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Endoscopy 2015; 47(S 01): E293-E294
DOI: 10.1055/s-0034-1392029
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Successful treatment of a proximal esophageal rupture with a luminal sponge

Michael Scharl
Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
,
Nadine Stanek
Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
,
Arne Kröger
Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
,
Peter Bauerfeind
Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
,
Christoph Gubler
Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
› Author Affiliations
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Publication History

Publication Date:
22 June 2015 (online)

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A 55-year-old man presented to the emergency department because of dysphagia. On admission, the patient reported retrosternal chest pain, and he was observed to be tachycardic and hypotensive. Physical examination showed soft-tissue emphysema over the sternal notch extending up to the neck bilaterally. Computed tomography identified a pneumomediastinum ([Fig. 1]).

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Fig. 1 Computed tomographic scan demonstrates pneumomediastinum in a 55-year-old patient presenting with dysphagia. A rupture of the proximal esophagus was eventually diagnosed.

Initial gastroscopy demonstrated a large esophageal wall defect just underneath the upper esophageal sphincter (UES) extending from 15 cm down to an intramural hematoma at a distance of 19 cm from the incisors ([Fig. 2]). A second gastroscopy after the patient’s admission to the intensive care unit 2 hours later revealed mucosal dehiscence at a distance of 18 cm from the incisors; however, because definite signs of a true transmural perforation were lacking, conservative therapy was initiated.

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Fig. 2 Initial gastroscopy shows rupture of the upper esophageal sphincter at 15 cm.

Follow-up computed tomography revealed the focal pooling of contrast agent at the left side of the proximal esophagus with small, perifocal gas inclusions; therefore, endoscopy was performed again. Besides a large mucosal defect, a 3-mm transmural defect was diagnosed, and a luminal sponge (Endo-SPONGE; B. Braun Medical, Melsungen, Germany) was placed below the UES ([Fig. 3]), as follows:

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Fig. 3 Placement of the luminal sponge. a Perforation of the esophageal wall. b Perforation of the esophageal wall from a different angle.

A 1–0 nonabsorbable suture was fixed at the proximal end of the suction tube within the sponge. When this loop was grasped by a forceps through the working channel, it was possible to position the sponge and the endoscope side by side into the desired location. The use of an overtube was not necessary. The sponge was then kept in place by applying a gentle traction on the tube, which was fixed at the nostril. After 4 days, the sponge was removed by again applying traction on the tube and pulling at the suture loop with the endoscopic forceps. The site of the perforation was covered with fibrin. No mucosal defect was visible ([Fig. 4]). Gastroscopy after another 7 days showed a sealed lesion without signs of perforation ([Fig. 5]). At 2 months after the event, no clinical signs or symptoms of a perforation were detectable.

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Fig. 4 Removal of the luminal sponge. a Luminal sponge in situ. b Rupture site after removal of the luminal sponge.
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Fig. 5 Esophageal mucosa 14 days after perforation. a There are no signs of persisting perforation. b The mucosal defect is closed.

Spontaneous esophageal perforation, so-called Boerhaave syndrome, occurs after vomiting. The most frequent symptoms are pain, dyspnea, emphysema, pneumomediastinum, and nausea/vomiting [1]. The mortality rate reaches 40 % once symptoms of sepsis occur [1] [2]. Endoscopic sponge therapy is a successful approach to the treatment of esophageal defects [3] [4] when the sponge is pushed into the wound cavity. Reported cases of patients with Boerhaave syndrome or iatrogenic esophageal perforation demonstrate that EndoVac (SybronEndo, Orange, California, USA) may even be the best choice for conservative treatment and does not result in relevant long-term side effects [3] [4]. A recent study demonstrated that in cases of anastomotic esophageal leak refractory to stenting alone, the stent-over-sponge (SOS) approach may be a valuable technique [5]. In this particular case, neither overstenting nor placement of the sponge into a cavity was possible because of the anatomical location near the UES. Nonetheless, it was possible to seal the transmural defect permanently with entirely luminal placement of the sponge.

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