- Email: [email protected]
Endoscopic Closure of Cervical Esophageal Perforation Caused By Traumatic Insertion of a Mucosectomy Cap
296
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 2007;84:296 – 8
[5]. Surgeons should adopt versatile and flexible policy towards esophagocoloplasty rather than adhering to the classic single approach. For esophageal reconstruction in corrosive injury with compromised mesocolon, ICG interposition vascularized by ICA provide a valuable alternative.
References
FEATURE ARTICLES
Fig 2. The operative diagram showing ileocolic graft (ICG) pedicled on ileocolic artery with a 25-cm long ileum and 15-cm colon. (A) Compromised mesocolon, the division of the ileum, ascending and transverse colon are marked in dotted lines. (B) The complete surgical result, showing ICG through the retrosternal route with neck end-to-end esophagoileostomy, end-to-side colojejunostomy, and ileocolostomy.
In most cases of corrosive injury, finding a good esophageal substitute for reconstruction is difficult. The stomach is inevitably destroyed, and mesentery within the territory of the MCA is often injured and compromised by intraabdominal dissemination of the caustics and direct contact thermal injury. Under these circumstances, an ICG, first introduced by Dor and colleagues [3] in 1963, proved to be a practical option. In our literature review, anatomical variations of superior mesenteric artery (SMA) were often described. According to Garcia-Ruiz and colleagues [4], the blood supply of the ascending colon mainly originates from a branch emanating from the ICA (66%), followed by the MCA (23.3 %), or even, less frequently, a direct branch of the superior mesenteric artery (10.7%). Therefore, ICA is probably the only constant branch of the superior mesenteric artery to the right colon and could be the preferred alternative vascular pedicle for ICG interposition. The left colon was not used in this case due to shorter graft length measured from splenic flexure and beyond, compared to the ICG. We found four key points of importance concerning the harvesting of the graft: (1) the root of ICA should be dissected high to its bifurcation from the superior mesenteric artery because it is the center of graft’s rotation; (2) marginal vascular communication between the cecum and ileum must be carefully verified; (3) the harvested ileal portion of the ICA-based ICG should be longer compared with MCA-based graft owing to the shorter well-perfused right colon; and (4) the graft’s perfusion evaluation with simple intraoperative trial clamping of the collateral vessel at the root level for unexpected variation in vascularity to avoid disastrous graft failure © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Urschel JD. Does the interponat affect outcome after esophagectomy for cancer? Dis Esophagus 2001;14:124 –30. 2. Renzulli P, Joeris A, Strobel O, et al. Colon interposition for esophageal replacement: a single-center experience. Langenbecks Arch Surg 2004;389:128 –33. 3. Dor J, Houel J, Richelme H, Dor V, Malmejac CI. Esophagoplasty with ileocecum. Ann Chir Thorac Cardiovasc 1964;3: 787–97. 4. Garcia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomy. Implications for laparoscopic surgery. Dise Colon Rectum 1996;39:906 –11. 5. Huttl TP, Wichmann MW, Geiger TK, Schildberg FW, Furst H. Techniques and results of esophageal cancer surgery in Germany. Langenbecks Arch Surg 2002;387:125–9.
Endoscopic Closure of Cervical Esophageal Perforation Caused By Traumatic Insertion of a Mucosectomy Cap Henning Gerke, MD, Gail C. Crowe, RN, and Mark D. Iannettoni, MD Division of Gastroenterology and Hepatology, Department of Medicine, and Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Cap-assisted endoscopic mucosal resection enables nonsurgical removal of superficial esophageal lesions. Perforation at the resection site is a rare but known complication of this technique. We report a case in which traumatic insertion of the mucosectomy cap led to perforation of the cervical esophagus. This complication has not been previously reported. The perforation was successfully closed by the endoscopic placement of clips. (Ann Thorac Surg 2007;84:296 – 8) © 2007 by The Society of Thoracic Surgeons
E
ndoscopic mucosal resection (EMR) in the esophagus has emerged as a therapeutic modality to remove superficial lesions including Barrett’s esophagus with high-grade dysplasia and early cancer. A variant of EMR uses a transparent cap attached to the endoscope tip with a snare positioned in the distal rim of the cap. Esophageal perforation at the resection site is a rare complication of this technique, which occurs in 0.6 to 1.6% [1, 2]. We report a case of cervical esophageal perforation due to Accepted for publication Feb 12, 2007. Address correspondence to Dr Gerke, Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, JCP 4548, Iowa City, IA 52242; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.02.027
Ann Thorac Surg 2007;84:296 – 8
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
297
FEATURE ARTICLES
Fig 1. Cervical esophageal perforation.
traumatic insertion of a mucosectomy cap. We believe that no such incidence has been previously reported. The perforation was successfully treated by endoscopic closure with clips. A 67-year-old woman with gastroesophageal reflux disease was referred for endoscopic ultrasound of a polypoid lesion concerning for early adenocarcinoma arising in a 3-cm segment of Barrett’s esophagus. Endoscopic ultrasound did not reveal any evidence of deep invasion. Therefore a cap-assisted EMR was performed during the same session using a flexible, oblique mucosectomy cap (EMR Kit with Soft Cap [Olympus America Corp, Melville, NY]). This procedure was performed without complications. The histology diagnosis was Barrett’s esophagus with high-grade dysplasia. Surveillance endoscopy after 3 months showed residual Barrett’s muFig 3. Esophagram showing endoscopic clips in the cervical esophagus. No leakage of barium is seen.
Fig 2. Partial closure of the perforation after placement of the first clip.
cosa. After submucosal injection of dilute epinephrine solution (20 mL, 1:100,000), cap-assisted EMR with the soft oblique mucosectomy cap was performed at two adjacent areas. This required reintubation with the caploaded endoscope, which was difficult due to active tightening of the upper esophageal sphincter by the patient. After the final insertion of the cap-loaded endoscope, mucosal trauma caused by the edge of the cap was suspected. Endoscopic reassessment after completion of the EMR revealed a 1.5-cm long perforation in the cervical esophagus (Fig 1). Closure of the perforation with endoscopic clips was immediately performed (Fig 2). Three Resolution clips (Boston Scientific Corp, Natick, MA) and one Quickclip (Olympus America Corp) were used. The patient was hospitalized and broad spectrum antibiotics were administered. She remained afebrile. An esophagram a week later showed the endoscopic clips in the esophagus. No leakage of barium was
298
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 2007;84:296 – 8
seen (Fig 3). The patient tolerated an oral diet and was discharged. At 6 month follow-up the patient was free of symptoms. Endoscopy showed a well-healed perforation site. A single endoscopic clip was still in place (Fig 4). No residual Barrett’s mucosa was present in the distal esophagus.
Comment
FEATURE ARTICLES
Esophageal perforation is a very infrequent complication of endoscopic mucosal resection [1–3]. The risk is further reduced by submucosal saline or dilute epinephrine injection [1]. In the reported case, the perforation did not occur at the mucosectomy site but in the cervical esophagus due to traumatic insertion of a soft EMR cap. Usually the flexible cap adjusts to the shape of the hypopharynx and enables atraumatic passage into the esophagus. However, in our case, sideways compression of the cap resulted in a fairly sharp edge that cut into the esophageal wall. The formation of pointy edges by lateral compression of the mucosectomy cap is illustrated in figure 5. Our experience emphasizes that great caution is warranted during insertion of this type of EMR cap. We treated the perforation by closure with endoscopic clips. Successful endoscopic clip repair has been previously reported for esophageal perforations from foreign body ingestion [4, 5], Boerhaave syndrome [6], endoscopic dilation [7, 8], and EMR [2]. We suggest that it should be
Fig 5. A soft mucosectomy cap is attached to the endoscope tip. Sideways compression of the cap results in pointy edges.
the procedure of choice in small iatrogenic perforations that are immediately detected. We believe that perforations up to 2 cm in length can be treated with endoscopic clips. However, approximation of the wound edges with clips is not always possible and may be limited by inability to achieve en-face position with the endoscope. If endoscopic treatment fails, surgical closure may become necessary.
References
Fig 4. Endoscopic view at 6-month follow-up. The perforation site is healed. A single clip is still present.
1. Inoue H, Kawano T, Tani M, Takeshita K, Iwai T. Endoscopic mucosal resection using a cap: techniques for use and preventing perforation. Can J Gastroenterol 1999;13:477– 80. 2. Shimizu Y, Kato M, Yamamoto J, et al. Endoscopic clip application for closure of esophageal perforations caused by EMR. Gastrointest Endosc 2004;60:636 –9. 3. Conio M, Ponchon T, Blanchi S, Filiberti R. Endoscopic mucosal resection. Am J Gastroenterol 2006;1013:653– 63. 4. Shimamoto C, Hirata I, Umegaki E, Katsu K. Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 2000;51: 736 –9. 5. Abe N, Sugiyama M, Hashimoto Y, et al. Endoscopic nasomediastinal drainage followed by clip application for treatment of delayed esophageal perforation with mediastinitis. Gastrointest Endosc 2001;54:646 – 8. 6. Sriram PV, Rao GV, Reddy ND. Successful closure of spontaneous esophageal perforation (Boerhaave’s syndrome) by endoscopic clipping. Indian J Gastroenterol 2006;25:39 – 41. 7. Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R, Meucci C. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;9:720 –2. 8. Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608 –11.
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 2007;84:296 – 8
[5]. Surgeons should adopt versatile and flexible policy towards esophagocoloplasty rather than adhering to the classic single approach. For esophageal reconstruction in corrosive injury with compromised mesocolon, ICG interposition vascularized by ICA provide a valuable alternative.
References
FEATURE ARTICLES
Fig 2. The operative diagram showing ileocolic graft (ICG) pedicled on ileocolic artery with a 25-cm long ileum and 15-cm colon. (A) Compromised mesocolon, the division of the ileum, ascending and transverse colon are marked in dotted lines. (B) The complete surgical result, showing ICG through the retrosternal route with neck end-to-end esophagoileostomy, end-to-side colojejunostomy, and ileocolostomy.
In most cases of corrosive injury, finding a good esophageal substitute for reconstruction is difficult. The stomach is inevitably destroyed, and mesentery within the territory of the MCA is often injured and compromised by intraabdominal dissemination of the caustics and direct contact thermal injury. Under these circumstances, an ICG, first introduced by Dor and colleagues [3] in 1963, proved to be a practical option. In our literature review, anatomical variations of superior mesenteric artery (SMA) were often described. According to Garcia-Ruiz and colleagues [4], the blood supply of the ascending colon mainly originates from a branch emanating from the ICA (66%), followed by the MCA (23.3 %), or even, less frequently, a direct branch of the superior mesenteric artery (10.7%). Therefore, ICA is probably the only constant branch of the superior mesenteric artery to the right colon and could be the preferred alternative vascular pedicle for ICG interposition. The left colon was not used in this case due to shorter graft length measured from splenic flexure and beyond, compared to the ICG. We found four key points of importance concerning the harvesting of the graft: (1) the root of ICA should be dissected high to its bifurcation from the superior mesenteric artery because it is the center of graft’s rotation; (2) marginal vascular communication between the cecum and ileum must be carefully verified; (3) the harvested ileal portion of the ICA-based ICG should be longer compared with MCA-based graft owing to the shorter well-perfused right colon; and (4) the graft’s perfusion evaluation with simple intraoperative trial clamping of the collateral vessel at the root level for unexpected variation in vascularity to avoid disastrous graft failure © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Urschel JD. Does the interponat affect outcome after esophagectomy for cancer? Dis Esophagus 2001;14:124 –30. 2. Renzulli P, Joeris A, Strobel O, et al. Colon interposition for esophageal replacement: a single-center experience. Langenbecks Arch Surg 2004;389:128 –33. 3. Dor J, Houel J, Richelme H, Dor V, Malmejac CI. Esophagoplasty with ileocecum. Ann Chir Thorac Cardiovasc 1964;3: 787–97. 4. Garcia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomy. Implications for laparoscopic surgery. Dise Colon Rectum 1996;39:906 –11. 5. Huttl TP, Wichmann MW, Geiger TK, Schildberg FW, Furst H. Techniques and results of esophageal cancer surgery in Germany. Langenbecks Arch Surg 2002;387:125–9.
Endoscopic Closure of Cervical Esophageal Perforation Caused By Traumatic Insertion of a Mucosectomy Cap Henning Gerke, MD, Gail C. Crowe, RN, and Mark D. Iannettoni, MD Division of Gastroenterology and Hepatology, Department of Medicine, and Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Cap-assisted endoscopic mucosal resection enables nonsurgical removal of superficial esophageal lesions. Perforation at the resection site is a rare but known complication of this technique. We report a case in which traumatic insertion of the mucosectomy cap led to perforation of the cervical esophagus. This complication has not been previously reported. The perforation was successfully closed by the endoscopic placement of clips. (Ann Thorac Surg 2007;84:296 – 8) © 2007 by The Society of Thoracic Surgeons
E
ndoscopic mucosal resection (EMR) in the esophagus has emerged as a therapeutic modality to remove superficial lesions including Barrett’s esophagus with high-grade dysplasia and early cancer. A variant of EMR uses a transparent cap attached to the endoscope tip with a snare positioned in the distal rim of the cap. Esophageal perforation at the resection site is a rare complication of this technique, which occurs in 0.6 to 1.6% [1, 2]. We report a case of cervical esophageal perforation due to Accepted for publication Feb 12, 2007. Address correspondence to Dr Gerke, Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, JCP 4548, Iowa City, IA 52242; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.02.027
Ann Thorac Surg 2007;84:296 – 8
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
297
FEATURE ARTICLES
Fig 1. Cervical esophageal perforation.
traumatic insertion of a mucosectomy cap. We believe that no such incidence has been previously reported. The perforation was successfully treated by endoscopic closure with clips. A 67-year-old woman with gastroesophageal reflux disease was referred for endoscopic ultrasound of a polypoid lesion concerning for early adenocarcinoma arising in a 3-cm segment of Barrett’s esophagus. Endoscopic ultrasound did not reveal any evidence of deep invasion. Therefore a cap-assisted EMR was performed during the same session using a flexible, oblique mucosectomy cap (EMR Kit with Soft Cap [Olympus America Corp, Melville, NY]). This procedure was performed without complications. The histology diagnosis was Barrett’s esophagus with high-grade dysplasia. Surveillance endoscopy after 3 months showed residual Barrett’s muFig 3. Esophagram showing endoscopic clips in the cervical esophagus. No leakage of barium is seen.
Fig 2. Partial closure of the perforation after placement of the first clip.
cosa. After submucosal injection of dilute epinephrine solution (20 mL, 1:100,000), cap-assisted EMR with the soft oblique mucosectomy cap was performed at two adjacent areas. This required reintubation with the caploaded endoscope, which was difficult due to active tightening of the upper esophageal sphincter by the patient. After the final insertion of the cap-loaded endoscope, mucosal trauma caused by the edge of the cap was suspected. Endoscopic reassessment after completion of the EMR revealed a 1.5-cm long perforation in the cervical esophagus (Fig 1). Closure of the perforation with endoscopic clips was immediately performed (Fig 2). Three Resolution clips (Boston Scientific Corp, Natick, MA) and one Quickclip (Olympus America Corp) were used. The patient was hospitalized and broad spectrum antibiotics were administered. She remained afebrile. An esophagram a week later showed the endoscopic clips in the esophagus. No leakage of barium was
298
CASE REPORT GERKE ET AL ENDOSCOPIC CLOSURE OF CERVICAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 2007;84:296 – 8
seen (Fig 3). The patient tolerated an oral diet and was discharged. At 6 month follow-up the patient was free of symptoms. Endoscopy showed a well-healed perforation site. A single endoscopic clip was still in place (Fig 4). No residual Barrett’s mucosa was present in the distal esophagus.
Comment
FEATURE ARTICLES
Esophageal perforation is a very infrequent complication of endoscopic mucosal resection [1–3]. The risk is further reduced by submucosal saline or dilute epinephrine injection [1]. In the reported case, the perforation did not occur at the mucosectomy site but in the cervical esophagus due to traumatic insertion of a soft EMR cap. Usually the flexible cap adjusts to the shape of the hypopharynx and enables atraumatic passage into the esophagus. However, in our case, sideways compression of the cap resulted in a fairly sharp edge that cut into the esophageal wall. The formation of pointy edges by lateral compression of the mucosectomy cap is illustrated in figure 5. Our experience emphasizes that great caution is warranted during insertion of this type of EMR cap. We treated the perforation by closure with endoscopic clips. Successful endoscopic clip repair has been previously reported for esophageal perforations from foreign body ingestion [4, 5], Boerhaave syndrome [6], endoscopic dilation [7, 8], and EMR [2]. We suggest that it should be
Fig 5. A soft mucosectomy cap is attached to the endoscope tip. Sideways compression of the cap results in pointy edges.
the procedure of choice in small iatrogenic perforations that are immediately detected. We believe that perforations up to 2 cm in length can be treated with endoscopic clips. However, approximation of the wound edges with clips is not always possible and may be limited by inability to achieve en-face position with the endoscope. If endoscopic treatment fails, surgical closure may become necessary.
References
Fig 4. Endoscopic view at 6-month follow-up. The perforation site is healed. A single clip is still present.
1. Inoue H, Kawano T, Tani M, Takeshita K, Iwai T. Endoscopic mucosal resection using a cap: techniques for use and preventing perforation. Can J Gastroenterol 1999;13:477– 80. 2. Shimizu Y, Kato M, Yamamoto J, et al. Endoscopic clip application for closure of esophageal perforations caused by EMR. Gastrointest Endosc 2004;60:636 –9. 3. Conio M, Ponchon T, Blanchi S, Filiberti R. Endoscopic mucosal resection. Am J Gastroenterol 2006;1013:653– 63. 4. Shimamoto C, Hirata I, Umegaki E, Katsu K. Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 2000;51: 736 –9. 5. Abe N, Sugiyama M, Hashimoto Y, et al. Endoscopic nasomediastinal drainage followed by clip application for treatment of delayed esophageal perforation with mediastinitis. Gastrointest Endosc 2001;54:646 – 8. 6. Sriram PV, Rao GV, Reddy ND. Successful closure of spontaneous esophageal perforation (Boerhaave’s syndrome) by endoscopic clipping. Indian J Gastroenterol 2006;25:39 – 41. 7. Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R, Meucci C. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;9:720 –2. 8. Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608 –11.