Endoscopic Vacuum Therapy for the Management of Proximal Oesophageal Perforation: A Case Report

Figure 3: Endoscopy at second sponge change, note formation of granulation tissue.

Figure 4: Endoscopy at 3rd sponge change, defect has been replaced with granulation tissue.

Discussion

Oesophageal perforations are rare but potentially fatal medical emergencies that necessitate accurate diagnosis and management within 24 hours to minimise mortality and morbidity [2,3] . Perforations may be iatrogenic, spontaneous, or secondary to foreign body material. The latter is uncommon but is associated with a higher risk of complications [1]. Presenting symptoms are diverse, complicating the diagnostic process, and are dependent on the perforation’s location within the oesophagus [1]. The most common clinical manifestations include chest or abdominal pain and dysphagia [4]. Patients presenting with signs and symptoms suggestive of oesophageal perforation should undergo urgent diagnostic imaging. Lateral neck X-rays are the most readily accessible modality; however, they possess lower diagnostic specificity [4]. Contrast oesophagography remains the definitive standard for diagnosis; however, a CT scan of the neck and chest can yield valuable diagnostic information, including the location of the perforation and the presence of pneumomediastinum and mediastinitis [2]. Management is contingent on the site of perforation, the duration taken for diagnosis, the level of contamination and the hemodynamic status of the patient. While conventional treatment primarily involved operative procedures, such as primary repair or oesophagectomy, non-operative approaches, including endoscopic interventions, have become increasingly employed in carefully selected patients [1,4]. Non-operative management generally involves nil by mouth, antibiotics, and endoscopic techniques such as stenting, which, although effective, are associated with a significant risk of complications [1]. Endoscopic Vacuum Therapy has been an innovative tool for managing postoperative anastomotic leaks in both oesophagogastric and colorectal settings [5]. It is now becoming an increasingly popular approach to managing foregut perforations, including oesophageal perforations [6]. It can be used in conjunction with non-operative management, as exemplified in this case, bridging the gap between operative and non-operative management. Several recent studies on the use of EVT for both oesophageal perforations and leaks demonstrate an approximately 88-100% success rate in resolving these issues, with low 30-day mortality rates and very few complications, regardless of patients’ age or co-morbidities [7-10]^. Furthermore, whilst EVT may require multiple operative interventions and, on average, a longer hospital stay, its lower morbidity outweighs these drawbacks, especially as it can be employed safely across a diverse patient population, including those unable to undergo primary surgical repair, and may serve as an adjunct to surgical intervention to expand treatment options [6,11,12]. Although the current data are encouraging, most studies focus on post-operative oesophageal leaks or iatrogenic perforations, and more research is needed on the use of EVT as a primary, non-operative management option for spontaneous and foreign body perforations, which may pose greater diagnostic challenges and lead to delayed diagnosis. The authors believe that Endoscopic vacuum therapy is a valuable, safe and low-morbidity management option for oesophageal perforation in selected patients. In this instance, EVT facilitated effective drainage of mediastinal sepsis and promoted healing of the oesophageal defect.

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