C0264 - Endoscopic Management Using OverStitch for Esophageal Perforation

Introduction: Morbidity and mortality rates of esophageal perforation are high. Treatment includes endoscopic, surgical, and conservative approaches. The OverStitch^TM Endoscopic Suturing System (OESS) is a novel technique which has proved efficacious in treating an esophageal perforation.

Case Description/Methods: A 91-year-old woman with past history of hypertension was transferred to our hospital with a retropharyngeal and mediastinum fluid collection concerning for esophageal perforation. The patient presented with shortness of breath and cough and was found to have right-sided pleural effusion. After chest tube placement, patient complained of dysphagia and reported aspiration. Computed tomography of the chest revealed a retropharyngeal abscess which was suspicious for esophageal perforation. Surgery performed an immediate left neck incision and drainage and placed a gastrostomy tube. A follow-up esophagram showed persistent leakage and gastroenterology was consult. Esophagogastroduodenoscopy revealed a 1cm perforation at the cricopharyngeal plane just above the upper esophageal sphincter. An OESS was performed, and she was kept n.p.o. with gastrostomy tube feeding. At a 17 day follow up, a repeat esophagram showed no evidence of contrast extravasation and the patient was doing well.

Discussion: Esophageal perforation is a life-treathening condition and is a surgical emergency. Mortality rate can approach 60% with delays in treatment and can be reduced to 10-25% with immediate treatment. Death is cause by severe mediastinitis, empyema, or sepsis. The standard treatment is still controversial. Surgery remains mainstay of the treatment. In hemodynamically unstable patients, emergency airway should be established followed by primary closure and wide drainage. Non-operative management include volume resuscitation, respiratory supportive, and n.p.o. status. Endoscopic treatment include clips, stent, and suturing. The success of the repair depend on the extent of the nonviable tissue. In our patient, she has persistent leakage after drainage and underwent OverStitch^TM closure. This case demonstrates the utility and efficacy of endoscopic suturing using OverStitch^TM device to treat complicated esophageal perforation.