Management of huge infected esophageal defect boosts submucosal tunnel endoscopic resection using endoscopic endovacular therapy. Submucosal tunnel endoscopic resection is a minimally invasive intervention for management of esophageal submucosal tumor, with reported risk of complication, especially among large lesions originated from the first layer. A 32-year-old male patient with dysphagia and weight loss. Endoscopic assessment revealed large submucosal tumor 24 cm from incisors. EOS reported 7 cm leiomyoma originated from the second layer. Our decision was to do ESD. Endoscopic assessment raised the doubt of deep origin of the lesion. We changed the strategy to STIR instead of ESD. Submucosal tunnel placed 2 cm above the lesion and started to isolate the lesion from the surrounding submucosal. With more dissection, the lesion found to originate from the fourth layer. STIR procedure continued and isolate the lesion from the surrounding submucosal. Full thickness myotomy was needed to totally remove the lesion. Multiple trials to extract the large lesion resulted in extension of the mucosal incision. The large incision was then closed using multiple hemoclips due to unavailability of suturing device. The lesion was totally extracted in piecemeal fashion. Pathology confirmed a leiomyoma. Two days after the procedure, the patient developed high-grade resistant fever with signs of infection. CT sheath in day 3 showed a large contained mediastinal leak. Gastroscope revealed detachment of multiple proximal clips with huge infected esophageal defect. We decided to place handmade modified endovacuum, which allow a tailored size for the vacuum according to the defect length. We decided to place handmade modified endovacuum, which allow a tailored size for the vacuum according to the defect length. The endovacuum made using nasogastric tube, antibacterial tab introduced through the patient nose and placed in the defect and connected to a continuous negative suction. Marked improvement of the patient clinical and laboratory condition 24 hours after placement of the endovacuum therapy. We exchanged the endovacuum every 5 to 7 days. After two endovacuum exchange, the size of the defect markedly decreased in size with absence of any sign of infection. We removed all missed clips in the defect piece and over the healed mucosa and placed a new endovacuum. With removal of the pores endovacuum, we have a small clean defect with healed mucosa in the distal end. Real-time contrast injection under fluoroscopic guidance showed shorted effect not communicating with the mediastinum. We decided to do mucosectomy for the distal mucosal bridge to connect the remnant defect to the esophageal lumen. The last endovacuum was a long one. Placed intranuminal with adjusted lens 4 cm above and below the remaining defect. Follow-up gastroscope after 10 days showed totally sealed defect. Modified endoscopic endovacuum therapy may be a valuable option to treat large esophageal defect, especially in low-resources setting.

esophageal defect management

submucosal tunnel endoscopic resection

dysphagia

endoscopic submucosal dissection

mediastinal leak