Spontaneous perforation of an intramural esophageal pseudodiverticulosis treated with intraluminal endoscopic vacuum therapy using a double-lumen vacuum drainage with intestinal feeding tube

Abstract

An intraluminal variant of endoscopic vacuum therapy (EVT) 1 2 was used in a case of acute spontaneous perforation of the esophagus. To enable simultaneous enteral nutrition, a double-lumen vacuum drainage with intestinal feeding tube was constructed. A 31-year-old woman with the human immunodeficiency virus presented with thoracic pain and dysphagia after vomiting caused by a bolus of dry fish. Computed tomography revealed a perforation of the thoracic esophagus with discharge of air ( Fig. 1 ). Endoscopy found an acute transmural perforation from 26 cm to 31 cm ( Fig. 2 ). Intraluminal EVT 1 2 was started within 24 hours after the perforation event. Fig. 1  Thoracic computed tomography showing perforation (P) of the esophagus with extraluminal air next to the esophagus. Fig. 2  Endoscopy revealed a long perforation in the esophagus (arrows). A triluminal tube (Freka Trelumina, CH/Fr 16/9, 150 cm; Fresenius Kabi AG, Bad Homburg, Germany) was used to construct a double-lumen vacuum drainage device ( Fig. 3 ). First, the ventilation channel of the tube was blocked with a clamp, as it was not required for the procedure. Then the tube was inserted nasally and guided out orally. All openings of the drainage channel were wrapped in a 15-cm length of open-pore polyurethane foam (Suprasorb CNP; Wundschaum, Lohmann & Rauscher GmbH & Co. KG, Neuwied, Germany), and secured with a suture. The double-lumen drainage device was then inserted endoscopically and the intestinal feeding channel was placed in the stomach. The open-pore polyurethane foam section of the tube covered the perforation region completely. After application of negative pressure with an electronic device (KCI V.A.C. Freedom; KCI USA Inc., San Antonio, Texas, USA; setting – 125 mmHg, continuous, intensity 10), the esophageal lumen collapsed around the foam. Fig. 3  Construction of the double-lumen vacuum drainage device. PU, polyurethane foam; S, suture; lP, lateral perforations of the gastric channel; IC, intestinal feeding channel of the tube. Placement of the drainage device (and its removal after treatment) was performed using a standard gastroscope and carbon dioxide insufflation with the patient under general anesthesia. The patient was transferred to a normal ward immediately after drainage placement. After EVT for 5 days, the drainage device was removed by pulling the tube. The foam had been sucked onto the perforation wound ( Fig. 4 ), which was closed and covered with an erosive pattern ( Fig. 5 ). No fistula could be observed. Three days after the end of therapy, a small ulceration could be seen at the site of the former perforation, and after 18 days, complete healing of the perforation region was achieved. In addition, an intramural esophageal pseudodiverticulosis ( Fig. 6 ) was detected as a possible explanation for the perforation. Fig. 4  Day 5 of endoscopic vacuum therapy. The polyurethane foam (PU) had been sucked onto the perforation wound. Fig. 5  Day 5 of endoscopic vacuum therapy. Vacuum drainage was removed, revealing the former perforation site, which showed an erosion pattern (Er). Fig. 6  At follow-up endoscopy 18 days after treatment, complete healing was achieved and an esophageal pseudodiverticulosis was found. Double-lumen vacuum drainage with intestinal feeding tube enabled full enteral nutrition from the beginning of esophageal intraluminal EVT ( Video 1 ). Video 1: Endoscopic vacuum therapy for perforation of esophageal pseudodiverticulosis. Endoscopy_UCTN_Code_TTT_1AO_2AI