Successful Management of Pharyngeal Perforation Caused by Overtube Insertion During Endoscopic Submucosal Dissection

Abstract

A woman in her 70s underwent endoscopic submucosal dissection (ESD) for gastric-type adenoma in the anterior wall of the upper gastric body with intravenous anesthesia. We decided to use an overtube to control the air volume in the stomach. The overtube was inserted under endoscopic guidance using a sufficient amount of lubricating jelly. We encountered resistance when the top of the overtube was advanced to the pharynx; therefore, we stopped the overtube insertion and pulled the tube out immediately. We observed a linear injury in the posterior wall of the hypopharynx. The injury was deep and diagnosed as a pharyngeal perforation. Computed tomography (CT) revealed free air in the neck, with mediastinal emphysema. Conservative treatment was initiated after consultation with the otorhinolaryngologist; the patient received nothing per mouth and was administered intravenous antibiotics. The patient did not develop a fever and no signs of inflammation were observed. CT performed on postoperative day (POD) 5 revealed the disappearance of the mediastinal emphysema and a soft diet was introduced. The patient was discharged on POD 7. The ESD was postponed to two months later and was performed successfully. The scar of the perforation site was confirmed. In this report, we describe an extremely rare adverse event associated with overtube insertion. Although the incidence of pharyngeal perforation is low and its management is controversial, it was done without surgical intervention in the present case.