Iatrogenic esophageal perforation caused by insertion of a gastric tube during a fundoplication
operation is a severe and rare intraoperative complication. A 64-year-old woman underwent
laparoscopic Nissen fundoplication. Intraoperatively, a large-bore gastric tube was
inserted as a placeholder for the esophageal lumen. At 5 days after the procedure,
increasing inflammation parameters and thoracic pain led to endoscopic examination.
At 5 cm from the oral side of the gastroesophageal junction, we found a transmural
defect of 1.5 cm in diameter ([Fig. 1 a]). The perforation opened into an extraluminal cavity filled with salvia and food
([Fig. 1 b]), which was removed endoscopically. For intracavitary endoscopic negative pressure
therapy (ENPT) [1]
[2]
[3], open-pore polyurethane foam drainage (OPD; Endo-SPONGE; B. Braun Melsungen AG,
Melsungen, Germany), 1.5 cm in diameter and 4 cm in length was fixed with a suture
to the tip of a gastric tube (Ventrol, 12 Ch × 120 cm; Covidien Argyle, Dublin, Ireland).
The foam was inserted using endoscopic forceps and pushed into the cavity through
the defect. The tube was led out nasally, and negative pressure was applied using
an electronic pump (KCI Activac; – 125 mmHg, continuous, highest intensity). Suction
resulted in drainage and collapse of the cavity and closure of the defect ([Fig. 2], [Video 1]).
Fig. 1 Endoscopic view of the esophageal perforation (P). a The perforation in the distal esophagus. b The perforation and the extraluminal cavity (C) filled with salvia and food.
Fig. 2 Application of negative pressure resulted in the perforation (P) being sucked onto
the open-pore polyurethane foam drainage sponge (OPD) and closure of the defect.
Video 1 Endoscopic negative pressure therapy for iatrogenic esophageal perforation, resulting
in complete healing of the perforation defect.
ENPT was continued for 12 days in total. Drainage was renewed four times, in an interval
of 1 – 3 days. At the first exchange after 3 days, we found that the foam was blocked
with mucous secretions ([Fig. 3]). We subsequently reduced the exchange interval. After 10 days of intracavitary
ENPT, the shrunken cavity was filled with granulation tissue ([Fig. 4]).
Fig. 3 Day 3 of endoscopic negative pressure therapy before exchange of open-pore polyurethane
foam drainage (OPD). The device was without suction function. The pores of the OPD
were blocked with secretions and the drainage device needed to be changed. The OPD
tube (t) was led out nasally and connected externally to the electronic vacuum device.
Fig. 4 Endoscopic image 8 days after the end of endoscopic negative pressure therapy. Treatment
resulted in closure of the perforation defect, which is filled with granulation tissue
(G). dS, distal esophageal sphincter.
The final period of ENPT was done within the esophageal lumen (intraluminal ENPT)
using a double-lumen open-pore film drainage (OFD) [4]
[5]. OFD was built with a Trilumina tube (Freka Trelumina, CH/Fr 16/9, 150 cm; Fresenius
Kabi AG, Bad Homburg, Germany) and a thin, double-layered, open-pore film (Suprasorb
CNP, Drainage Film; Lohmann & Rauscher International, Rengsdorf Germany) [5].
After the end of ENPT, enteral nutrition was started with a soft diet. At follow-up
endoscopy 64 days after the end of ENPT, we observed complete healing and a small
scar.
Endoscopy_UCTN_Code_TTT_1AQ_2AI
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