This case presentation describes the management of two patients with esophageal perforations and leaks. Case 1 involved a 56-year-old female with an achalasia perforation during dilation who developed a retroperitoneal collection. She was initially treated with an esophageal stent but later required exploratory laparotomy for drainage and lavage due to sepsis. Case 2 was a 62-year-old male who presented 48 hours after chest pain following vomiting, and was found to have a perforation into the right pleural cavity. He underwent thoracoscopic lavage, drainage, and stent placement.

1. Case Presentation
GE Junction leak
Dr Dhaval Mangukiya

2. Case 1
• 56 year Female
• No Medical comorbidities
• Achalsia cardia
• Attempted rigid dilatation

3. Case 1
• Post procedure day 1
• Severe abdominal pain
• Respiratory discomfort
• Blood Investigation – Normal
• No s/o sepsis

4. Case 1
• CT Scan with Oral & IV contrast
• Leak at GE junction
• Collection in retro peritoneum up to left para
renal space
• What are the options for further Mx??

5. Case 1
• Post procedure day 3
• SEMS covered esophageal stent

6. Case 1
• Post procedure day 4
• Respiratory distress
• Tachycardia
• Hypotension
• Low WBC counts (2600)
• Low platelets (67000)
• Hb – 7.2
• INR 1.8
• Repeat CT scan – No active contrast leak, Collection
same

7. Case 1
• Exploratory laparotomy
• Drainage and Lavage
• Appx 800 ml of retroperioneal frank pus with
necrotic material
• Stent position checked at GE junction
• Lower esophageal perforation with friable wall
• Feeding Jejunostomy

8. Case 1
• Post op ventilatory support
• Ionotropes
• Broad spectrum antibiotics
• FJ feed
• Recoverd in 72 hour from sepsis

9. Case 1
• Post op day 6 (Exploration)
• Stent partly migrated in stomach
• Patient on full FJ feed
• Drain / RT in situ
• Draining dirty fluid
• No sepsis
OPTIONS???

10. Case 1
• Masterly inactivity
• Maintain nutrition by feeding
• Discharged on post op day 16

11. Case 1
• Follow up after 1 month
• Improving
• Still weak
• Requiring support for routine activities
• Stent partly in esophagus and partly in stomch
RT in situ through stent
• One drain in situ still draining appx 30-50 ml of
dirty fluid

12. Case 1
• Further plan
• CT with oral contrast
• Surgery
• Stent adjustment
• New stent
• Wait for more improvement

14. Case 2
• 62 year male
• Known Hypertensive
• Allergic Asthmatic
• History of severe chest pain since 2 days
• Event started following vomiting

15. Case 2
• Presented to us after 48 hours
• Mild chest discomfort
• Stable vitals
• No s/o sepsis
• CT scan esophageal perforation with leak right
pleural cavity and posterior mediastinum
minimal collection

16. Case 2
• Urgent surgery
• Stenting
• Antibiotic

17. Case 2
• Thoracoscopic lavage given
• Drainage tube
• Feeding jejunostomy
Findings

18. Case 2
• Post operatively shifted to endoscopy theatre
• SE Covered stent placement

19. Case 2
• Post operative
• Ionotropes
• Ventilator
• Broad spectrum antibiotics (Mero/Clinda)
• Recovered in 4 days
• Extubated on post op day 6

20. • Within 6 hrs of presentation
– If no collection Endoscopic treatment
– If collection surgery and repair
• After 6 hrs
– Lavage and drainage with feeding access
– Followed by endoscopic treatment

21. • More than one half of all esophageal perforations
are iatrogenic and most of these occur during
endoscopy
• Other causes
– Spontaneous perforation (Boerhaave’s Syndrome): 15
percent
– Foreign body ingestion: 12 percent
– Trauma: 9 percent
– Intra-operative injury: 2 percent
– Malignancy: 1 percent

22. • A delay of greater than 24 hours in diagnosis and treatment of an esophageal perforation is
associated with a higher mortality rate compared with an early diagnosis and treatment initiation
(27 versus 14 percent)
– cervical perforations having the lowest mortality rate (6 percent)
– thoracic perforations (27 to 34 percent)
– intra-abdominal perforations (21 to 29 percent).
• A primary repair is the gold standard of care and should be utilized for perforations of the thoracic
and abdominal esophagus
• Diversion is reserved for patients who present with clinical instability and more extensive operative
procedure is not possible, or when extensive esophageal damage precludes a primary repair
• While no guidelines exist, esophageal stents may be appropriate for patients with extensive
comorbidities, advanced mediastinal sepsis, or large esophageal defects and the patient’s inability
to tolerate more extensive surgery
• Nonoperative management should be reserved for clinically stable patients with no evidence of
systemic inflammation, expediently diagnosed perforations, and no drainage of any collection into
the pleura or peritoneum