Trauma endoscopy: endoscopic closure of an esophageal perforation caused by knife stabbing
30 April 2019 (eFirst)
A young woman was admitted to the emergency room after being assaulted with a knife, resulting in a deep cervical wound. On examination, she had subcutaneous emphysema in the neck and air leakage from her trachea. Because of a compromised airway, she underwent endotracheal intubation. Computed tomography angiography (CTA) revealed a tracheal perforation, but no clear esophageal defect ([Fig. 1]).
At surgical exploration, the trachea appeared to be perforated on both the anterior and posterior walls. The trachea was surgically repaired and a right-sided tension pneumothorax was treated with a chest tube. Because of the injury to the posterior wall of the trachea, there was a suspicion of esophageal perforation, which was not visible during surgical exploration. To explore the esophagus further, an additional surgical exposure would have been needed and therefore a diagnostic gastroscopy was performed during surgery.
Gastroscopy showed both longitudinal entry and exit wounds in the proximal esophagus ([Fig. 2 a]). It was decided that endoscopic closure should be feasible and subsequently, both perforations were closed using a total of six standard through-the-scope clips (Resolution 360 Clip Take Control; Boston Scientific, Marlborough, Massachusetts, USA) ([Fig. 2 b]; [Video 1]). Next day, a barium swallow was performed, which showed no leakage of contrast ([Fig. 3]). After further recovery, the patient was discharged in good clinical condition. At follow-up after 3 months, the patient had made a good recovery and a repeat barium swallow showed no leakage of contrast, with two clips still in place.
Video 1 Endoscopic closure of a traumatic endoscopic perforation caused by knife stabbing. First the exit wound is closed with two through-the-scope clips, then the contralateral entry wound is closed by four clips.
To our knowledge, this is the first case describing endoscopic closure of a stab wound. Endoscopic closures are frequently performed for iatrogenic perforations or perforations caused by foreign objects. Over-the-scope clips, through-the-scope clips, and covered self-expandable metal stents are frequently used. These developments have resulted in a change in the treatment paradigm from major surgery to endoscopic closure and conservative treatment  .
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- 2 Sudarshan M, Elharram M, Spicer J. et al. Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?. Surgery 2016; 160: 1104-1110