Conservative Treatment of Transmural Perforation with Mediastinal Leakage after Balloon Dilation: A Case Report

Abstract

The incidence of esophageal perforations during balloon dilation is 0 14% (1 3). An esophageal perforation is classified into three types: a type I-intramural perforation; a type II-transmural perforation; and a type IIItransmural perforation with mediastinal leakage (4). Fasting, parenteral alimentation, and antibiotics are generally used to treat types-I and II esophageal perforations. However, a type III esophageal perforation showing progressive clinical deterioration needs to be treated surgically (4, 5). There are no reports of a successful conservative treatment for a type III esophageal rupture after esophageal balloon dilation.We report a case of a successful conservative, non-surgical treatment for a transmural perforation with mediastinal leakage after a balloon dilation. Case ReportA 43-year-old man was admitted to our institution complaining of intermittent swallowing difficulties with an 11 year duration. The patient had received a subtotal gastrectomy with an esophagogastrostomy 11 years earlier due to a bleeding ulcer in the gastric fundus, and had subsequently experienced severe swallowing difficulties for seven days. One year after surgery, the patient received an esophageal stent at the anastomotic site because the site showed a severe focal stenosis. However, the stent was removed two weeks after placement under endoscopic guidance on account of its upward migration. Subsequently, the patient's swallowing difficulty improved markedly from 2 (intolerance to soft food) to 0 (regular feeding). The patient had received esophagography at a local clinic due to swallowing difficulties. The esophagography showed severe focal stenosis at the anastomotic site (Fig. 1). A 43-year-old man was admitted complaining of swallowing difficulties. The esophagography revealed severe stenosis at the esophagogastric anastomotic site. Esophagography after balloon dilatation showed a transmural perforation with mediastinal leakage. The patient was treated conservatively for one week at which time the esophagography showed no further leakage at the anastomotic site and the good passage of barium. A 2-year follow-up chest computed tomography (CT) showed good patency of the esophageal lumen and the marked resorption of barium in the mediastinum.