Endoscopic Clip Application for Postoperative Residual Esophageal Duplication Cyst

Abstract

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, with− out any response. At admission, the clinical examination was un− remarkable 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 exten− sive 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 sur− gery, 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 re− vealed 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 (Fig− ures 2 b). The first clip was only able to catch one wall of the leak− age site, but the use of two more clips led to successful approxi− mation 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 histolo− gy of the excised cyst showed features of a congenital duplication cyst. DiscussionEsophageal 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.

Esophageal Duplication Cysts in 97 Adult Patients: A Systematic Review

“…One postoperative complication was reported in a 35‐year‐old woman, who developed chest pain and fever on her POD 10. A swallow study revealed a leakage into the posterior mediastinum, which was successfully resolved by endoscopy applying metallic clips [35]. One 30‐year‐old male patient died in whom a thoracotomy was performed for resecting an EDC.…”

“…If the cyst is not promptly diagnosed, it might cause severe complications such as perforation [20,[27][28][29][30], mild bleeding [31,32] intramural hematoma [33] and massive hemorrhage into the pleura space [34]. Infection is another known complication of EDC [35][36][37][38]. Agarwal et al [39] and Tomar et al [40] reported two young adults who presented with an EDC masquerading pericarditis and post-infective bronchiectasis, respectively.…”