Esophageal perforation has a high morbidity and mortality [1]. Endoscopic treatments include the use of self-expanding metal stents (SEMSs) and
endoscopic vacuum therapy (EVT). Recently, an innovative hybrid stent combining both
approaches, the VAC Stent (MicroTech), has been approved [2].
A 45-year-old man was admitted with Boerhaave syndrome. Thoracic CT showed acute mediastinitis
with bilateral pleural effusion. Upper endoscopy confirmed a 6-mm transmural defect
in the distal esophagus that was treated using a 12 × 23-mm fully covered self-expanding
metal stent (FCSEMS). Although the stent stayed in place the patient remained septic
after 2 weeks. Oral contrast-enhanced computed tomography (CT) and methylene blue
drainage into the right chest tube suggested persistent esophagopleural fistula. A
stent-in-stent approach using a 155 × 23-mm FCSEMS to improve coaptation also failed
to resolve the fistula after 6 weeks.
Placement of a VAC Stent was proposed ([Video 1]). During the procedure both FCSEMS were removed displaying purulent granulation
tissue over the previous esophageal laceration ([Fig. 1]
a). A marking clip was placed 3 cm below at the gastric body and a metallic guidewire
passed into the antrum. After saline irrigation, the introducer system was inserted
transorally over-the-wire. The stent was successfully deployed under fluoroscopy ([Fig. 1]
b–d). The suction catheter was switched to the nose and connected to a vacuum pump at
–120 mmHg during the first 24 h and then adjusted to –80 mmHg. Irrigation with 40
mL saline 3 times per day and starting on liquid diet after 72 h were advised. Stent
removal was scheduled after 7 days with the pump being switched off the day before.
The stent was detached by gently insinuating the endoscope between the stent and esophageal
wall while irrigating profusely with saline. It was then removed by grasping the wire
at the proximal end ([Fig. 2]). Esophageal inspection revealed extensive granulation without extravasation of
contrast ([Fig. 3]). Control CT confirmed successful closure of the fistula ([Fig. 4]) and the now asymptomatic patient was discharged.
Fig. 1
a Purulent granulation tissue over the previous esophageal
laceration in a patient with Boerhaave syndrome. b, c Deployment of
the innovative hybrid VAC Stent under fluoroscopic view. d
Endoscopic view of the deployed stent.
Fig. 2
a, b The novel hybrid stent in situ. c
The stent is detached by gently insinuating the endoscope between the stent and the
esophageal wall while irrigating profusely with saline. d Removal
of the stent by grasping the wire at the proximal end.
Fig. 3
a The vacuum therapy stent after removal. b,
c Endoscopic inspection after stent removal revealed extensive and friable
granulation tissue. d Fluoroscopic control revealed no
extravasation of contrast.
Fig. 4 Computed tomography (CT) images. a Before therapy, the persistent esophagopleural fistula (arrow) can be seen. b Successful closure of the fistula is confirmed after therapy with the novel vacuum
stent.
Successful treatment, using an innovative hybrid vacuum stent, of a refractory esophagopleural
fistula in a patient with Boerhaave syndrome.Video 1
The VAC Stent combines the functions of a SEMS with EVT, avoiding migration while
maintaining luminal patency [2]
[3]
[4]. This case demonstrates its effectiveness for treating esophageal perforation.
Endoscopy_UCTN_Code_TTT_1AO_2AZ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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