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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 100-102

Cervical esophageal perforation during gastroscopy in adults: Case report – Report of two cases


Department of Gastroenterology and Hepatology, Apollo Hospitals International Limited, Ahmedabad, Gujarat, India

Date of Submission28-Oct-2018
Date of Acceptance03-Apr-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Apurva Shah
Department of Gastroenterology, Apollo Hospitals International Limited, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_84_18

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  Abstract 


Cervical esophageal perforation is rare and associated with a high morbidity and mortality >20% if misdiagnosed. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract. We describe two cases of cervical esophageal perforations during negotiating the cricopharynx. Both patients had malignant stricture in mid and lower esophagus, respectively, and developed iatrogenic perforation during palliative metallic stenting – one of the two by a pediatric gastroscope. Both the patients were diagnosed as having esophageal perforation in the first 6 h after procedure and successfully managed with medical management. Patients with small perforations and minimal extraesophageal involvement may be managed with nonoperative treatment.

Keywords: Esophageal perforation, iatrogenic, metallic stenting, triangle of Killian


How to cite this article:
Shah A, Bohra S. Cervical esophageal perforation during gastroscopy in adults: Case report – Report of two cases. Apollo Med 2019;16:100-2

How to cite this URL:
Shah A, Bohra S. Cervical esophageal perforation during gastroscopy in adults: Case report – Report of two cases. Apollo Med [serial online] 2019 [cited 2019 Aug 18];16:100-2. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/100/260692




  Introduction Top


Esophageal perforation is potentially life-threatening condition with high morbidity and mortality rate of >20% due to several factors such as a lack of a strong serosal layer, the unusual blood supply of the organ, and the proximity of vital structures.[1],[2] Iatrogenic action is the main cause of cervical esophageal perforation. The causes of iatrogenic esophageal perforation include endoscopic procedures, nasogastric tube insertion, difficult endotracheal intubation, percutaneous tracheostomy, and surgery of the mediastinal organs including resection of lung cancer, operations on the cervical spine, thyroidectomy, and palliative intubation, stenting, or laser treatment of esophageal tumors.[3] Foreign body ingestion, penetrating trauma, and corrosive injury are other causes of perforations.

Neck pain, dysphagia, odynophagia, subcutaneous emphysema, fever, dysphonia, hoarseness, and crepitus in the neck are relatively common findings following a perforation of cervical esophagus.[4] Investigation by imaging tests such as chest radiography, contrast swallow, computed tomography (CT), and endoscopy will confirm the diagnosis. The diagnosis and management of cervical esophageal perforation remains a challenging clinical problem. The outcome depends on the etiology, site, and size of perforation, the presence of concomitant esophageal disease, the interval between perforation and initiation of therapy, and the overall health of the patient. We describe two cases of cervical esophageal perforations here with highlighting factors with particular clinical importance for informed decision-making during the first 24 h of treatment in hospital.


  Case Reports Top


Case 1

An 83-year-old woman with a diagnosis of adenocarcinoma of lower esophagus admitted for palliative metallic stenting for dysphagia. Pediatric gastroscope was used for procedure under conscious sedation. A blind tract was noted just below pyriform fossa during insertion of the scope which was suspected to be a false passage created accidentally in the wall of the esophagus; scope was withdrawn immediately. Pediatric scope was again negotiated into esophagus from opposite pyriform fossa and metallic stenting done over guide wire for lower esophageal malignant stricture uneventfully. Six hours after procedure, the patient complained of mild throat pain; but, on examination, vital parameters were normal and there were neither crepitus nor subcutaneous emphysema noted. Chest X-ray and CT scan chest were advised to rule out upper esophageal perforation which revealed significant pneumomediastinum and minimal left pleural effusion with possibility of cervical esophageal leak and expanded metallic stent in midlower esophagus [Figure 1] and [Figure 2]. The patient was kept nil by mouth, started on intravenous antibiotics, analgesics, fluids, and proton-pump inhibitors. Due to contained leakage without systemic symptoms of infection, careful observation and conservative treatment were continued after discussion with the surgeon. Gastrografin swallow on the 6th day postprocedure showed no contrast leak. The patient was started on liquids followed by soft diet which was well tolerated, discharged on the 10th day. The patient remained asymptomatic, tolerating full diet at 1-month follow-up.
Figure 1: Computed tomography chest showing significant pneumomediastinum and expanded metallic stent in midlower esophagus

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Figure 2: X-ray chest showing pneumomediastinum and minimal left-sided pleural effusion with metallic stent in esophagus

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Case 2

A 50-year-old woman admitted for palliative metallic stenting of midesophageal squamous cell carcinoma (SCC). Gastroscopy was done under conscious sedation. There was some difficulty while negotiating the cricopharynx. During procedure, the patient developed respiratory distress and stridor with subcutaneous emphysema; so, stenting was not done; the patient was shifted to intensive care unit – kept nil by mouth, started on intravenous antibiotics and parenteral nutrition, and intubated for airway protection. Chest X-ray revealed bilateral pneumothorax, pneumomediastinum, and pneumoperitoneum. Emergency left-sided intercostal drainage (ICD) tube insertion was done for pneumothorax. Contrast-enhanced CT chest revealed mild pneumomediastinum, pneumothorax with ICD in situ, and midesophageal SCC, but no obvious site of perforation identified. Large amount of air was noted in the neck and upper chest suggestive of small cervical esophageal perforation. The patient was shifted to ward after extubation, clinical stabilization, and removal of ICD. The patient underwent laparoscopic feeding gastrostomy and discharged.


  Discussion Top


Cervical esophageal perforations are often iatrogenic, but perforation by pediatric gastroscope is poorly described in literature. Timely diagnosis and appropriate treatment of esophageal perforation remains challenging, but both are important for managing patients. CT scan is the most sensitive radiological study for the diagnosis of cervical esophageal perforation. Small cervical tears can usually be treated conservatively as the perforation or leak is contained within the triangle of Killian in the neck.[5] Most small cervical perforations have a good outcome with conservative treatment with intravenous antibiotics and nil by mouth. Improved attention to nonspecific symptoms, signs, and early diagnosis based on imaging may translate into better outcomes for patients, many of whom are elderly with significant comorbidity. Endoscopic therapy with clipping is possible, but visualization of the area may be difficult and endoscopic stent placement to cover the perforation may not always be feasible. Some authors suggest that conservative medical management with antibiotics and nasogastric tube insertion could be useful in tears <2 cm.[6] Primary repair and drainage should be standard treatment for large perforations involving the esophagus in which spontaneous healing cannot be expected.[7]

In our case series, both the patients had malignant stricture in lower and midesophagus, respectively; one patient undergone gastroscopy by pediatric gastroscope for palliative metallic stenting. Both developed cervical esophageal perforation while inserting the scope below cricopharynx. Both the patients were diagnosed within 6 h of procedure and managed by conservative therapy without surgery which was consistent with literature that most cervical perforations have a good outcome with conservative treatment with intravenous antibiotics and nil by mouth.[7]

Improved attention to nonspecific symptoms, signs, and early diagnosis based on imaging may translate into better outcomes for patients, many of whom are elderly with significant comorbidity in whom esophageal surgery would have considerable morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ryom P, Ravn JB, Penninga L, Schmidt S, Iversen MG, Skov-Olsen P, et al. Aetiology, treatment and mortality after oesophageal perforation in Denmark. Dan Med Bull 2011;58:A4267.  Back to cited text no. 1
    
2.
Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: A twenty-seven year Canadian experience. Ann Thorac Surg 2011;92:209-15.  Back to cited text no. 2
    
3.
Gupta NM, Kaman L. Personal management of 57 consecutive patients with esophageal perforation. Am J Surg 2004;187:58-63.  Back to cited text no. 3
    
4.
Johnson SB. Esophageal trauma. Semin Thorac Cardiovasc Surg 2008;20:46-51.  Back to cited text no. 4
    
5.
Jones WG 2nd, Ginsberg RJ. Esophageal perforation: A continuing challenge. Ann Thorac Surg 1992;53:534-43.  Back to cited text no. 5
    
6.
Hagan WE. Pharyngoesophageal perforations after blunt trauma to the neck. Otolaryngol Head Neck Surg 1983;91:620-6.  Back to cited text no. 6
    
7.
Bufkin BL, Miller JI Jr., Mansour KA. Esophageal perforation: Emphasis on management. Ann Thorac Surg 1996;61:1447-51.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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