Endoluminal Vacuum for Spontaneous Esophageal Perforation

Abstract

Endoscopic endoluminal vacuum therapy is a technique that has been used traditionally for the management of surgical anastomotic leakages and perforations in the esophagus and colon. We present a case of the use of this technique in a spontaneous esophageal perforation of unknown etiology. After review of the available literature, in this video, we demonstrate the use of this technique in a novel therapy of spontaneous esophageal perforations. Patient is a 64 year old man without a significant past medical history who developed retrosternal chest pain and was found to have a spontaneous esophageal perforation that resulted in a walled off mediastinal cavity upon initial endoscopic evaluation. The cavity was filled with debris content and extensive irrigation and lavage was performed with hydrogen peroxide for further examination. To help facilitate healing, the decision was made to place an endoluminal wound vacuum. An endoluminal sponge was sutured onto a sixteen french nasogastric tube which was facilitated down the upper intestinal tract endoscopically and placed in the cavity. External suction was attached and placed at 125 mmHG on continuous suction. After 4 days, the patient had a repeat endoscopy that showed improvement in the cavity size and notable healing. A hard object was identified which was thought to be the source of the original perforation, however it was unclear the identity of this object. The sponge was downsized and replaced. A week later, the patient had a third endoscopy which demonstrated a significantly smaller cavity with healthy granulation tissue. At this time, the patient had wanted to facilitate discharge so we decided to place a fully covered esophageal stent. The patient clinically progressed well and had been tolerating a regular diet prior to discharge. Patient had a follow up endoscopy for removal of the stent and the mediastinal cavity was no longer visualized. A small outpouching remained which was closed with one hemostatic clip. The patient had been seen for follow up with stable PO tolerance and no further complications. This case helped to highlight a new therapy with a pre-existing technique for spontaneous esophageal perforations. With serial endoscopy and downsizing of the endoluminal sponge, we recognize that perforations have the ability to heal quickly and safely. This technique can be a tool to help patients avoid invasive measures to treat esophageal perforations with good endoscopic and clinical outcome. Watch the video: https://goo.gl/Nu1HDC