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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 72-74

Denture-induced esophageal perforation: Role of esophagogastroduodenoscopy and fully covered self-expandable metallic stent


1 Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh, India
2 Department of MDS – Orthodontics and Craniofacial Surgery – Dental College, IGMC, Shimla, Himachal Pradesh, India
3 Department of Otorhinolaryngology, IGMC, Shimla, Himachal Pradesh, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Rajesh Sharma
Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_63_17

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  Abstract 


Acute esophageal perforations are potentially life-threatening events that carry high morbidity and mortality rates. There has been a paradigm shift in the standard treatment of acute esophageal perforations from surgery to esophageal stents over the last two decades. We report a case of a 62-year-old male, managed successfully with fully covered esophageal stent for foreign body (denture)-induced acute esophageal perforation. The report also highlights the failure of routine radiological investigation to detect and localize denture (as dentures are made of radiolucent material).

Keywords: Contrast-enhanced–computed tomography, esophagogastroduodenoscopy, fully covered–self-expandable metallic stent


How to cite this article:
Sharma R, Bodh V, Bodh D, Sharma B, Sharma D, Shaweta. Denture-induced esophageal perforation: Role of esophagogastroduodenoscopy and fully covered self-expandable metallic stent. CHRISMED J Health Res 2018;5:72-4

How to cite this URL:
Sharma R, Bodh V, Bodh D, Sharma B, Sharma D, Shaweta. Denture-induced esophageal perforation: Role of esophagogastroduodenoscopy and fully covered self-expandable metallic stent. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 3];5:72-4. Available from: http://www.cjhr.org/text.asp?2018/5/1/72/223124




  Introduction Top


Esophageal perforations are potentially life-threatening, that carries high morbidity and mortality rates. There has been a paradigm shift in the standard treatment of acute esophageal perforations from surgery to esophageal stents over the last two decades. Dentures are made of radiolucent material (poly-methyl methacrylate), which can be missed on routine radiological investigations including CT scan. Esophagogastro duodenoscopy is helpul not only in detection but also in retrieval of dentures. Acute esophageal perforations can be successfully managed with FC-SEMS.


  Case Report Top


A 62-year-old male referred to our institute, with a history of accidental ingestion of denture 10 days back. There was a history of difficulty and pain during swallowing both for solids and liquids that started after denture ingestion. There was no history of coughing, difficulty in breathing and fever. On examination, crepitus present on palpation of neck and anterior chest. Rest of the systemic examination was unremarkable. Routine blood investigations including hemogram, fasting blood sugar, renal and liver function tests were within normal limits except for neutrophilic leukocytosis (total leucocyte count 18,000 μ/L, with neutrophils of 85%). Water soluble contrast study [Figure 1] of esophagus revealed contrast extravasations from cervical esophagus. Contrast-enhanced–computed tomography (CT) neck and thorax [Figure 2]a and [Figure 2]b revealed left posterior rupture of upper esophagus at D1 level, with extravasations of oral contrast into soft tissue spaces on the lateral aspect of the neck with extensive surgical emphysema in pharyngeal space and cervical soft tissues bilaterally. The surgical emphysema was also extending into the anterior mediastinum, posterior soft tissues on the left side of neck and soft tissues of the left hemithorax. CT of neck did not reveal any metal artefact in our case, as denture is made up of radiolucent polymethylmethacrylate, making imaging diagnosis difficult. Esophagogastroduodenoscopy revealed denture impacted at upper esophagus and retrieved with snare [Figure 3]a.
Figure 1: Gastrografin esophagram arrow shows contrast extravasations from cervical esophagus

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Figure 2: (a) Arrow shows extensive cervical surgical emphysema (b) arrow shows cervical esophageal contrast extravasations, arrowhead shows surgical emphysema

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Figure 3: (a) Arrow shows denture impacted at upper esophagus (b) arrow shows fully covered–self-expandable metallic stent after placement

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After denture removal, small rent was noticed on opposite walls of esophagus in upper part of esophagus. In view of acute esophageal perforation, fully covered–self-expandable metallic stent (FC-SEMS) was placed across the esophageal perforation [Figure 3]b and proximal end of SEMS was tied with plastic thread and anchored to canines (to prevent inward migration). He was started per orally after 12 h. FC-SEMS was removed after 6 weeks, and complete healing of esophageal tear was achieved.


  Discussion Top


Acute esophageal perforations are potentially life-threatening events that carry high morbidity and mortality rates.[1] Due to a lack of a protective serosal surface, perforations of the esophagus can easily expand into the surrounding tissue, leading to mediastinitis and empyema of the pleural cavity.[2] Detection of the radiolucent foreign body like dentures (made of poly-methyl methacrylate a radiolucent material), is difficult with a routine radiological investigation like X-ray and CT making esophagogastroduodenoscopy the investigation of choice for detecting, localizing, and removing radiolucent foreign body as seen in our case. The management of esophageal perforation depends on the site, size, and etiology of the underlying disease.

The reported mortality from treated esophageal perforation is 10%–25%, when therapy is initiated within 24 h of perforation, and it is 40%–60% when the treatment is delayed.[3]

Conventionally, surgery is considered as a gold standard treatment for an acute esophageal perforation. There has been a paradigm shift toward the use of esophageal stents for acute esophageal perforations over the last two decades.

Esophageal stent placement was used primarily for the treatment of malignant strictures until the development of a new generation of biomaterials that allowed the production of easily removable occlusive stents.

Earlier SEMS was reserved for palliation for malignant esophageal strictures and malignant tracheo-esophageal fistulae [4] because of the potential esophageal damage associated with extraction including reports of irreparable, sometimes life-threatening, fistulae.

Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined a nonpermeable covering, radial force sufficient to occlude a transmural esophageal injury and improved ease of removability. These advances set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. FC-SEMS is safe and less invasive treatment as compared to surgery.

The utilization of FC-SEMS began in high-risk patients who had either previously undergone a failed operative repair or were unsuitable candidates for transthoracic repair of an esophageal leak with success rate of 95%.[5] Some centers have developed hybrid treatment protocol which includes operative or percutaneous drainage of infected spaces, the establishment of enteral nutrition along with esophageal stent placement. Oversize of stent both in length, and diameter (21–25 mm) has beneficial effect on stent migration and seal the leak relatively quickly.[6]

Contrast esophagram is performed, minimum after 24 h after stent placement to document successful leak occlusion.[6]

Factors associated with an increased failure rate of FC-SEMS include esophageal injury >6 cm in length, injury that traversed gastroesophageal junction, proximal cervical esophagus, or leak in gastric conduit in esophagectomy patients.[7]

Regarding optimal time for esophageal stent removal, rates of complications were higher in patients whose stent was left in place for >4 weeks when treating an acute perforation or longer than 2 weeks when treating an anastomotic leak. Leaks which persisted beyond these time intervals were evaluated for surgical repair or a modification of stent therapy.[8]

Success rates of FC-SEMS in the treatment of acute perforations (100%), fistula (71.4%), and anastomotic leaks (80%).[9]

Direct endoluminal closures of iatrogenic perforations have been reported with clips (through-the-scope, over-the-scope) and endoluminal suturing techniques.[10] Endoclips in the esophagus could be considered when perforation diameter is small (<2 cm) but surgical intervention is recommended if perforation is recognized late (greater 24 h), or larger perforation diameter (>2 cm) and if there is evidence of leak into the mediastinum.[11]


  Conclusion Top


Acute benign esophageal perforations are potentially life-threatening events, and there has been a paradigm shift in management from surgery to esophageal stents (FC–SEMS) over the last two decades. A routine radiological investigation including X-rays and CT has failed to detect radiolucent foreign body such as denture making esophagogastroduodenoscopy the investigation of choice for detecting, localizing, and removing radiolucent foreign body.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raju GS, Thompson C, Zwischenberger JB. Emerging endoscopic options in the management of esophageal leaks (videos). Gastrointest Endosc 2005;62:278-86.  Back to cited text no. 1
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2.
Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS, et al. Esophageal perforation: A therapeutic challenge. Ann Thorac Surg 1990;50:45-9.  Back to cited text no. 2
    
3.
Brewer LA 3rd, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the esophagus. Am J Surg 1986;152:62-9.  Back to cited text no. 3
    
4.
Ell C, Hochberger J, May A, Fleig WE, Hahn EG. Coated and uncoated self-expanding metal stents for malignant stenosis in the upper GI tract: Preliminary clinical experiences with Wallstents. Am J Gastroenterol 1994;89:1496-500.  Back to cited text no. 4
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5.
Nelson DB, Silvis SE, Ansel HJ. Management of a tracheoesophageal fistula with a silicone-covered self-expanding metal stent. Gastrointest Endosc 1994;40:497-9.  Back to cited text no. 5
[PUBMED]    
6.
Ong GK, Freeman RK. Endoscopic management of esophageal leaks. J Thorac Dis 2017;9:S135-45.  Back to cited text no. 6
    
7.
Freeman RK, Ascioti AJ, Giannini T, Mahidhara RJ. Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak. Ann Thorac Surg 2012;94:959-64.  Back to cited text no. 7
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8.
Freeman RK, Ascioti AJ, Dake M, Mahidhara RS. An assessment of the optimal time for removal of esophageal stents used in the treatment of an esophageal anastomotic leak or perforation. Ann Thorac Surg 2015;100:422-8.  Back to cited text no. 8
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9.
Suzuki T, Siddiqui A, Taylor LJ, Cox K, Hasan RA, Laique SN, et al. Clinical outcomes, efficacy, and adverse events in patients undergoing esophageal stent placement for benign indications: A Large multicenter study. J Clin Gastroenterol 2016;50:373-8.  Back to cited text no. 9
[PUBMED]    
10.
Raju GS. Endoscopic closure of gastrointestinal leaks. Am J Gastroenterol 2009;104:1315-20.  Back to cited text no. 10
[PUBMED]    
11.
Yılmaz B, Unlu O, Roach EC, Can G, Efe C, Korkmaz U, et al. Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand? Dig Endosc 2015;27:641-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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