Jonathan Kiev, MD
Esophageal perforation is a morbid condition with potentially fatal consequences if not managed aggressively. Traditional management mandates early exploration, buttressed repair, drainage, and antibiotic therapy. Even in the best of circumstances, morbidity and mortality are high. Numerous reports document the need for exploration within 24 hours to minimize continued soilage. As technology has improved, new and novel approaches to perforation management have been tested. Esophageal stents are playing an ever expanding role as well as gastroenterologists and surgeons have become more aggressive in dilating strictures and stenosis.
We present a case of Boerhaave’s syndrome in an elderly patient who waited four days before presenting to the hospital in extremis. On vasopressors at laparotomy, nonviable edematous tissue with obvious liquefaction necrosis was found surrounding a large perforation. Despite aggressive debridement, there was non-viable tissue and repair and buttress were not possible and would have failed. Esophageal exclusion and drainage were the only options in this frail septic patient, however, his kyphotic stature negated cervical esophagostomy. Instead, he was managed via percutaneous esophagostomy drainage placed via ultrasound and fluoroscopic guidance. This unique approach was accomplished through a transcervical puncture of an Atlas angioplasty balloon (Bard) placed per os in the the midesophagus, above the perforation and exclusion. A 15Fr Gordon drainage catheter was placed over the guidewire and was initially used for drainage. Eventually, the ligated and excluded esophagus recannalized, and tube feedings were initiated via the drainage catheter. All drains were eventually removed and the patient was advanced to a soft diet without dysphagia.
This case report documents a unique approach to esophagostomy tube placement and obviates the pain, discomfort, and complications associated with long term nasogastric tube decompression. By using this technique for tube placement, a cervical esophagostomy was not necessary.
Session: Poster Presentation
Program Number: P510