MedStar Georgetown University Hospital Washington, DC
Wei Yan, MD1, Preeti Gupta, MD, MPH2, Evan Brady, MD1, Shervin Shafa, MD1; 1MedStar Georgetown University Hospital, Washington, DC; 2Medstar Georgetown University Hospital, Washington, DC
Introduction: Iatrogenic esophageal perforation is a rare but serious complication. Clinicians often fail to consider the diagnosis, resulting in delays in treatment. We report the first case of an esophageal perforation related to bronchoscopy requiring endoscopic evaluation and closure with endoclips.
Methods: An 81-year-old woman developed chest pain, neck swelling and odynophagia following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a subcarinal lymph node to rule out malignancy. Post-procedure chest x-ray and CT showed extensive pneumomediastium (PMS). No esophageal abnormalities were noted. She was managed conservatively and most of her symptoms improved except for dysphagia. A repeat CT scan was obtained on hospital day 7 and it revealed resolving PMS, but a large new extraluminal collection of fluid, air and contrast adjacent to the proximal and mid-thoracic esophagus (Fig.1-2) suggestive of a contained esophageal perforation. She underwent an esophagogastroduodenoscopy (EGD), which identified a pinpoint defect in the posterior esophageal mucosa 1cm distal to the upper esophageal sphincter (UES). Given the proximity of the lesion to the UES and its size, two endoclips were used rather than a stent (Fig.3). Successful closure was confirmed by intraoperative fluoroscopy as well as a subsequent XR esophagram. A CT scan 4 weeks after our intervention showed complete resolution of the posterior fluid collection and pneumomediastinum. Discussion: EBUS-TBNA is a safe and effective means of evaluating intra-thoracic neoplasms and lymphadenopathy. Esophageal perforation is a rare complication and requires a high index of suspicion. The presenting symptoms (e.g. neck pain, chest pain, subcutaneous emphysema, dysphagia) are non-specific and often attributed to more common complications. While surgery remains the mainstay of treatment, the use of endoscopic closure techniques is an effective alternative for stable patients with minimal injuries or patients who are poor surgical candidates. Patient selection is important and must be individualized in order to achieve best outcomes. This case highlights several criteria for non-surgical management including clinical/hemodynamic stability (especially with delayed diagnosis), location of perforation (e.g. cervical or thoracic esophagus), leakage contained within the neck or mediastinum, no neoplastic tissue involvement and small size. Endoclips are safe and effective for defects < 2cm.
Figure 1. Contrasted CT scan of chest showing a collapsed esophagus with a posterior, elongated extraluminal collection of fluid (blue arrows), contrast (red arrow) and gas (green arrow). A = anterior, P = posterior, H = head; F = foot; L =left
Figure 2. Contrasted CT scan of chest showing a posterior extraluminal collection of fluid, air and contrast (red arrow). The esophagus and trachea are marked by yellow and white arrows, respectively.
Figure 3. Endoscopic visualization of the esophageal defect (white arrow), followed by closure of the defect with 2 endoclips.
Disclosures: Wei Yan indicated no relevant financial relationships. Preeti Gupta indicated no relevant financial relationships. Evan Brady indicated no relevant financial relationships. Shervin Shafa indicated no relevant financial relationships.