A case of Sengstaken-Blakemore tube-induced esophageal rupture repaired by endoscopic clipping

Development of a Balloon Tamponade Task Trainer

Variceal hemorrhage is a life-threatening complication of patients with cirrhosis. If a patient is hemodynamically unstable and unable to undergo endoscopic therapy, a balloon tamponade device may be placed to temporize the hemorrhage until definitive management may be performed. Placement of these devices may be performed by practitioners of several different medical specialties. Placement of balloon tamponade devices requires multiple steps and several different pieces of equipment. Performing the procedure incorrectly can lead to iatrogenic injuries such as esophageal necrosis or perforation. Since this is a relatively rare procedure often placed under high-stress situations, practicing in a low-stakes setting, such as a simulation lab, allows practitioners to hone their skills. Commercially available task trainers for balloon tamponade device placement are not available. In this paper, we describe how to modify an inexpensive airway task trainer for this purpose using commonly available and cost-effective materials.

Management of a large delayed esophageal perforation in a fresh liver transplant patient with endoscopic placement of a nasopleural drainage tube-a case report

Esophageal perforation in liver transplant recipients is a rare phenomenon. We herein report a case of an esophageal perforation due to Sengstaken–Blakemore tube in a liver-transplant recipient diagnosed 6 weeks post-transplant. A 2.5-cm mid-esophageal perforation communicating with large complex fluid collection in the pleural space was found. During endoscopy, 16Fr Salem Sump nasopleural tube (NP) was placed traversing through esophageal perforation into inferior aspect of the collection. Over the following 4 weeks, NP decompressed the cavity, allowed its closure and the tube was slowly retracted. By the end of 4 weeks, NP was removed with follow-up esophagogram showing no extravasation of contrast and a healed perforation. Hence, the esophageal perforation was successfully treated via this unique nonoperative approach without the need for major surgery. In instances of chronic leak with a stable patient, this nonoperative strategy should be considered even in immunocompromised patients.

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.

Role of endoscopic clipping in the treatment of oesophageal perforations

With advances in endoscopic technologies, endoscopic clips have been used widely and successfully in the treatment of various types of oesophageal perforations, anastomosis leakages and fistulas. Our aim was to summarize the experience with two types of clips: The through-the-scope (TTS) clip and the over-the-scope clip (OTSC). We summarized the results of oesophageal perforation closure with endoscopic clips. We processed the data from 38 articles and 127 patients using PubMed search. Based on evidence thus far, it can be stated that both clips can be used in the treatment of early (< 24 h), iatrogenic, spontaneous oesophageal perforations in the case of limited injury or contamination. TTS clips are efficacious in the treatment of 10 mm lesions, while bigger (< 20 mm) lesions can be treated successfully with OTSC clips, whose effectiveness is similar to that of surgical treatment. However, the clinical success rate is significantly lower in the case of fistulas and in the treatment of anastomosis insufficiency. Tough prospective randomized multicentre trials, which produce the largest amount of evidence, are still missing. Based on experience so far, endoscopic clips represent a possible therapeutic alternative to surgery in the treatment of oesophageal perforations under well-defined conditions.

Closing perforations and postperforation management in endoscopy: esophagus and stomach

Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.

Dislodgement of variceal bands after esophageal balloon tamponade for variceal bleeding

A 43-year-old male with alcoholic cirrhosis underwent EGD for hematemesis which revealed bleeding, grade II, lower esophageal varices that were endoscopically ligated with 6 bands. All the bands remained attached to varices at the completion of EGD. Despite apparent initial hemostasis, balloon tamponade was performed one hour later for suspected continued bleeding. Due to suspected continuing bleeding, EGD was repeated 4 h after initial EGD, and 3 h after balloon tamponade. This EGD revealed the esophageal varices; none of the bands remaining on esophageal mucosa; multiple mucosal stigmata likely from trauma at initial site of variceal bands before dislodgement; and 3 dislodged bands in gastric body, duodenal bulb, or descending duodenum. The patient expired 17 h thereafter from hypovolemic shock. This single report may suggest an apparently novel, balloon tamponade complication: dislodgement of previously placed, endoscopic bands. The proposed pathophysiology is release of bands by stretching entrapped, esophageal mucosa during esophageal balloon tamponade. This complication, if confirmed, might render balloon tamponade a less desirable option very soon after band ligation.