The Novel Use of Endoscopy via a Cervical Oesophago ...
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West Indian Med J 2017; 66 (1): 185 LETTERS TO THE EDITOR The Novel Use of Endoscopy via a Cervical Oesophago-cutaneous Fistula for Removal of a Dislodged Stent in a Case of Boerhaave’s syndrome The Editor, Sir, A 41-year-old African-American male presented to the emer- gency room with chest and abdominal pain associated with dyspnoea following multiple episodes of emesis. Assessment and imaging revealed proximal and distal oesophageal perfo- rations. The patient was emergently taken to the operating room where a diverting fistula of the cervical oesophagus was created through the neck. The distal perforation was stented with a self-expand- able metal stent (SEMS). The patient was discharged in stable condition with nutritional needs met by the placement of a je- junostomy tube. Follow-up at two months revealed a healed distal oesophagus but a dislodged distal stent, now present in the stomach. The gastroenterology service used the existing cervical fistula, after dilator insertion, to access the oesopha- gus. The dislodged stent was confirmed to be in the stomach lumen. The SEMS was retrieved with rat tooth graspers and, after manipulation using a circumferential evacuation tech- nique, the SEMS was extracted in one piece from the dilated cervical fistula (Figs.A to D). Boerhaave’s syndrome is spontaneous perforation of the oesophagus in the absence of pre-existing pathology due to a sudden rise in intra-oesophageal pressure, typically during vomiting (1). If untreated, mortality approaches 100% and emergent surgical or endoscopic therapy with self-expandable plastic stent (SEPS) or SEMS placement is indicated (2, 3). Recently, encouraging results have been published utilizing stenting and diligent nonoperative care of this condition (2). This complicated case of proximal and distal perforation, uti- lizing an iatrogenic cervical oesophago-cutaneous fistula to re- move a dislodged SEMS, has never been described in published literature to the authors’ knowledge. Boerhaave’s syndrome remains a major life threatening event and the specific treatment should be selected according to each individual patient. Although classically this has been surgical, improvements in endoscopic procedures with SEMS or SEPS placement have shown decreased morbidity and mor- tality rates. The fistula used for endoscopy in this case was di- lated prior to scope insertion to minimize further trauma to the at risk cervical oesophagus. Endoscopy may thus, be used un- conventionally, in select cases, as a viable option to surgical intervention when suitable cautionary measures are taken. Figures A to D (from left to right below) demonstrates the use of the cervical oesophago-cutaneous fistula for endo- scope insertion as well as removal of the SEMS through this same fistula employing rat-tooth graspers. The completely re- moved SEMS is seen in Figure D. Keywords: Boerhaave’s syndrome, dislodged stent retrieval, oesophago-cutaneous fistula B Mourad 1 , V Ramoutar 2 , B John 3 , J Munoz 4 From: 1 Pulmonary and Critical Care Medicine Fellow, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, USA, 10025, 2 Nephrology Fellow, University of Florida, Jacksonville, FL, USA, 32209, 3 Gastroenterologist, Digestive Diseases Center, San Antonio, TX, USA, 78215 and 4 Gastroenterologist, Borland-Groover Clinic, Jacksonville, FL, USA, 32256. Correspondence: Dr V Ramoutar, University of Florida Col- lege of Medicine, Jacksonville, Box L14, 653-1 W 8 th Street, Jacksonville, FL, USA, 32209. email: [email protected]. edu Figure: Use of cervical oesophago-cutaneous fistula. DOI: 10.7727/wimj.2014.155
Transcript of The Novel Use of Endoscopy via a Cervical Oesophago ...
West Indian Med J 2017; 66 (1): 185
LETTERS TO THE EDITOR
The Novel Use of Endoscopy via a Cervical Oesophago-cutaneous Fistula for Removal of a Dislodged Stent in a Case of Boerhaave’s syndrome
The Editor,
Sir,
A 41-year-old African-American male presented to the emer-gency room with chest and abdominal pain associated withdyspnoea following multiple episodes of emesis. Assessmentand imaging revealed proximal and distal oesophageal perfo-rations. The patient was emergently taken to the operatingroom where a diverting fistula of the cervical oesophagus wascreated through the neck.
The distal perforation was stented with a self-expand-able metal stent (SEMS). The patient was discharged in stablecondition with nutritional needs met by the placement of a je-junostomy tube. Follow-up at two months revealed a healeddistal oesophagus but a dislodged distal stent, now present inthe stomach. The gastroenterology service used the existingcervical fistula, after dilator insertion, to access the oesopha-gus. The dislodged stent was confirmed to be in the stomachlumen. The SEMS was retrieved with rat tooth graspers and,after manipulation using a circumferential evacuation tech-nique, the SEMS was extracted in one piece from the dilatedcervical fistula (Figs.A to D).
Boerhaave’s syndrome is spontaneous perforation of theoesophagus in the absence of pre-existing pathology due to asudden rise in intra-oesophageal pressure, typically duringvomiting (1). If untreated, mortality approaches 100% andemergent surgical or endoscopic therapy with self-expandableplastic stent (SEPS) or SEMS placement is indicated (2, 3).Recently, encouraging results have been published utilizingstenting and diligent nonoperative care of this condition (2).This complicated case of proximal and distal perforation, uti-lizing an iatrogenic cervical oesophago-cutaneous fistula to re-move a dislodged SEMS, has never been described inpublished literature to the authors’ knowledge.
Boerhaave’s syndrome remains a major life threateningevent and the specific treatment should be selected accordingto each individual patient. Although classically this has beensurgical, improvements in endoscopic procedures with SEMSor SEPS placement have shown decreased morbidity and mor-tality rates. The fistula used for endoscopy in this case was di-lated prior to scope insertion to minimize further trauma to theat risk cervical oesophagus. Endoscopy may thus, be used un-
conventionally, in select cases, as a viable option to surgicalintervention when suitable cautionary measures are taken.
Figures A to D (from left to right below) demonstratesthe use of the cervical oesophago-cutaneous fistula for endo-scope insertion as well as removal of the SEMS through thissame fistula employing rat-tooth graspers. The completely re-moved SEMS is seen in Figure D.
Keywords: Boerhaave’s syndrome, dislodged stent retrieval, oesophago-cutaneous fistula
B Mourad1, V Ramoutar2, B John3, J Munoz4
From: 1Pulmonary and Critical Care Medicine Fellow, MountSinai West, Icahn School of Medicine at Mount Sinai, NewYork, NY, USA, 10025, 2Nephrology Fellow, University ofFlorida, Jacksonville, FL, USA, 32209, 3Gastroenterologist,Digestive Diseases Center, San Antonio, TX, USA, 78215 and4Gastroenterologist, Borland-Groover Clinic, Jacksonville,FL, USA, 32256.
Correspondence: Dr V Ramoutar, University of Florida Col-lege of Medicine, Jacksonville, Box L14, 653-1 W 8th Street, Jacksonville, FL, USA, 32209. email: [email protected]. edu
Figure: Use of cervical oesophago-cutaneous fistula.
DOI: 10.7727/wimj.2014.155
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ture. BMJ 2013; 346: 3095.2. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, en-
doscopic and medical management strategies. Curr Opin Gastroenterol2010; 26: 379–83.
3. Eroglu A, Turkyilmaz A, Aydin Y. Yekeler E, Karaoglanoglu N. Current management of esophageal perforation: 20-years experience. Dis Esophagus 2009; 22: 374–80.
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