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Highlights • Spontaneous esophageal rupture is usually treated surgically. • However, endoscopic interventions can be performed with good outcomes. • Approach is based on degree of infection in the mediastinum and thoracic cavity. • We used an over-the-scope clip for esophageal rupture localized to mediastinum. • The esophageal perforation was closed once the inflammatory response subsided., Introduction and importance Spontaneous esophageal rupture is a life-threatening condition caused by a sudden increase in the intraesophageal pressure. While surgery is the mainstay of management for spontaneous esophageal ruptures, in recent years, an increasing number of patients have been managed with endoscopic interventions. We report a case of spontaneous esophageal rupture managed with endoscopic closure using an over-the-scope clip (Ovesco Endoscopy AG, Tübingen, Germany). Case presentation A 68-year-old female presented with epigastric pain and left-sided back pain following vomiting. A computed tomography scan revealed mediastinal emphysema and an esophagogram showed leakage from the left side of the lower thoracic esophagus into the mediastinum. The patient was diagnosed with spontaneous esophageal rupture localized to the mediastinum and was treated conservatively. However, she had persistent fever and continuing esophageal leakage on the esophagogram. On the 12th day of admission, a gastrointestinal endoscopy was performed, which found a 10-mm full-thickness longitudinal laceration on the left side of the lower esophagus. Endoscopic closure using an over-the-scope clip was performed. The next day, the patient became afebrile. One week later, esophagogram revealed slight residual leakage and an additional endoscopic closure using an over-the-scope clip was performed; the patient subsequently had an uneventful recovery and was discharged on the 44th day of admission. Clinical discussion Endoscopic closure using an over-the-scope clip led to a good outcome in this patient with spontaneous esophageal rupture. Conclusion Endoscopic closure using an over-the-scope clip is an effective and minimally invasive technique for selected patients with spontaneous esophageal rupture.

Highlights • LSG leaks often complicate post-operative recovery and require additional surgery. • Current non-invasive measures for LSG leaks can increase morbidity. • Endoscopy may serve as advancement in non-invasive management using materials in an innovative method., Introduction Conservative management for gastric leak and fistulae after laparoscopic sleeve gastrectomy (LSG) often results in prolonged hospitalization as well as requirement of TPN or recurrent surgery (Casella et al., 2009) [1]. Endoscopically-placed stents are an additional non-invasive method, but are associated with the complication of stent migration in up to 50% of cases (Casella and co-workers, 2009) [1,4]. As other non-invasive means of treatment are absent, we believe this case demonstrates a new technique for multiple gastric leaks following LSG in patients without sepsis or peritonitis. Presentation of case A patient developed a staple line gastric leak that persisted for 10 weeks following LSG despite multiple modalities of treatment. She refused to undergo stent placement, so via esophagogastroduodenoscopy (EGD), fistula margins were cauterized with argon plasma coagulation and a fibrin sealant was injected to include the surrounding area. Endoclips were placed along the fistula tracts. A repeat procedure was required. Follow up imaging confirmed resolution of gastric leak and patient did not experience additional complications. Discussion The patient was able to discontinue TPN and return to an oral diet. Both procedures were well tolerated and did not require hospitalization. Conclusion Endoscopic management of multiple gastric leaks and fistulae using fibrin seal, endoclips, and cauterization appears to be a promising noninvasive form of treatment with a lower associated morbidity and shortened hospitalization.