Pharyngoesophageal perforation during introduction of an echoendoscope treated with a fully covered self-expandable metal stent

A 69-year-old woman with a history of renal transplantation was investigated for biliary duct dilation. She was receiving treatment with prednisone and tacrolimus.

Echoendoscopy was performed with a radial scope (Olympus GF-UE160) with the patient under conscious sedation. During introduction of the endoscope, perforation was observed in the pharyngoesophageal area. The decision was made to place a fully covered self-expandable metal stent (23 × 12 mm; Wallflex, Boston Scientific), completely covering the defect in the oropharynx ([Fig. 1]). The patient was intubated first to avoid the discomfort caused by the stent, and was then moved to the resuscitation unit. The stent was removed 5 days later with apparent resolution of the perforation. Computed tomography (CT) and a barium esophagogram confirmed resolution of the defect ([Fig. 2]; [Fig. 3]). A small fluid collection at the mediastinum without air bubbles, shown on CT ([Fig. 2]), was treated conservatively with antibiotics ([Video 1]). The patient recovered completely with no symptoms of dysphagia.

Fig. 1 A fully covered self-expandable metal stent was placed at the site of the pharyngoesophageal perforation.

Fig. 2 A barium esophagogram showed no perforation after stent retrieval.

Fig. 3 Computed tomography showed a small collection at the mediastinum, with no air bubbles.

Video 1 Iatrogenic pharyngoesophageal perforation treated with a fully covered self-expandable metal stent and orotracheal intubation.

Iatrogenic oropharyngeal perforation is a rare complication of echoendoscopy, occurring in 0.03 % of explorations [1] [2]. The rate is probably higher with echoendoscopes and duodenoscopes because of their rigidity and lateral or oblique viewing. In the oropharynx, it is not possible to close a perforation with either normal or over-the-scope clips. Other cases have been published in which resolution of the defect in 3 days was reported [3] [4], but because our patient was being treated with prednisone, we preferred to delay removal of the stent.

Endoscopy_UCTN_Code_CPL_1AL_2AG

• References

• 1 Das A, Sivak Jr MV, Chak A. Cervical esophageal perforation during EUS: a national survey. Gastrointest Endosc 2001; 53: 599-602
• 2 Eloubeidi MA, Tamhane A, Lopes TL. et al. Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management. Am J Gastroenterol 2009; 104: 53-56
• 3 Kumbhari V, Azola AA, Tieu AH. et al. Iatrogenic pharyngoesophageal perforations treated with fully covered self-expandable metallic stents (with video). Surg Endosc 2015; 29: 987-991
• 4 Mosquera-Klinger G, Torres Rincon R. Iatrogenic pharyngoesophageal perforations treated with fully covered self-expandable metal stents: Case report. Gastroenterol Hepatol 2019; 42: 429-430