Self-expanding metal stents for esophageal perforation with nasogastric tube insertion in esophageal carcinoma.

Sir,

We report a rare complication of nasogastric tube (NG) insertion. A 71-year-old male, known case of carcinoma lower 1/3rd esophagus, postchemoradiotherapy was admitted for the second cycle of radiation therapy. For enteral nutrition NG insertion was performed. On next day of NG tube insertion, patient started complaining of chest pain, upper abdominal pain, breathlessness, and hurried breathing. Chest X-ray showed left sided pleural effusion [Figure 1]. Computed tomography (CT) thorax showed pneumomediastinum with air tracking along the descending thoracic aorta and few pockets of air in retrocrural compartment with mild left pleural effusion and subsegmental collapse of posterobasal segments of the left lower lobe. Gastrograffin swallow study was done suspecting esophageal perforation during NG tube insertion. Contrast leak into the left side of the mediastinum was seen from the distal esophagus ~3.5 cm from the gastroesophageal (GE) junction [Figure 2]. Distal esophagus (for a length of 3 cm) just above the GE junction was narrowed in caliber. Diagnosis of perforation at lower 3.5 cm of the esophagus was confirmed. Patient was shifted to multidisciplinary intensive care unit for observation and noninvasive ventilation for respiratory compromise. Total parentral nutrition was initiated and left intercostal drain was put for pleural effusion. Patient improved in the course of 6 days and self-expanding metal stents (SEMS) was placed in strictured lower 1/3rd of esophagus endoscopically. A repeat Gastrograffin scan the following day showed no leak of contrast from the esophagus into the pleural cavity [Figure 3]. Meanwhile, chest X-ray showed clearing of pleural effusion and stent in situ.

Figure 1

Chest radiography showing left sided pleural effusion

Figure 2

Gastrograffin swallow study showing contrast leak from the distal esophagus ~3.5 cm from the gastroesophageal junction into left side mediastinum

Figure 3

Self-expanding metal stents in situ in strictured lower 1/3rd of esophagus with no leak in Gastrograffin scan

Though NG tube insertion is a routinely performed procedure, esophageal perforation is rare and life-threatening complication. The most common causes of esophageal perforation are iatrogenic injury following endoscopy, balloon dilatation, stent placement, trans esophageal echocardiography, etc., which account for 59% of perforations.[1] Esophageal carcinoma and therapeutic radiotherapy predispose such patients to perforation. Early diagnosis and prompt treatment are vital in reducing mortality. Patients with already compromised esophagus require additional caution while NG tube insertion. Surgical and conservative approaches for management have been reported depending on cause, site, extent of leak, and patient condition. Pneumomediastinum and synpneumonic effusion are both known sequalae of esophageal perforation. Symptoms and signs can be nonspecific. CT scan and gastrograffin scan should be used early. Gastrograffin scan is a confirmatory test. Pneumothorax was absent. However, effusion and respiratory compromise prompted intercostal drain placement, which improved patient condition. However, leak from the perforated esophagus continued and collection in the intercostal drain persisted. Hence, SEMS was considered. SEMS have been described for traumatic esophageal perforations and anastomotic leaks.[2] Improved survival rates, low mortality and morbidity have been documented. A clinical success rate of 63-100% has been found for perforations and anastomotic leaks.[3] However, it is associated with stent migration and ulceration. The mortality rate after surgical repair of iatrogenic perforation of esophagus and anastomotic leaks ranges from 12% to 50%, respectively.[4] Placement of such stents are not highly invasive and are not associated with significant perioperative risks.