Complete Endoscopic Closure (Clipping) of a Large Esophageal Perforation After Pneumatic Dilation in a Patient with Achalasia

Abstract

The risk of esophageal perforation following endoscopic balloon dilation for achalasia is in the range of 1%-5%, with a mortality rate of 1%-20%. Perforations need to be recognized early, and, if reasonable, an immediate endoscopic repair should be pursued quickly. Herein, we report a case of successful endoscopic closure by clipping of a large iatrogenic perforation in a patient with achalasia. An 80-year-old woman with achalasia was admitted to our institution to undergo pneumatic dilation. A 40-mm balloon dilator with inflation pressure of 20 psi was used for 2 minutes as usual. During the procedure, the patient had a transient bradycardia. Endoscopic control showed a 2-cm rupture of the distal esophagus. Prompt endoscopic repair of the perforation by endoclips (n = 6) was then attempted, followed by conservative management by total parenteral nutrition and intravenous antibiotics. Endoscopic clipping completely closed the esophageal perforation. The patient was given oral nutrition 10 days later without any complications. Six months after discharge from the hospital, the patient was healthy and free of dysphagia. Endoscopy showed complete healing of the esophageal mucosa without luminal stenosis. This report highlights that prompt endoscopic clipping is a useful means to close a large esophageal perforation caused by pneumatic dilation.

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

“…In the first one, Huang et al reported four patients with large esophageal perforations secondary to endoscopic retrograde cholangiopancreatography (ERCP) probes. In the second case report, esophageal perforation occurred during pneumatic dilation in a patient with achalasia . In the third case report, perforation occurred because of endoscopic management of food impaction in the upper esophagus .…”

Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting

“…Acute perforations are potentially life-threatening emergencies in which prompt closure is required to avoid contamination of visceral spaces [13]. The management of patients with esophageal perforation following esophageal dilation depends upon the severity of the perforation and the elapsed time between the perforation and the diagnosis [14].…”

Minimally invasive management of esophageal perforation

“…As this method is new, there is limited data on the successful use of clips for the closure of esophageal perforation. [22][23][24] Over-The-Scope Clips (OTSC)…”