J Korean Med Sci.  2014 May;29(5):739-742. 10.3346/jkms.2014.29.5.739.

Gastroplasty for Esophageal Perforation after Endoscopic Balloon Dilatation for Achalasia: Two Cases

• Kim H

• KMID: 1786119
• DOI: http://doi.org/10.3346/jkms.2014.29.5.739

Abstract

Esophageal perforation after endoscopic forceful pneumatic dilatation for achalasia is a devastating complication and surgical treatment is necessary. A 65-yr-old man and a 54-yr-old woman referred for esophageal perforation two hours after pneumatic dilatation and during the procedure, respectively. Gastroplasties through thoracotomy were performed in both cases and their recoveries were uneventful. The esophagogram with gastrografin on the post-operative 8th day did not show any passage disturbance or leakage at the anastomosis site. On the follow-up endoscopy 4 to 6 months after operation revealed that reflux esophagitis of LA classification A were noted in the both patients. They did not complain any reflux symptom or dysphagia for 9 to 13 months after operation. Instead of the most widely used procedure; primary repair of perforation site, wrapping with intercostal muscle flap and esophagomyotomy, gastroplasty was performed in two cases of iatrogenic esophageal perforation in achalasia and experienced good results.

Keyword

Gastroplasty; Esophageal Perforation; Esophageal Achalasia

MeSH Terms

Aged
Deglutition Disorders/complications
Endoscopy, Gastrointestinal/*adverse effects
Esophageal Achalasia/*surgery
Esophageal Perforation/*surgery
Esophagus/*surgery
Female
Gastroesophageal Reflux/complications
Gastroplasty/*methods
Humans
Male
Middle Aged
Thoracotomy

Figure

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  Fig. 1 Chest CT scan of the patient of case 1. It reveals that focal rupture at the left lateral wall of lower thoracic esophagus just above esophagogastric junction (arrow), large amount of pneumomediastinum, small amount of mediastinal fluid collection and left pleural effusion.

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  Fig. 2 Esophagogastroscopic findings of case 2. (A) Preoperative view of distal esophagus. Arrow indicated the ruptured esophageal wall, through which the pleural cavity could be identified. (B) Postoperative view of anastomosis site from distal body.

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  Fig. 3 Esophagogram of case 2 on the postoperative 8th day. Passage disturbance or leakage of contrast was not detected at the anastomosis portion.

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  Fig. 4 (A) Longitudinal incision of all layers was made as long as the length of perforated esophagus onto the cardia across the lower esophageal sphincter. Transverse single layer interrupted suture with 4-0 black silk were passed through all layers of esophagus and cardia with the knots tied on the outside (a to a', b to b'), suggesting the Heineke-Mikulicz pyloroplasty. (B) Redundant cardia was wrapped over the anastomosis site like as a partial fundoplication of Belsey Mark IV procedure.

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