Post written by Dronamraju Sujay Prabhath, MD, Shiran Shetty, DM, Balaji Musunuri, DNB, and Praveen M.C.S., MD, from the Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India.

An 85-year-old man with severe chest pain, difficulty breathing, and decreased air entry in the right-lower lung zone after endoscopic dilatation of a benign esophageal stricture was diagnosed with an iatrogenic esophageal perforation, which led to a right-sided hydropneumothorax. Because of his poor performance status, surgical intervention was not deferred.

Upper endoscopy showed a large midesophageal perforation. Over-the-scope clips, the initial best option, were attempted but unsuccessful. Hence, a fully covered self-expandable metal stent was placed over the defect, and an intercostal drain was inserted to manage the hydropneumothorax.

However, after removal of the self-expandable metal stent, the perforation persisted. To address the remaining defect, endoluminal vacuum therapy was attempted. However, because of the unavailability of commercial endoluminal vacuum devices, an innovative, indigenous endosponge was created by attaching the sponge to the distal end of a Ryle’s tube and connecting it to a negative-pressure wound therapy device. Using rat tooth forceps, we guided the endosponge to the site of the esophageal defect and maintained a pressure of 125 mm Hg. The sponge was replaced every 3 days, with its size adjusted to match the size of the defect. Over time, a noticeable reduction in the defect size was observed.

Despite 4 sessions of endoluminal vacuum therapy, the perforation remained. Consequently, the helical tacking system was used. Tacks were placed 5 to 10 mm from the margin of the mucosal defect, first securing healthy tissue before insertion of the tacks into the target tissue using a Persian drill handle. A zig-zag pattern was used to ensure optimal coverage of the perforation. After each tack placement, the suture was tightened before the push catheter was removed to allow for the suture cinch to secure the tissue and maintain the tension.

After the procedure, an oral gastrograffin study confirmed absence of any leak. The patient was discharged 3 days after the procedure after restarting oral feeds. Review after 1 week showed significant improvement in the chest x-ray. Following ongoing physical rehabilitation and nutritional optimization, the patient demonstrated a 5-kg weight gain at 4-month follow-up, accompanied by an improvement in quality of life. Notably, no additional endoscopic interventions were required during this period.  

This case highlights the challenges encountered in managing a complex esophageal perforation in a patient with multiple comorbidities, for whom surgical treatment was not an option.

Management of complex cases necessitates a multidisciplinary team, particularly when conventional treatment protocols fail. In such scenarios, a multistep strategy for defect closure should be considered. To the best of our knowledge, this represents the first reported use of the helical tacking system for management of esophageal perforation in our country yielding favorable outcomes.   

Endoscopic view shows placement of the helical tacking system.

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