Successful repair of iatrogenic esophageal perforation with novel through the scope closure endoclips

Esophageal perforations, a rare but life-threatening emergency, have traditionally required surgery for repair. However, endoscopic therapy has emerged as a promising alternative. This case describes the use of novel through-the-scope appositional clips for closing large full-thickness defects and placing esophageal stents for stricture prophylaxis. A 54-year-old woman with a history of dysphagia was found to have a non-obstructing Schatzki ring at the gastroesophageal junction when evaluated at an outpatient endoscopy center. An 18 mm Savary dilator was used without complication, but blood was noted after removal. A 1.5 cm full-thickness perforation in the lower esophagus was identified on repeat endoscopy, and she was subsequently transferred to a tertiary medical center in stable condition for further management. On arrival at the hospital, she received a computed tomography scan revealing a 2.5 × 3.2 cm esophageal perforation with gas dissecting through the mediastinum. Broad-spectrum IV antibiotics, antifungals, and high-dose IV proton pump inhibitors were administered. During esophagogastroduodenoscopy (EGD), a bleeding perforation 28–33 cm from the incisors was visualized and repaired using 10 hemostatic Mantis endoclips (Boston Scientific) ([Fig. 1], [Fig. 2]). Then gastrografin was injected without any evidence of a leak. Finally, a 23 mm × 10.5 cm fully covered WallFlex stent (Boston Scientific) was placed for stricture prophylaxis and sutured with through-the-scope suturing to prevent stent migration. Approximately 5 months post-perforation, the patient underwent repeat EGD for a thorough examination of the esophageal mucosa, demonstrating healthy scar tissue at the site of the initial defect. In addition, repeat esophagram studies post-operatively up until 8 weeks after perforation continued to demonstrate no evidence of a leak ([Video 1]). This case illustrates the efficacy of endoscopic therapy for managing full-thickness esophageal perforations using novel appositional through-the-scope clips and esophageal stents for stricture prevention.

Fig. 1 Full-thickness esophageal defect with visualization of the mediastinum.

Fig. 2 Utilizing Mantis anchor-prong technology to effectively grasp and appose large esophageal tissue segments for successful endoclip application and closure.

Endoscopic repair of full-thickness perforation using 10 Mantis endoclips with subsequent covered stent placement to prevent stricture formation. Repeat EGD and esophagram showing successful tissue approximation and no leak.Video 1

Endoscopy_UCTN_Code_CPL_1AH_2AL

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

Thank you so much to my mentors at the OSU GI department for giving me the opportunity to help develop this interesting case to contribute to the literature and education on this topic.

Publication History

Article published online:
19 May 2025