Immediate Placement of a Temporary Covered Stent for the Management of Iatrogenic Malignant Esophageal Perforation

Abstract

Traditional therapy for esophageal perforation has been surgical repair of the esophagus. However, perforations diagnosed and treated surgically within 24 h continue to have a mortality rate between 12% and 36% [1]. Recently, covered stents have been introduced as a safe and effective therapeutic modality to treat esophageal perforation after surgery or medical procedures [2]. Only a few reports have explored the effectiveness of treating malignant esophageal perforation using retrievable stent placement [3, 4]. However, in most reported series of stent removal, has required general anesthesia and esophagoscopy. A 65-year-old man had dysphagia for 2 months, initially with solid foods and subsequently with liquids. A barium esophagogram demonstrated a distal esophageal stricture involving the esophagogastric junction (Fig. 1A). The stricture was proven by endoscopic biopsy to be esophageal squamous cell carcinoma. The patient underwent chemotherapy, but his dysphagia worsened. The patient was admitted to our institution, and balloon dilation with subsequent chemotherapy and radiation therapy was planned because of concern for the risk of stent migration and gastroesophageal reflux after stenting of a short-segmental stricture involving the gastroesophageal junction. Written informed consent was obtained from this patient before stent placement. After topical anesthesia was applied to the pharynx before the procedure using an aerosol spray, a 0.035-inch angled guidewire (Radiofocus Guide Wire M; Terumo, Tokyo, Japan) was inserted under fluoroscopic guidance through the mouth, across the esophagogastric junction stricture, and into the stomach. A balloon catheter (20 9 80 mm; Cordis-Johnson & Johnson, Miami Lakes, FL) was passed over the guidewire to the esophagogastric junction stenosis, and the balloon catheter was slowly inflated under fluoroscopic guidance with a diluted water-soluble contrast medium until the ‘‘hour-glass deformity’’ created by the stricture disappeared from the balloon contour. After balloon dilation, a water-soluble contrast medium study showed contrast leakage into the mediastinum from the esophagogastric junction (Fig. 1B). Retrievable covered stent insertion and placement (18 9 60 mm, polytetrafluoroethylene covered; Taewoong, Seongnam, Korea) were performed immediately to occlude the leakage (Fig. 1C). After stent placement, the patient had mild chest pain but no leukocytosis or fever. Barium esophagographs obtained both 1 and 3 days after stent placement showed a patent stent lumen with no leakage. The patient was initially allowed a soft diet and subsequently a solid diet. The patient underwent chemotherapy and radiation therapy (total dose 6,000 cGy) after stent placement. The stent was successfully removed 3 weeks after being placed without complications, and a water-soluble contrast medium study performed after stent removal showed improvement of the stricture with no leakage (Fig. 1E). The patient’s remaining scheduled chemotherapy and radiation therapy were performed after stent removal. Follow-up esophagograms obtained 1 week and 2 months after stent removal demonstrated good flow of contrast H.-T. Hu J. H. Kim Department of Radiology, Henan Tumor Hospital, Zhengzhou 450008, Henan Province, People’s Republic of China