‘Bear-Clawing Boerhaaveʼs’: OTSC Closure of an Esophageal Rupture Through an Overtube

Abstract

A 41 year-old female without significant medical history was admitted to our tertiary care medical center with one month history of solid and liquid food dysphagia and a two-day history of intractable nonbloody emesis followed by severe epigastric and substernal chest pain. An EKG revealed sinus tachycardia and standard laboratory parameters were unremarkable. An emergent CT scan revealed pneumatosis of the proximal stomach, gastroesophageal junction, and distal esophagus without evidence of free air (Figure 1). Symptoms resolved with medical therapy and an urgent esophagogastroduodenoscopy (EGD) was planned. A standard 9 mm gastroscope could not be advanced past an esophageal web at 15 cm from incisors. A 4.9 mm gastroscope was used to intubate the esophagus and traverse the web. At 35 cm, a large, left esophageal wall tear was visualized and extended 5 cm distally to a false lumen located 2 cm proximal to gastroesophageal junction (Figure 2). The findings were suggestive of esophageal dissection without perforation. The stomach and duodenum appeared normal. An esophageal overtube was placed in standard fashion to “dilate” the proximal web and to act as a working channel. An 11 mm x 6 mm, type t Over-The-Scope-Clip (OTSC, Ovesco Endoscopy) system was attached to endoscope tip and advanced into the esophagus through the overtube. The edges of the false lumen were approximated carefully and the clip was deployed closing the defect while maintaining luminal patency (Figure 3). Post-procedure water soluble esophagram revealed no esophageal leak and confirmed patency of esophageal lumen. The patient tolerated a liquid diet, and three days later a repeat EGD revealed the clip in place, with no stenosis of true lumen. Patient's diet was advanced to soft foods and she was discharged with GI clinic follow-up.Figure 1Figure 2Figure 3Boerhaave's syndrome is a rupture of the esophageal wall caused by repetitive vomiting and both the syndrome and its treatment with emergent surgical repair are associated with significant morbidity and mortality. The OTSC device aggregates a large amount of tissue to facilitate closure of perforations, fistulas and anastomotic leaks. Endoscopic closure of esophageal perforation using the OTSC clip system is a minimally invasive, easy to use, robust and successful method that has been described in a few case reports and should be considered in all cases of Boerhaave's syndrome.