Hybrid therapy of late diagnosed esophageal perforation, complicated by mediastinitis and bilateral empyema.

An 81-year-old man was admitted to our hospital with clinical deterioration 6 days after diagnostic gastroscopy. Computed tomography (CT) scan showed distal esophageal perforation, bilateral empyema, and a contrast leak into the right pleural cavity (▶Fig. 1). Bilateral video-assisted thoracoscopy was performed, evacuating the empyema, debriding the pleural spaces, and incising the mediastinal pleura. The site of esophageal perforation was located, and mediastinal and pleural drains were placed (▶Video1). During the same session upper endoscopy was performed, which showed an approximately 12mm perforation in the distal third of the esophagus. We used an over-the-scope clip (OTSC; Ovesco, Tübingen, Germany) to close the defect. A gastrografin esophagogram performed immediately after clip deployment showed no contrast leak (▶Fig. 2). A fully covered selfexpanding metal stent (SEMS; Wallstent; Boston Scientific, Marlborough, Massachusetts, USA) was placed to cover the perforation site after OTSC deployment (▶Video2). A CT scan 7 days after closing the perforation showed improvement of the pleural effusion (▶Fig. 3 a). A gastrografin study showed no contrast leak (▶Fig. 3b). The patient re-started an oral diet, and was discharged 13 days after closure of the perforation. The stent was removed without complications 1 month later. A CT scan showed a small encapsulated left pleural effusion, which was successfully drained. Esophageal perforation remains a lifethreatening condition despite the advances of surgery and intensive care. Iatrogenic injury is the most common cause [1, 2]. Most cases are treated by surgery, with high morbidity and mortality especially in elderly and multimorbid patients [1]. Endoscopic therapy is a valuable option for perforations that are recognized early [3]. Placement of a fully covered SEMS is associated with a high stent migration rate, especially in cases without a stenosis and if located in the region of the cardia [2, 4]. Partially covered E-Videos