Treatment of esophageal perforation with mediastinal abscess by nasomediastinal drainage placement
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CASE REPORT
Treatment of esophageal perforation with mediastinal abscess by nasomediastinal drainage placement Yasutoshi Shiratori1 · Kenji Nakamura2 · Takashi Ikeya1 · Katsuyuki Fukuda1 Received: 20 April 2020 / Accepted: 1 June 2020 © Japanese Society of Gastroenterology 2020
Abstract Although endoscopic submucosal dissection has been increasingly performed for managing superficial esophageal carcinomas, the risk of post-operative esophageal stenosis remains. Endoscopic balloon dilation for esophageal stenosis is the most common cause of esophageal perforation. Esophageal perforation complicated with mediastinal abscess and sepsis has a high mortality rate. The standard treatment for esophageal perforation is closure. However, the late diagnosis of a case necessitates that treatment of mediastinitis be prioritized over closure of the perforation. We report the case of a 70-year-old man with post-endoscopic submucosal dissection stenosis who underwent endoscopic balloon dilation. Six days after the 16th endoscopic balloon dilation, the patient came to our hospital with a complaint of chest discomfort. Upon assessment, an esophageal perforation and a mediastinal abscess became evident. Because the patient’s systemic condition remained stable, instead of performing surgery, we treated the patient conservatively by placing a nasomediastinal drain. After daily rinsing, the mediastinal abscess eventually regressed on the 15th hospital day. The esophageal perforation also closed spontaneously after removing the drainage tube. Nasomediastinal drainage placement appears to be effective in treating an esophageal perforation with a mediastinal abscess. Keywords Esophageal perforation · Abscess · Nasomediastinal drainage · Balloon dilation · Esophageal stenosis
Introduction Although endoscopic submucosal dissection (ESD) has been increasingly used for managing superficial esophageal carcinomas, the risk of post-operative esophageal stenosis remains problematic [1]. Despite prophylactic methods such as oral steroid administration being carried out [2], once a stenosis is formed, endoscopists need to correct it by performing endoscopic balloon dilation (EBD). Generally, EBD is the most common cause of esophageal perforation and carries a 4–9% risk of perforation [3, 4]. Esophageal perforation with mediastinal abscess has a high mortality rate [5, 6]. Criteria for selecting the conservative treatment of esophageal perforation have been reported [7]. Our case also emphasized the possibility of conservative * Yasutoshi Shiratori [email protected] 1
Division of Gastroenterology, St. Luke’s International Hospital, 9‑1 Akashi‑cho, Chuo‑ku, Tokyo 104‑8340, Japan
Division of Gastroenterology, Tokyo Dental College Ichikawa General Hospital, Tokyo, Japan
2
treatment. However, reports on the method of infection control are scarce and not established [8, 9]. In addition, this case has already been passed 6 days after EBD. The late diagnosis of a case necessitates that treatment of mediastinitis be prioritized over closure
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