Endoscopic Management of a Perforated Esophageal Adenocarcinoma

Abstract

Purpose: Esophageal perforation secondary to dilation of esophageal malignancy can be a catastrophic event. Mediastinitis that results from the perforation can rapidly progress to purulent mediastinal collections and due to the close anatomic proximity between the esophagus and pleura, esophago-pleural fistula and empyema ensues. Surgical options are limited in this situation due to significant morbidity and mortality. We describe endoscopic management of such case with optimal clinical outcome. A 67-year-old gentleman presented to our ER with fever, right sided chest and back pain. An EGD was performed by a referring surgeon 3 days prior to presentation due to progressive solid food dysphagia and weight loss. A 5-cm malignant appearing mass was found in the mid to distal esophagus that was balloon dilated and biopsies confirmed a poorly differentiated adenocarcinoma. He felt back pain after the endoscopy however was reassured and sent home. Within 12 hours of the procedure he developed spiking fevers and pleuritic chest pain that radiated to his back. On admission BP was 80/60 mmHg and temperature, 39.3°C. CT scan revealed pneumomediastinum, an empyema in the right lung, and mediastinal fluid collection around aorta and heart with a free extravasation of contrast between esophagus and the fluid collection. An emergent EGD confirmed a 2.5-cm trans-mural perforation through the right esophageal wall with a clearly visible mediastinum. A partially covered wall flex metal stent was placed successfully across the defect. A subsequent CT scan confirmed completely sealed defect with no contrast extravasation. He underwent a trans-hiatal esophagectomy, pathology indicating a 5.5 cm invasive poorly differentiated T3 adenocarcinoma. His hospital course was finally complicated by development of a left pleural empyema which required decortication. After responding to antibiotics, he was discharged for palliative chemotherapy and radiation. Esophageal perforation requires emergent detection as it is crucial in a favorable clinical outcome. Empyema is diagnosed clinically with CT chest and pleural fluid studies which reveal leukocytosis, low pH (<7.20), low glucose (<60 mg/dL), a high LDH (lactate dehydrogenase), elevated protein and culture for pathogens. Definitive therapy entails emergent drainage and IV antibiotics. The prognosis of pleural empyema in the setting of malignancy is dependent on detection and expeditious closure of the anatomic defect.