esophageal Perforation in Boerhaave Syndrome Using the Over-the-Scope Clip. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:444-450. [PMID: 38476151 PMCID: PMC10928871 DOI: 10.1159/000527317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/30/2022] [Indexed: 03/14/2024]
Abstract
Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.
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Affiliation(s)
- João Estorninho
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Pimentel
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Marta Gravito-Soares
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Elisa Gravito-Soares
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Pedro Amaro
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Figueiredo
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Hayashi H, Nagao N, Yamazaki K, Asai R, Tanaka C, Kawai M. Spontaneous esophageal rupture managed with endoscopic closure using an over-the-scope clip: A case report. Int J Surg Case Rep 2021; 80:105691. [PMID: 33640637 PMCID: PMC7933483 DOI: 10.1016/j.ijscr.2021.105691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/04/2021] [Accepted: 02/20/2021] [Indexed: 11/11/2022] Open
Abstract
Spontaneous esophageal rupture is usually treated surgically. However, endoscopic interventions can be performed with good outcomes. Approach is based on degree of infection in the mediastinum and thoracic cavity. We used an over-the-scope clip for esophageal rupture localized to mediastinum. The esophageal perforation was closed once the inflammatory response subsided.
Introduction and importance Spontaneous esophageal rupture is a life-threatening condition caused by a sudden increase in the intraesophageal pressure. While surgery is the mainstay of management for spontaneous esophageal ruptures, in recent years, an increasing number of patients have been managed with endoscopic interventions. We report a case of spontaneous esophageal rupture managed with endoscopic closure using an over-the-scope clip (Ovesco Endoscopy AG, Tübingen, Germany). Case presentation A 68-year-old female presented with epigastric pain and left-sided back pain following vomiting. A computed tomography scan revealed mediastinal emphysema and an esophagogram showed leakage from the left side of the lower thoracic esophagus into the mediastinum. The patient was diagnosed with spontaneous esophageal rupture localized to the mediastinum and was treated conservatively. However, she had persistent fever and continuing esophageal leakage on the esophagogram. On the 12th day of admission, a gastrointestinal endoscopy was performed, which found a 10-mm full-thickness longitudinal laceration on the left side of the lower esophagus. Endoscopic closure using an over-the-scope clip was performed. The next day, the patient became afebrile. One week later, esophagogram revealed slight residual leakage and an additional endoscopic closure using an over-the-scope clip was performed; the patient subsequently had an uneventful recovery and was discharged on the 44th day of admission. Clinical discussion Endoscopic closure using an over-the-scope clip led to a good outcome in this patient with spontaneous esophageal rupture. Conclusion Endoscopic closure using an over-the-scope clip is an effective and minimally invasive technique for selected patients with spontaneous esophageal rupture.
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Affiliation(s)
- Hirokatsu Hayashi
- Department of Surgery, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
| | - Narutoshi Nagao
- Department of Surgery, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
| | - Kenji Yamazaki
- Department of Gastroenterology, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
| | - Ryuichi Asai
- Department of Surgery, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
| | - Chihiro Tanaka
- Department of Surgery, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
| | - Masahiko Kawai
- Department of Surgery, Gifu Prefectural General Medical Center, 4-6-1 Noisshiki, Gifu-City, Gifu-Prefecture, 500-8717, Japan.
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Al-Zahir AA, AlSaif OH, AlNaimi MM, Almomen SAM, Meshikhes AWN. Boerhaave's Syndrome: Delayed Management Using Over-the-Scope Clip. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:816-821. [PMID: 31178585 PMCID: PMC6581015 DOI: 10.12659/ajcr.916320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patient: Male, 43 Final Diagnosis: Boerhaave’s syndrome Symptoms: Dyspnoea • epigastric pain • vomiting Medication: — Clinical Procedure: Over-the scope-clip and pleurodesis Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Ali Ahmed Al-Zahir
- Department of Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Osama Habib AlSaif
- Department of Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Ishikawa Y, Tagami T, Hirashima H, Fukuda R, Moroe Y, Unemoto K. Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases. J NIPPON MED SCH 2018; 84:241-245. [PMID: 29142186 DOI: 10.1272/jnms.84.241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.
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Affiliation(s)
- Yumiko Ishikawa
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | | | - Reo Fukuda
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Yuuta Moroe
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
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Abstract
INTRODUCTION Operative and interventional treatment of Boerhaave's syndrome include closure of the esophageal defect and drainage of the septic focus. Initial reports on the use of endoscopic vacuum therapy (EVT) of Boerhaave's syndrome are now available. This article describes the experiences gained from the clinical application in two patients using this new surgical endoscopic procedure. The current literature regarding treatment of Boerhaave's syndrome is presented. MATERIAL AND METHODS Open-pore drainage is endoscopically placed either through the transmural defect in the extraluminal wound cavity (intracavitary EVT) or overlapping the defect into the esophageal lumen (intraluminal EVT). The application of a negative pressure results in active drainage directed to the lumen and simultaneously in defect closure. Through these therapeutic measures the perforation defect and the septic focus can be healed. Open-pore drains are manufactured from drainage tubes and open-pore foam or an open-pore film. RESULTS In both patients the distal esophageal perforation defects were completely healed using EVT. In 1 patient the treatment with EVT alone lasted 8 days. For the second patient EVT was combined with an open thoracotomy for decortication of pleural empyema. The treatment with EVT lasted 23 days and 1 cycle of EVT was carried out with an new open-pore film drainage (OFD). Surgical treatment to close the defect or an esophageal resection was not necessary for both patients. In the currently available studies and single case reports of ETV for Boerhaave's syndrome, 11 patients (84 %) of a total of 13 patients have been successfully treated. CONCLUSION First clinical experiences have demonstrated that with EVT draining of the septic focus and closure of the Boerhaave defect at the gastroesophageal junction can be achieved. The EVT is an organ-preserving endoscopic surgical treatment, which can be an alternative and complementary to traditional surgery.
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Affiliation(s)
- G Loske
- Department for General, Abdominal, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg gGmbH, Alfredstraße 9, 22087, Hamburg, Germany.
| | - T Schorsch
- Department for General, Abdominal, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg gGmbH, Alfredstraße 9, 22087, Hamburg, Germany
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Otsuka K, Murakami M, Ariyoshi T, Yamashita T, Goto S, Watanabe M, Aoki T. Endoscopic clipping of spontaneous esophageal rupture: Case reports of three patients. Int J Surg Case Rep 2017; 38:18-22. [PMID: 28750314 PMCID: PMC5526513 DOI: 10.1016/j.ijscr.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Spontaneous esophageal rupture is a life-threatening condition which is difficult to diagnose early, and is usually treated surgically. Prolonged hospitalization is common. Non-operative treatment of esophageal rupture localized to the mediastinum has been reported. We report three patients with spontaneous esophageal rupture successfully managed with endoscopic clipping. CASE PRESENTATIONS Two patients had ruptures localized to the mediastinum, and were discharged within one week of undergoing closure. The third patient presented with Boerhaave's syndrome with a leak into the pleural space and needed prolonged hospitalization (34days), but she did not need surgery and began oral intake two days after endoscopic clipping. The patient had an uneventful recovery.
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Affiliation(s)
- Koji Otsuka
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan.
| | - Masahiko Murakami
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Tomotake Ariyoshi
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Takeshi Yamashita
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Satoru Goto
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Makoto Watanabe
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Takeshi Aoki
- Division of Gastroenterological and General Surgery, Department of Surgery, Showa University School of Medicine, 142-8666 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
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Saxena P, Khashab MA. Endoscopic Management of Esophageal Perforations: Who, When, and How? ACTA ACUST UNITED AC 2017; 15:35-45. [PMID: 28116696 DOI: 10.1007/s11938-017-0117-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.
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Affiliation(s)
- Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA
| | - Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA.
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Raithel M, Albrecht H, Scheppach W, Farnbacher M, Haupt W, Hagel AF, Schellerer V, Vitali F, Neurath MF, Schneider HT. Outcome, comorbidity, hospitalization and 30-day mortality after closure of acute perforations and postoperative anastomotic leaks by the over-the-scope clip (OTSC) in an unselected cohort of patients. Surg Endosc 2016; 31:2411-2425. [PMID: 27633439 DOI: 10.1007/s00464-016-5242-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/07/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute gastrointestinal (GI) wall defects contain a high risk of morbidity and mortality and may be closed endoscopically by a full-thickness over-the-scope clip (OTSC). METHODS Unselected consecutive patients presenting with acute non-surgical perforations or postoperative anastomotic leaks or perforations underwent attempted OTSC placement as primary closure method after interdisciplinary consensus in three tertiary referral centres. Their clinical data and intervention characteristics were evaluated in an intention to treat analysis during a 24-month period to assess closure rates, 30-day mortality, hospitalization and comorbidity. RESULTS In total, 34 patients (16 females, 18 males, 69.5 years) were included with 22 non-surgical perforations and 12 postoperative anastomotic leaks or perforations. Definitive closure of the perforations and leaks was achieved in 26/34 patients (76.5 %). Successful closure of the GI wall defect resulted in a significantly shorter hospital stay (8 days, p = 0.03) and was significantly correlated with comorbidity (r = 0.56, p = 0.005). In the group with OTSC failure, hospitalization was 18 days and 6 of 8 patients (75 %) required immediate surgery. Three deaths occurred in the group with successful OTSC closure due to comorbidity, while one death in the OTSC failure group was related to a refractory perforation. Favourable indications and locations for a successful OTSC procedure were identified as PEG complications, endoscopic or postoperative leaks of stomach, colon or rectum, respectively. CONCLUSIONS In unselected patients, OTSC was effective for closure of acute GI wall defects in more than 75 % of all patients. Clinical success and short hospitalization were best achieved in patients without comorbidity, but closure of the perforation or the anastomotic leak was found to be not the only parameter relevant for patient outcome and mortality.
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Affiliation(s)
- M Raithel
- Department of Medicine II, Gastroenterology and Interventional Endoscopy, Waldkrankenhaus St. Marien, Erlangen, Germany.
| | - H Albrecht
- Department of Medicine 1, Gastroenterology, University Erlangen, Erlangen, Germany
| | - W Scheppach
- Internal Medicine and Gastroenterology, Julius-Spital, Würzburg, Germany
| | - M Farnbacher
- Internal Medicine and Gastroenterology, Clinics, Fürth, Germany.,Gastroenterology Practice, Erlangen, Germany
| | - W Haupt
- Surgical Department, University Erlangen, Erlangen, Germany
| | - A F Hagel
- Department of Medicine 1, Gastroenterology, University Erlangen, Erlangen, Germany
| | - V Schellerer
- Surgical Department, University Erlangen, Erlangen, Germany
| | - F Vitali
- Department of Medicine 1, Gastroenterology, University Erlangen, Erlangen, Germany
| | - M F Neurath
- Department of Medicine 1, Gastroenterology, University Erlangen, Erlangen, Germany
| | - H T Schneider
- Internal Medicine and Gastroenterology, Clinics, Fürth, Germany
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Lázár G, Paszt A, Mán E. Role of endoscopic clipping in the treatment of oesophageal perforations. World J Gastrointest Endosc 2016; 8:13-22. [PMID: 26788259 PMCID: PMC4707319 DOI: 10.4253/wjge.v8.i1.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/25/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Ngo E, Born P, Strebel H. Endoscopic treatment of an oesophageal rupture using an over-the-scope clip (OTSC): A case report. Arab J Gastroenterol 2015. [PMID: 26206430 DOI: 10.1016/j.ajg.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Oesophageal rupture (Boerhaave syndrome) is a rare but serious complication after vomiting. Early intervention is mandatory in order to avoid a deleterious outcome for the patient. This case report describes the endoscopic approach using an over-the-scope clip.
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Affiliation(s)
- Elmar Ngo
- II. Medizinische Klinik, Rotkreuzklinikum München, Nymphenburgerstrasse 163, 80634 Munich, Germany
| | - Peter Born
- II. Medizinische Klinik, Rotkreuzklinikum München, Nymphenburgerstrasse 163, 80634 Munich, Germany.
| | - Hendrik Strebel
- II. Medizinische Klinik, Rotkreuzklinikum München, Nymphenburgerstrasse 163, 80634 Munich, Germany
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