2114 Pharyngo-esophageal Perforation During Endoscopic Ultrasound: Case Report and Literature Review

Abstract

INTRODUCTION: EUS related serious complications such as luminal perforation, pancreatitis and bleeding are rare. We report a case of EUS-related pharyngo-esophageal perforation, successfully managed conservatively and brief literature review. CASE DESCRIPTION/METHODS: A 75-year-old male presented with elevated LFTs without jaundice. CA 19-9 was elevated (112 U/mL). CT revealed a double duct sign and a 3 cm pancreatic head mass (Figure 1). Decision was made to proceed with EUS with FNA. Diagnostic EGD noted no luminal esophageal narrowing. The linear array echoendoscope was inserted into the oropharynx but was difficult to pass into the esophagus secondary to cervical osteophytes. The gastroscope was reinserted into the esophagus. Minimal pharyngeal mucosal trauma was noted. A savary guidewire was passed into the stomach; the gastroscope was removed. The echoendoscope was backloaded onto the wire and reinsertion attempted. Despite gentle maneuvers and multiple attempts, resistance to passage was encountered, esophageal intubation was not possible; the echoendoscope was removed. Repeat EGD revealed a 2 cm deep mucosal tear extending from the posterior pharynx to the esophageal inlet without full-thickness perforation or significant bleeding (Figure 2). The gastroscope and the guidewire were removed and the procedure was terminated. Patient complained of throat pain, especially with swallows. CT showed pneumomediastinum and extraluminal air and edema adjacent to the right aspect of the pharynx & esophagus (Figure 3), consistent with a pharyngo-esophageal microperforation. Thoracic surgery was consulted, antibiotics started, patient kept NPO. The patient remained hemodynamically stable with improved pain and no need for surgical intervention, discharged home on post-procedure day 4. DISCUSSION: EUS is a safe procedure with complication rates comparable to EGD. The rate of esophageal perforation is very low, ranging from 0.03-0.04%. The treatment for pharyngo-esophageal perforation depends upon the degree, location, timing of diagnosis, hemodynamic status and clinical status of the patient. In a case series of 16 cervical esophageal perforations, 44% of patients had history of difficult intubation with endoscopic procedures. 81% were managed conservatively.1 Early recognition and timely management is critical for ensuring an excellent outcome with conservative management. JOURNAL/ajgast/04.03/00000434-201910001-02115/figure1/v/2023-08-15T171636Z/r/image-tiff JOURNAL/ajgast/04.03/00000434-201910001-02115/figure2/v/2023-08-15T171636Z/r/image-tiff JOURNAL/ajgast/04.03/00000434-201910001-02115/figure3/v/2023-08-15T171636Z/r/image-tiff