Successful Endoscopic Band Ligation of Esophageal Perforation by Fish Bone Ingestion

Introduction

Esophageal perforation by foreign body ingestion leads to fatal complications such as retropharyngeal or paraesophageal abscess and mediastinitis. ¹ Thus, an impacted fish bone in the esophageal wall should be removed by endoscopic procedure or surgery.^2,3 In the absence of a major vessel injury, esophageal foreign body removal can be performed by the endoscopic method. If acute esophageal perforation is observed after the endoscopic procedure, the management of esophageal perforation involves surgery or a conservative approach. ⁴ As endoscopic techniques have developed, some case reports have described successful repairs of esophageal perforation by endoscopic clips or stents.

To our knowledge, there have been no reports of endoscopic closure by endoscopic band ligation of esophageal perforation. Herein, a successful case is reported.

Case Report

A 68-year-old man was admitted complaining of substernal pain and dysphagia. He reported having swallowed a fish bone about 15 hours previously. The patient was obese but had been in good health.

On physical examination, respiratory rate was 20 breaths/minute, blood pressure was 140/90 mm Hg, pulse rate was 94 beats/minute, and temperature was 36.6°C. Clear breathing sound at both lung fields was heard on auscultation. Chest and abdomen X-ray findings were normal. There was no evidence of subcutaneous emphysema in the cervical and thoracic area. Laboratory tests found a white blood cell count of 10,800 cells/μL. The hemoglobin level was 14.1 g/dL, and the platelet count was 198,000 cells/L.

Based on the consideration of an impending esophageal perforation, an endoscopy was performed immediately. The sharp edge of the fish bone was stuck in a posterior wall of the lower esophagus, and oozing of blood from the site of the impacted fish bone was found. Using a rat-tooth forceps, the fish bone was dislodged without damage to the esophageal wall by a flexible endoscope (model GIF-Q260J; Olympus, Tokyo, Japan). After removal of the fish bone, a 3-mm-sized deep round opening was observed in the esophageal wall. As the patient had complained substernal pain continuously, although there was no evidence of esophageal perforation on X-ray images and physical examination, we could not rule out esophageal perforation. An endoscopic band (model MD-48710; JIIN CNT, Seoul, Korea) was applied at the opening site (Fig. 1).

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FIG. 1.

(a) Endoscopic view of the impacted fish bone. (b) The removed fish bone. (c) An opening found at the site of the impacted fish bone. (d) Endoscopic band ligation of the esophageal perforation.

One hour after the procedure, the chest computed tomography (CT) scan showed pneumomediastinum and subcutaneous emphysema in the lower anterior neck, suggesting esophageal perforation by the fish bone. However, there was no local abscess (Fig. 2a). Because the general condition of the patient was good, conservative treatment with intravenous antibiotics (ampicillin, sulbactam, and netilmicin sulfate), proton pump inhibitors, and total parenteral nutrition was given. The next day, his body temperature was 37.7°C, and the white blood cell count was 16,500 cells/μL. After consultation with a thoracic surgery specialist, in his septic condition, he would have been subjected to an operation. Fortunately, he did not complain any more of substernal pain. Over time, his vital sign and laboratory findings improved.

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FIG. 2.

(a) One hour after the procedure, the chest computed tomography scan shows pneumomediastinum. (b) After 2 weeks, the pneumomediastinum has nearly disappeared.

After 2 weeks, a follow-up chest CT scan showed that pneumomediastinum had nearly disappeared (Fig. 2b). Follow-up endoscopy revealed a whitish scar at the previous mucosal opening site without the applied band (Fig. 3). The patient was given oral nutrition, and 22 days after endoscopic repair, he was discharged.

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FIG. 3.

Endoscopic view of the repaired perforation 2 weeks after the procedure.

Discussion

Ingested foreign bodies can frequently lodge in the esophagus. Esophageal perforations by a foreign body account for 7%–14% of all esophageal perforations, so the foreign body in the esophagus has to be removed immediately. ⁵ Jeen et al. ⁶ described 22 cases in which esophageal sharp foreign bodies were removed by endoscopic procedures successfully except for 1 case in which a fish bone was so large to be extracted surgically. Although the foreign body is removed, the mortality of esophageal perforation is still at a high level. The reported mortality from treated esophageal perforation is 10%–25% when therapy is initiated within 24 hours of perforation, and it is 40%–60% when the treatment is delayed.^7–12 The treatment of esophageal perforation is controversial. Recently, it has been found that patients with small, well-defined tears and minimal extraesophageal involvement may be better managed by nonoperative treatment. ¹³

Advances in endoscopic closure devices have increased therapeutic options. Some case reports have described endoscopic clips for closing acute and chronic esophageal perforations.^14–17 However, there are limitations, as in applying a clip to a large-sized perforation as well as to angulated areas, because of the clip's relatively small size. Endoscopic placements of removable covered esophageal stents are effective for closing large esophageal perforations with an irregular margin such as a perforation after pneumatic dilatation in achalasia, but the possibility of migration and foreign body sensation of the stent itself are of concern. ¹⁸ Fibrin sealant has also been used in esophageal perforation. ¹⁹

In our case, endoscopic band ligation for acute esophageal perforation was attempted for the first time. Until now, general indications for endoscopic band ligation in esophageal diseases include variceal bleeding control and closure of a Mallory–Weiss tear. Although there have never been endoscopic band ligations for esophageal perforations, some cases in which band ligation has been used for colonic perforation have already been reported. Han et al. ²⁰ described that endoscopic closure of a colon perforation with band ligation is easier and faster than endoclipping, even if the maximal diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. Also, in esophageal perforation, due to its narrow inner diameter, controlling the angle would be very difficult to someone who is not skilled enough. Therefore, use of band ligation for endoscopic closure of esophageal perforation would be much quicker and easier than endoclipping. However, in the case of esophageal perforation, the efficacy of endoscopic band ligation for large as well as for small timely repaired perforations is not identified. In addition, there are limitations such as the foreign body sensation of the band and the risk of a loosened band. Therefore, more investigations are needed in the future.

In conclusion, in our case endoscopic band ligation for acute esophageal perforation by foreign body ingestion is a meaningful, first-tried therapeutic procedure. The patient was completely cured, and the endoscopic procedure was more cost-effective, safer, and easier than surgery. Therefore, in the case of an early defect, if the patient is stable clinically, endoscopic band ligation for acute esophageal perforation should be considered. However, during close observation of the clinical course, any signs and symptoms of sepsis warrant immediate surgical treatment.