Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report

Abstract

BackgroundSpontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients.Case presentationA 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH2O and at − 20 cmH2O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day.ConclusionConservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.

Perforación esofágica espontánea

“…Las tasas de mortalidad reportadas varían mucho, entre 4% y 80% 9 . La PEE puede ser mortal si no recibe tratamiento en una etapa temprana, teniendo complicaciones como mediastinitis, empiema torácico y sepsis grave 10 . El manejo adecuado de la PEE sigue siendo controvertido, se toman en cuenta múltiples factores como sitio y severidad de la PEE, el tiempo que transcurra entre la perforación y el diagnóstico, la patología del esófago, etiología, la forma clínica de presentación, la experiencia del cirujano y la posibilidad de realizar procedimientos endoscópicos 2,7,11 .…”

“…Según Matsumoto y cols. 10 , el tratamiento conservador se limita a pacientes con un problema en el mediastino o entre el mediastino y la pleura visceral, con síntomas y signos mínimos de sepsis. Ellos consideran una prioridad controlar la sepsis y mejorar el estado general, evitando así, el trauma quirúrgico que podría ser fatal.…”

Percutaneous transesophageal gastro-tubing for the management of anastomotic leakage after upper GI surgery: a report of two clinical cases

“…However, placing two tubes simultaneously is a rather complex procedure. As we have found that a W-ED tube is used for a patient with spontaneous esophageal perforation [28], we thought it could apply to PTEG. While the inner diameter is smaller than double PTEG tubes, it is certainly easier to insert, as the size of the W-ED tube just fits the cervical fistula.…”

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

“…The advantage of this tube is that it can be used for simultaneous gastrointestinal tract decompression therapy and enteral feeding, thereby possibly accelerating healing of the anastomotic leakage. Accordingly, some reports have been available regarding the conservative treatment of anastomotic leakage and gastrointestinal tract perforation using the W-ED tube [8][9][10][11].…”

“…Although reports of gastric remnant necrosis after gastrectomy have been rare [3][4][5][6][7], mortality rates have been considerably high when present [6,7]. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression [8][9][10][11], had been developed for anastomotic leakage and postoperative nutritional management after upper gastroenterological surgery [8][9][10][11][12]. Herein, we report a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.…”