Abstract
Esophageal perforation is a rare but life-threatening condition with historically high morbidity and mortality. Traditional management has relied on urgent surgical repair, but advances in endoscopic therapy have expanded non-surgical options. We present a case of an 84-year-old male patient with an esophageal perforation caused by food impaction in the setting of a Schatzki ring, successfully managed through a stepwise endoscopic approach using a fully covered self-expanding metal stent (FCSEMS) followed by argon plasma coagulation (APC) and endoscopic clipping to close a residual defect. The patient with risk factors including advanced age, chronic esophageal strictures, and a history of repeated dilations presented with acute dysphagia and chest pain following food impaction. Imaging revealed a distal esophageal perforation with pneumomediastinum and developing mediastinal fluid collection. Esophagogastroduodenoscopy (EGD) identified an impacted food bolus and a 1 cm perforation surrounded by necrotic debris. Endoscopic debridement was performed, and a fully covered 23 mm × 120 mm EndoMAXX esophageal stent (Merit Medical Systems, Inc., South Jordan, UT) was deployed under fluoroscopic guidance to seal the defect. At the two-week follow-up EGD, the stent remained in position with granulation tissue formation. Due to persistent dysphagia, likely secondary to stent-related granulation tissue, mucosal inflammation, or mechanical irritation, the stent was removed. At eight weeks, a small residual 3 mm perforation was visualized. This was treated with APC (1.2 L/min, 20 W) to ablate epithelialized edges, followed by mechanical closure using two MANTIS clips (Boston Scientific Corporation, Marlborough, MA). A percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) tube was surgically placed for enteral support. A 10-week endoscopy confirmed mucosal healing with embedded clips and no surrounding inflammation. At 16 weeks, an esophagram demonstrated complete closure without a leak. The PEG-J tube was removed, and the patient resumed normal oral intake, underscoring the effectiveness of stepwise endoscopic management for esophageal perforation. This case illustrates the effective use of multimodal endoscopic therapy for esophageal perforation. Fully covered stent placement achieved initial closure and containment, while a secondary endoscopic intervention (APC with clipping) successfully sealed a persistent micro-perforation. The sequential minimally invasive approach obviated the need for thoracic surgery and its associated risks. Advances in endoscopic stents, tissue ablation, and clipping devices offer a paradigm shift in managing esophageal perforations, especially in elderly or high-risk patients.