Utility of the over-the-scope-clip system for treating a large esophageal perforation

A 64-year-old woman presented with subcircumferential superficial esophageal carcinoma three-fourths the circumference of the esophagus in the upper thoracic esophagus (Fig. 1a). The depth of tumor invasion was evaluated as cT1a-MM by white light observation, narrow band imaging with magnifying endoscopy, and endoscopic ultrasound. No lymph node metastasis was evident on computed tomography (CT) images. Preoperative diagnosis was 0-IIc, cT1a-MM, 40 mm, cN0, cStage 0. According to the Japanese guidelines for the diagnosis and treatment of esophageal cancer, the Cancer Board for esophageal cancer of our hospital decided to perform ESD [3]. After obtaining informed consent, ESD was performed using an IT knife nano (KD-612, Olympus Medical Systems, Tokyo, Japan). Circumferential dissection (Fig. 1b) was necessary and to prevent the likely onset of stenosis, she received a local injection of triamcinolone acetonide (100 mg) into the submucosa underlying the ulcer immediately after ESD and was started on oral predonine therapy (30 mg/day) 1 week after ESD, which was tapered over a 2-month period. Histopathology findings indicated squamous cell carcinoma (0-IIc type, T1a-MM, ly1, v0, HM(−), and VM(−)). Additional treatment was considered because of the high risk for lymph node metastasis suggested by a positive finding of lymphatic involvement.

Two months after ESD, upper endoscopy revealed a residual ulcer, but no stenosis. However, stenosis was detected 1 month later (Fig. 1c). An endoscope (distal end external diameter, 9.8 mm) was inserted to traverse the stenosis but it penetrated the wall through to the mediastinum, leaving a perforation in the upper-right side of the stenotic area (Fig. 1d). Attempted closure with an endoclip (Olympus Medical Systems, Tokyo, Japan) was unsuccessful due to the large size of the perforation and fragility of the ulcer floor.

We therefore employed the OTSC system to close the perforation (Fig. 2a). The branches of the OTSC Twin Grasper were released to grasp the sides of the lesion. Because the perforation hole had gaping edges, I opened one branch and grasped one edge of the perforation first. Then I opened the other branch and maneuvered the grasper to the other edge and grasped it, and then retracted into the attachment to place the clip (Fig. 2b). Closure was deemed successful. The patient fasted and received antibiotics, and her only complaint was mild chest discomfort. She did not develop fever, and both her leukocyte count and C reactive protein level were within normal range. Contrast radiography performed 5 days after the OTSC procedure revealed no leakage (Fig. 3). Oral intake of food and fluid was resumed and 3 weeks after contrast radiography her condition was sufficiently improved. After discussing the option of surgical treatment which is standard for her with our thoracic surgeon, the patient declined surgery and opted instead for CRT. Because re-examination by CT revealed no metastasis, preventive CRT was considered still effective, despite treatment was delayed by 1 month. Then she was completed CRT. At endoscopy 2 months after completing chemotherapy, the endoscope with a conventional-sized distal tip (9.8 mm) could traverse the site despite the presence of minor stenosis (Fig. 4). The patient reported no difficulties with nutritional intake. Because mild chest discomfort continued due to the OTSC, the clip was cut by argon plasma coagulation and removed. Thereafter, her complaints disappeared.