A232 COMBINATION OF EVAC AND BARIATRIC STENTS IN THE MANAGEMENT OF ESOPHAGEAL PERFORATION

Treatment of oesophageal perforation relies on endoscopic procedures. We present a case of iatrogenic oesophageal perforation treated with a novel endoscopic treatment Review of litterature with PubMed, Ovid Medline. Key words EVAC, stent, esophageal perforations, vaccum system An 84-year-old lady was refered for an oesophageal perforation following a para-esophageal hiatal hernia repair. The perforation was complicated by a intra-thoracic collection. A previous percutaneous drainage had failed. A first gastroscopy (EGD) performed demonstrated a 1x2cm distal oesophageal perforation leading to a 13.7x22.1cm cavity. A 22mmx120mm stent (Hanarostent Esophaus Bening BS (CCC), M.I. Tech, South Korea) was put in place. A barium swallow 2 days later revealed a persistent leak and partial migration of the stent. A second EGD was performed, an EVAC system was constructed with a sponge (V.A.C. Therapy GranuFoam, Kinetic Concepts, USA) fixed to a nasogastric tube. The material was positioned at the perforation site and sealed in place with a 28x240mm bariatric stent (Hanarostent Esophagus Bariatric Surgery (CCC)). Oral nutrition was resumed and tolerated. Fourteen days later, an EGD showed a 50% reduction in the size of the cavity. The EVAC was reinstalled and a regular 22x120mm stent was placed (Hanarostent Esophagus Benign BS (CCC)). In order to prevent its migration its proximal portion was anchored to the nasogastric tube with a clip (Resolution Clip, Boston Scientific, USA). Unfortunately a leak occurred and a fouth EGD was required 6 days later. The stent was replaced by a 28x240mm bariatric stent. Twenty-one days later the last EGD confirmed complete regression of the cavity and healing of the oesophageal defect. The endoscopic material was removed and oral nutrition continued. To our knowledge this is the first case in which an iatrogenic oesophageal perforation is managed using the combination of EVAC and bariatric stents. Gubler et al described the use of EVAC with regular endoscopic stents but in their cases oral nutrition could not be resumed between the endoscopic interventions and the use of stents was required after removal of the EVAC system. We believe that the use of bariatric stents was the corner stone of our management. With their larger diameter they provide complete apposition of the material to the mucosal wall providing excellent sealing, allowing oral nutrition between the interventions. This technic enabled us to us to manage and treat the cavity without percutaneous drainage or surgery The combination of EVAC with bariatric stents should be considered as a first line management option for the treatment of oesophageal perforation when using minimally invasive interventions. These results need to be validated in prospective studies None

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