Treatment of oesophageal and subcardial perforations caused by balloon dilatations of corrosive strictures with two removable covered metallic stents and drainage

Introduction: Oesophageal perforations are often treated in recent years with covered metallic stents avoiding invasive surgical intervention. Dilatation of severe corrosive strictures carries an increased risk of perforation. The authors report on double stent and drainage treatment of an oesophageal and later a subcardial perforation after dilatations of multiple corrosive stenoses.

Patient and methods: A 42 years old woman drank large amount of hydrochloric acid to commit suicide. The patient was admitted to surgical department with inability of swallowing. Proximal and distal esophageal, subcardial and gastric outlet stenoses were revealed after dilatations of oesophago-cardial strictures. Perforation occurred on 29th of November 2010 during the second dilatation of oesophagus and it was treated with placement of covered metallic stent. Partial gastrectomy (Billroth I) was performed one week later due to gastric outlet stenosis along with jejunal feeding tube implantation and transient transhiatal drainage. The dilatations of stenoses at both ends of the stent were necessary two weeks later.

The dilatation of recurrent subcardial corrosive stenoses one month later caused another perforation. Gastrographin swallowing revealed subcardial leakage and the water-soluble contrast medium got into a separated peritoneal cavity. The place of perforation was not identified during laparotomy; therefore only drainage was carried out. The leakage was demonstrated 10 day later, and it was sealed by insertion of a second, overlapping covered metallic stent. The drains were removed subsequently. After further dilatation of the proximal oesophageal stenosis the nutrition of the patient was continued orally. The extraction of the stents is planned at a later time.

Conclusions: The occurrence of subcardial perforation is an indication for surgery. In this case only drainage was performed, therefore the leakage was sealed by covered metallic stent. Covered, removable metallic stents are applicable not only in esophageal perforations, but also in selected cases of subcardial perforation, together with drainage.