Endoscopic Clip Application for Postoperative Residual Esophageal Duplication Cyst

• Case Report
• Discussion
• References

Case Report

A 35-year-old woman presented with coughing, left-sided chest pain, and high-grade intermittent fever that had persisted for 3 weeks. She had received a course of antibiotics for a week, without any response. At admission, the clinical examination was unremarkable except for toxemia. The chest examination did not reveal any abnormality. A chest radiograph showed mediastinal widening and chest computed tomography revealed a cyst 8 × 10 × 4 cm in size communicating with the mid-esophagus, with an air-fluid level. An infected esophageal duplication cyst was diagnosed and the patient underwent surgery. Due to extensive adhesions, however, only partial excision of the cyst was achieved, and only a partially successful attempt could be made to suture the defect in the esophageal wall. Ten days after surgery, the patient developed chest pain, with a spiking fever. A contrast study revealed an esophageal leak into the posterior mediastinum (Figures [1 ] a). An upper endoscopic examination revealed a tear 7 - 8 mm long in the mid-esophagus (Figures [2 ] a).

After the patient had provided informed consent, metallic clips (Olympus, Tokyo, Japan) were applied to close the leak (Figures [2 ] b). The first clip was only able to catch one wall of the leakage site, but the use of two more clips led to successful approximation of the edges of the leak. The patient was kept nil per os for 72 h and given broad-spectrum antibiotics. A repeat contrast study on day 15 (Figures [1 ] b) and endoscopic examinations on days 7 and 21 revealed complete healing of the leak. The histology of the excised cyst showed features of a congenital duplication cyst.

Discussion

Esophageal duplication cysts generally present in childhood [1] [2]. Patients with duplication cysts in the upper third of the esophagus, as in the case described here, rarely reach adult life without experiencing any symptoms [3]. Mediastinitis occurs rarely in these patients [2]. The present patient presented for the first time with a mediastinal fluid collection at 35 years of age. Due to adhesions around the cyst, complete excision was not possible, and an attempt was made to close the esophageal defect, which failed. In these circumstances, a repeat exploration can be fraught with complications, and it was therefore decided to use Hemoclips to close the esophageal defect.

Hemoclips were first introduced in 1992 to close an esophageal tear after resection of a submucosal tumor [4]. Reports in the literature describe the use of the clips to treat post-esophagectomy leaks [5], spontaneous perforations [6], leaks following hydrostatic balloon dilation for esophageal achalasia [7], and submucosal resection of tumors in the esophagus [8]. Most endoscopists [4] [5] [6] [7] [8] have used two to four clips, and only a single session has been required in most cases, but Rodella et al. [5] reported two applications in one patient and three in another. A further five patients in the report required only a single session. All of these patients had adenocarcinoma of the cardia/stomach and had undergone esophagogastrostomy, esophagojejunostomy, or gastrojejunostomy. The interval from the diagnosis of leakage to clip application varied from 1 day to 33 days.

Hemoclips can be applied in most leaks or perforations, as the applicator allows rotation of the clips. One would imagine that only small defects (less than 20 mm) could be closed, as larger defects may have gaping edges [5]. There have been no reports on the use of Hemoclips to treat larger defects.

We would reiterate here the conclusions drawn by Rodella et al. [5], that metallic clip application represents a safe and easily repeated method of treating leaks in the upper gastrointestinal tract. After clipping, the median time until closure of the leak is clearly shorter than with surgery or conservative treatment.

References

• 1 Overhaus M, Decker P, Zhou H. et al . The congenital duplication cyst: a rare differential diagnosis of retrosternal pain and dysphagia in a young patient.  Scand J Gastroenterol. 2003;  38 337-340
  CrossrefPubMedSearch in Google Scholar
• 2 Holemans J A, Rankin S C. Case report: oesophageal duplication cyst causing left lung collapse and hypoperfusion.  Br J Radiol. 1995;  68 82-84
  PubMedSearch in Google Scholar
• 3 Minor G R. Mediastinal cyst treated by marsupialization to the esophagus.  Ann Surg. 1954;  139 203-235
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• 4 Binmoeller K F, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma.  Gastrointest Endosc. 1993;  39 172-174
  CrossrefPubMedSearch in Google Scholar
• 5 Rodella L, Laterza E, de Manzoni G. et al . Endoscopic clipping of anastomotic leakages in esophagogastric surgery.  Endoscopy. 1998;  30 453-456
  Thieme ConnectPubMedSearch in Google Scholar
• 6 Blocksom J M, Sugawa C, Tokioka S, Williams M. The Hemoclip: a novel approach to endoscopic therapy for esophageal perforation.  Dig Dis Sci. 2004;  49 1136-1138
  CrossrefPubMedSearch in Google Scholar
• 7 Wewalka F W, Clodi P H, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia.  Endoscopy. 1995;  27 608-611
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Shimizu Y, Kato M, Yamamoto J. et al . Endoscopic clip application for closure of esophageal perforations caused by EMR.  Gastrointest Endosc. 2004;  60 636-639
  CrossrefPubMedSearch in Google Scholar

R. Kochhar, MD

Dept. of Gastroenterology · Postgraduate Institute of Medical Education and Research

Chandigarh 160 012 · India

Fax: +91-172-2744401

Email: dr_kochhar@hotmail.com

References

• 1 Overhaus M, Decker P, Zhou H. et al . The congenital duplication cyst: a rare differential diagnosis of retrosternal pain and dysphagia in a young patient.  Scand J Gastroenterol. 2003;  38 337-340
  CrossrefPubMedSearch in Google Scholar
• 2 Holemans J A, Rankin S C. Case report: oesophageal duplication cyst causing left lung collapse and hypoperfusion.  Br J Radiol. 1995;  68 82-84
  PubMedSearch in Google Scholar
• 3 Minor G R. Mediastinal cyst treated by marsupialization to the esophagus.  Ann Surg. 1954;  139 203-235
  PubMedSearch in Google Scholar
• 4 Binmoeller K F, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma.  Gastrointest Endosc. 1993;  39 172-174
  CrossrefPubMedSearch in Google Scholar
• 5 Rodella L, Laterza E, de Manzoni G. et al . Endoscopic clipping of anastomotic leakages in esophagogastric surgery.  Endoscopy. 1998;  30 453-456
  Thieme ConnectPubMedSearch in Google Scholar
• 6 Blocksom J M, Sugawa C, Tokioka S, Williams M. The Hemoclip: a novel approach to endoscopic therapy for esophageal perforation.  Dig Dis Sci. 2004;  49 1136-1138
  CrossrefPubMedSearch in Google Scholar
• 7 Wewalka F W, Clodi P H, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia.  Endoscopy. 1995;  27 608-611
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Shimizu Y, Kato M, Yamamoto J. et al . Endoscopic clip application for closure of esophageal perforations caused by EMR.  Gastrointest Endosc. 2004;  60 636-639
  CrossrefPubMedSearch in Google Scholar

R. Kochhar, MD

Dept. of Gastroenterology · Postgraduate Institute of Medical Education and Research

Chandigarh 160 012 · India

Fax: +91-172-2744401

Email: dr_kochhar@hotmail.com