571. ESOPHAGEAL PERFORATION AFTER LOBECTOMY: PADLOCK CLIP TO THE RESCUE

Abstract

Abstract Esophageal perforation or fistula is a devastating condition with diagnostic and therapeutic challenges. It is associated with high morbidity and mortality due to its rapid progression to mediastinitis or peritonitis, septic shock and multiorgan failure. Iatrogenic perforation is the commonest in this era. We hereby report a case of esophagopulmonary fistula following a right lower lobectomy which was successfully treated with endoscopic clipping. A 52-year-old man presented with productive cough and weigh loss for 2 weeks. Initial workup in another center revealed right lung lower lobe lesion and a right lower lobectomy was done. Saliva and food particle were noted in chest drain on post-operative day 2 due to esophageal perforation. Re-thoracotomy, washout and esophageal repair was done. An open window thoracostomy was created for further drainage and parenteral nutrition was initiated. Histology of the lobectomy specimen revealed actinomycosis of right lung. However, there was persistent leak from the esophagus with suspicion of esophagopulmonary fistula. He was then transferred to our center for further treatment. OGDS revealed a 5mm defect at right lateral wall mid thoracic esophagus, about 28cm from incisor, with healthy and supple surrounding mucosa. Contrast study revealed esophagopulmonary fistula. Esophageal defect was successfully closed with over-the-scope padlock clip (Steris). Repeat contrast study 1 week later revealed resolution of fistula. Sepsis and source control, nutritional support with restoration of gastrointestinal tract intergrity are key steps in the management of esophageal perforation. Endoscopic treatment is efficacious, less invasive, and with the advantage of organ preservation. Endoscopic clipping is safe and effective in selected group of patients with esophageal perforation or fistula.