World Congress of Gastroenterology

WCOG 2019


 
Esophageal perforation: a pitch for the stitch, no stent for the rent
JENNIFER HIGA 1 SHAYAN IRANI 2

1- FOX CHASE CANCER CENTER
2- VIRGINIA MASON MEDICAL CENTER
 
Abstract:

There is an evolving role for therapeutic endoscopy in the repair of esophageal perforation. Esophageal perforations are highly morbid with a mortality rate of up to 46.5% in cases due to iatrogenic injury, and up to 50% for cases of Boerhaave’s syndrome with delayed presentation. Clinical management of esophageal perforations typically includes: NPO status, antibiotics, and chest tube placement depending on degree of mediastinal contamination. Repair of esophageal perforation has historically been surgical, with operative primacy replaced by less invasive endoscopic interventions using clips (through the scope or over the scope design) and fully or partially covered metal stents. Given the paucity of available data on outcomes for endoscopic suturing of esophageal perforations we present the outcomes of five different cases to highlight learning points and pitfalls for each scenario. We have elected to apply endoscopic suturing techniques in patients with acute and chronic esophageal perforation, iatrogenic and spontaneous in etiology. Successful repair of these esophageal perforations allowed patients to avoid surgery and resume PO intake. Five cases of esophageal perforation were successfully treated with endoscopic suturing. The technical success rate was 100%. One case required supplemental stent placement however all cases were managed non-operatively and with a full recovery. No adverse events occurred. Endoscopic suturing is a feasible treatment alternative to traditional endoscopic interventions like stenting. Problems associated with covered esophageal stents include: stent migration, reflux, pain, leaks refractory to stenting, and tissue overgrowth requiring multiple procedures for removal. Furthermore, some cases of esophageal perforation prove refractory to traditional methods of closure using stents and clips. Insufficient treatment of esophageal perforations lead to increased patient morbidity and mortality, prolonged hospital length of stay and cost. Endoscopic suturing as primary therapy for esophageal perforation is a promising treatment modality and warrants further investigation in larger series. [VIDEO FILE SUBMITTED VIA EMAIL]

Keywords:

 esophageal perforation, endoscopic suturing, chronic fistula