Endoscopic Clip Application for Postoperative Residual Esophageal Duplication Cyst

Case Report

A 35-year-old woman presented with coughing, left-sided chest pain, and high-grade intermittent fever that had persisted for 3 weeks. She had received a course of antibiotics for a week, without any response. At admission, the clinical examination was unremarkable except for toxemia. The chest examination did not reveal any abnormality. A chest radiograph showed mediastinal widening and chest computed tomography revealed a cyst 8 × 10 × 4 cm in size communicating with the mid-esophagus, with an air-fluid level. An infected esophageal duplication cyst was diagnosed and the patient underwent surgery. Due to extensive adhesions, however, only partial excision of the cyst was achieved, and only a partially successful attempt could be made to suture the defect in the esophageal wall. Ten days after surgery, the patient developed chest pain, with a spiking fever. A contrast study revealed an esophageal leak into the posterior mediastinum (Figures [1 ] a). An upper endoscopic examination revealed a tear 7 - 8 mm long in the mid-esophagus (Figures [2 ] a).

After the patient had provided informed consent, metallic clips (Olympus, Tokyo, Japan) were applied to close the leak (Figures [2 ] b). The first clip was only able to catch one wall of the leakage site, but the use of two more clips led to successful approximation of the edges of the leak. The patient was kept nil per os for 72 h and given broad-spectrum antibiotics. A repeat contrast study on day 15 (Figures [1 ] b) and endoscopic examinations on days 7 and 21 revealed complete healing of the leak. The histology of the excised cyst showed features of a congenital duplication cyst.

Figure 1 a Contrast radiograph, showing leakage into the posterior mediastinum. b The repeat contrast study on day 15, showing complete healing of the leak.

Figure 2 a Upper gastrointestinal endoscopy, showing a tear in the mid-esophagus. b Metallic clips have been applied to close the leak.

References

• 1 Overhaus M, Decker P, Zhou H. et al . The congenital duplication cyst: a rare differential diagnosis of retrosternal pain and dysphagia in a young patient.  Scand J Gastroenterol. 2003;  38 337-340
• 2 Holemans J A, Rankin S C. Case report: oesophageal duplication cyst causing left lung collapse and hypoperfusion.  Br J Radiol. 1995;  68 82-84
• 3 Minor G R. Mediastinal cyst treated by marsupialization to the esophagus.  Ann Surg. 1954;  139 203-235
• 4 Binmoeller K F, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma.  Gastrointest Endosc. 1993;  39 172-174
• 5 Rodella L, Laterza E, de Manzoni G. et al . Endoscopic clipping of anastomotic leakages in esophagogastric surgery.  Endoscopy. 1998;  30 453-456
• 6 Blocksom J M, Sugawa C, Tokioka S, Williams M. The Hemoclip: a novel approach to endoscopic therapy for esophageal perforation.  Dig Dis Sci. 2004;  49 1136-1138
• 7 Wewalka F W, Clodi P H, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia.  Endoscopy. 1995;  27 608-611
• 8 Shimizu Y, Kato M, Yamamoto J. et al . Endoscopic clip application for closure of esophageal perforations caused by EMR.  Gastrointest Endosc. 2004;  60 636-639