A 57-year-old woman was admitted to the intensive care unit with a 15-day history
of sore throat, neck pain, upper backache, and fever following the ingestion of a
tablet. Initial conservative management did not resolve the symptoms and a contrast-enhanced
computed tomography (CECT) scan of the chest was performed. The scan revealed posterior
mediastinitis ([Fig. 1]), secondary to upper esophageal perforation with bilateral pleural effusion. An
endoscopic assessment revealed a large perforation just below the cricopharynx in
the posterior wall ([Fig. 2]), with discharge of copious amount of pus. Surgical opinion was sought. The patient
provided informed consent following explanation of the option of surgical drainage
by thoracoscopy if endoscopic debridement was not complete.
Fig. 1 Contrast-enhanced computed tomography image showing extensive mediastinitis.
Fig. 2 Endoscopic image of the perforation site just below the cricopharynx.
The following day under sedation with anesthetic monitoring, the patient underwent
placement of a percutaneous endoscopic gastrostomy (PEG) tube, followed by endoscopic
mediastinal debridement ([Fig. 3], [Video 1]) using a standard 9.5-mm upper gastrointestinal endoscope, with suction, saline
lavage, and biopsy forceps for the removal of necrotic material. The entire procedure
took about 40 minutes. A nasomediastinal drainage tube (Ryles tube, 16 Fr) was then
placed using a guidewire ([Fig. 4]). The patient was kept nil per os, and PEG feeds were started after 48 hours. Broad
spectrum antibiotics were continued.
Fig. 3 Endoscopic image of the extent of mediastinitis.
Endoscopic mediastinal debridement for mediastinitis resulting from upper esophageal
perforation.
Fig. 4 Endoscopic placement of Ryles tube into the mediastinum for drainage.
The patient underwent further repeat endoscopic procedures at 3 days, and 1, 2, 3,
and 5 weeks. At 5 weeks, endoscopy showed complete closure of the perforation site,
and CECT chest ([Fig. 5]) showed near complete resolution of mediastinitis and pleural effusion. To date,
the patient has been followed for more than 6 months, and has been symptom free.
Fig. 5 Contrast-enhanced computed tomography showing resolution of the mediastinitis.
Mediastinitis secondary to esophageal perforation is a dreaded disease with high morbidity
and mortality. The majority of patients need surgical intervention in the form of
thoracotomy/thoracoscopy and esophageal repair if the condition is presented early,
or esophageal diversion if presentation is late. Often the recovery is prolonged and
involves multiple procedures. Endoscopic mediastinal debridement through the perforation
site is a novel method of minimally invasive procedure for such cases, with minimal
morbidity and good post-procedure recovery. Review of the literature shows only one
case series, involving a single center and 20 cases, with the procedure being performed
safely and effectively [1]. The current report describes a further case managed at a tertiary care hospital.
Endoscopy_UCTN_Code_TTT_1AO_2AI
