Ann Thorac Surg 2007;84:296-298
© 2007 The Society of Thoracic Surgeons
Case Reports
Endoscopic Closure of Cervical Esophageal Perforation Caused By Traumatic Insertion of a Mucosectomy Cap
Henning Gerke, MDa,*,
Gail C. Crowe, RNa,
Mark D. Iannettoni, MDb
a Division of Gastroenterology and Hepatology, Department of Medicine, Iowa City, Iowa
b Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Accepted for publication February 12, 2007.
* Address correspondence to Dr Gerke, Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, JCP 4548, Iowa City, IA 52242 (Email: henning-gerke{at}uiowa.edu).
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Abstract
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Cap-assisted endoscopic mucosal resection enables nonsurgical removal of superficial esophageal lesions. Perforation at the resection site is a rare but known complication of this technique. We report a case in which traumatic insertion of the mucosectomy cap led to perforation of the cervical esophagus. This complication has not been previously reported. The perforation was successfully closed by the endoscopic placement of clips.
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Introduction
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Endoscopic mucosal resection (EMR) in the esophagus has emerged as a therapeutic modality to remove superficial lesions including Barrett’s esophagus with high-grade dysplasia and early cancer. A variant of EMR uses a transparent cap attached to the endoscope tip with a snare positioned in the distal rim of the cap. Esophageal perforation at the resection site is a rare complication of this technique, which occurs in 0.6 to 1.6% [1, 2]. We report a case of cervical esophageal perforation due to traumatic insertion of a mucosectomy cap. We believe that no such incidence has been previously reported. The perforation was successfully treated by endoscopic closure with clips.
A 67-year-old woman with gastroesophageal reflux disease was referred for endoscopic ultrasound of a polypoid lesion concerning for early adenocarcinoma arising in a 3-cm segment of Barrett’s esophagus. Endoscopic ultrasound did not reveal any evidence of deep invasion. Therefore a cap-assisted EMR was performed during the same session using a flexible, oblique mucosectomy cap (EMR Kit with Soft Cap [Olympus America Corp, Melville, NY]). This procedure was performed without complications. The histology diagnosis was Barrett’s esophagus with high-grade dysplasia. Surveillance endoscopy after 3 months showed residual Barrett’s mucosa. After submucosal injection of dilute epinephrine solution (20 mL, 1:100,000), cap-assisted EMR with the soft oblique mucosectomy cap was performed at two adjacent areas. This required reintubation with the cap-loaded endoscope, which was difficult due to active tightening of the upper esophageal sphincter by the patient. After the final insertion of the cap-loaded endoscope, mucosal trauma caused by the edge of the cap was suspected. Endoscopic reassessment after completion of the EMR revealed a 1.5-cm long perforation in the cervical esophagus (Fig 1). Closure of the perforation with endoscopic clips was immediately performed (Fig 2). Three Resolution clips (Boston Scientific Corp, Natick, MA) and one Quickclip (Olympus America Corp) were used. The patient was hospitalized and broad spectrum antibiotics were administered. She remained afebrile. An esophagram a week later showed the endoscopic clips in the esophagus. No leakage of barium was seen (Fig 3). The patient tolerated an oral diet and was discharged.
At 6 month follow-up the patient was free of symptoms. Endoscopy showed a well-healed perforation site. A single endoscopic clip was still in place (Fig 4). No residual Barrett’s mucosa was present in the distal esophagus.
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Fig 4. Endoscopic view at 6-month follow-up. The perforation site is healed. A single clip is still present.
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Comment
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Esophageal perforation is a very infrequent complication of endoscopic mucosal resection [1–3]. The risk is further reduced by submucosal saline or dilute epinephrine injection [1]. In the reported case, the perforation did not occur at the mucosectomy site but in the cervical esophagus due to traumatic insertion of a soft EMR cap. Usually the flexible cap adjusts to the shape of the hypopharynx and enables atraumatic passage into the esophagus. However, in our case, sideways compression of the cap resulted in a fairly sharp edge that cut into the esophageal wall. The formation of pointy edges by lateral compression of the mucosectomy cap is illustrated in figure 5. Our experience emphasizes that great caution is warranted during insertion of this type of EMR cap. We treated the perforation by closure with endoscopic clips. Successful endoscopic clip repair has been previously reported for esophageal perforations from foreign body ingestion [4, 5], Boerhaave syndrome [6], endoscopic dilation [7, 8], and EMR [2]. We suggest that it should be the procedure of choice in small iatrogenic perforations that are immediately detected. We believe that perforations up to 2 cm in length can be treated with endoscopic clips. However, approximation of the wound edges with clips is not always possible and may be limited by inability to achieve en-face position with the endoscope. If endoscopic treatment fails, surgical closure may become necessary.
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Fig 5. A soft mucosectomy cap is attached to the endoscope tip. Sideways compression of the cap results in pointy edges.
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References
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Abstract
Introduction
