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A 93-year-old woman with known achalasia and remote Heller myotomy presented with chest pain after an episode of emesis. CT showed a dilated esophagus with pneumomediastinum. Upper endoscopy confirmed a large perforation 30 cm from the incisors.
A 23-mm × 12.5-cm fully covered metal stent was placed. An esophagram demonstrated extravasation of contrast material around the stent (Fig. 1). Upon transfer, repeated upper endoscopy showed a large transmural esophageal tear and extraluminal cavity (Fig. 2). The preexisting esophageal stent was removed, and an attempt was made to close the opening to the cavity with an over-the-scope clip and multiple through-the-scope clips.
Figure 1Esophagram with water-soluble contrast material demonstrating a single esophageal stent with incomplete coverage of a large esophageal perforation leading to contrast extravasation.
An esophagram after clip placement demonstrated continued extravasation of contrast material. A new approach was thought to be warranted (Video 1, available online at www.VideoGIE.org). Two 7F × 15-cm double-pigtail plastic stents were placed into the cavity with their distal ends extending into the stomach. Two side-by-side 23-mm × 15.5-cm partially covered metal esophageal stents were placed, but space remained between the stents and esophageal wall; therefore, a third 18-mm × 15.3-cm partially covered stent was placed alongside the first 2 stents (Fig. 3).
Figure 3Endoscopic view of side-by-side esophageal stents used to close the mural defect.
Injection of contrast material under fluoroscopy showed no extravasation (Fig. 4). A clear liquid diet was initiated. Because of the patient’s multiple comorbidities, she was transitioned to hospice care and she died 4 weeks after the procedure. Boerhaave syndrome has a high mortality rate from mediastinal infection and sepsis; management in achalasia is challenging because of the dilated esophagus. The use of multiple stents in this case allowed for closure of the defect.
Figure 4Repeated esophagram with water-soluble contrast material demonstrating 3 esophageal stents in tandem with complete coverage of the mural defect. Two double-pigtail stents are seen draining the extraluminal cavity into the stomach.
Dr Baron is a consultant for Medtronic and a consultant and speaker for Olympus America, Boston Scientific, W.L. Gore, and Cook Endoscopy. Dr James receives research and training support, in part, by a grant from the National Institutes of Health (T32 DK007634). Dr Brimhall disclosed no financial relationships relevant to this publication.
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