Complete endoscopic closure (clipping) of a large esophageal perforation after pneumatic dilation in a patient with achalasia

The risk of esophageal perforation following endoscopic balloon dilation for achalasia is in the range of 1 and 5% with a mortality rate of 1-20%. Perforations need to be recognized early and, if reasonable, an immediate endoscopic repair should be pursued quickly. Herein, we report a case of successful endoscopic closure by clipping of a large iatrogenic perforation in a patient with achalasia. An 80-year-old woman with achalasia was admitted to our institution to undergo pneumatic dilation. A 40-mm balloon dilator with inflation pressure of 20 PSI was used for 2 minutes as usual. During the procedure, the patient had a transient bradycardia. Endoscopic control showed a 2-cm rupture of the distal esophagus. Prompt endoscopic repair of the perforation by endoclips (n=6) was then attempted, followed by conservative management by total parenteral nutrition and intravenous antibiotics. Endoscopic clipping closed completely the esophageal perforation. The patient was given oral nutrition 10 days later without any complications. Six months after the discharge, the patient was healthy and free of dysphagia. Endoscopy showed complete healing of the esophageal mucosa without luminal stenosis. This report highlights that prompt endoscopic clipping is a useful means to close a large esophageal perforation caused by pneumatic dilation