A novel multi-step approach to managing a complex esophageal perforation. An 85-year-old male patient was admitted with severe chest pain, difficulty breathing, and decreased air entry in the right lower lung zone. He was diagnosed with an hydrogenic esophageal perforation, which led to a right-sided hydroneumothorax as confirmed by initial cross-sectional imaging. Due to his poor performance status, surgical intervention was deferred. Upon upper endoscopy, a significant mid-esophageal perforation was identified. A fully covered self-expanding metal stent was placed over the defect, and an intercostal drain was inserted to manage the hydroneumothorax. However, after removal of the stems, the perforation persisted. To address the remaining defect, endoluminal vacuum therapy was attempted. However, due to the unavailability of commercial endoluminal vacuum devices, an innovative indigenous endosponge was created by attaching the sponge to the distal endoparietal tube and connecting it to a negative pressure wound therapy device. Using rat-tooth forceps, the endosponge was guided to the site of the esophageal defect, and a pressure of 125 millimeters of mercury was maintained. The sponge was replaced every three days, with its size adjusted to match the size of the defect. Over time, a noticeable reduction in the defect size was observed, prompting the use of progressively smaller sponges. During this period, the patient was provided enteral nutrition through an esojuginal tube. Despite four sessions of endovac therapy, the perforation remained. Consequently, TAC and suture device, a novel technique for tissue closure, was employed. TACs were placed 5 to 10 millimeters from the margin of the mucosal defect, first securing healthy tissue before inserting the TACs into the target tissue using a Persian drill handle. The TACs were deployed using a push catheter, and tension was applied to the suture to eliminate slack. A zigzag pattern was used to ensure optimal coverage of the perforation. After each TAC placement, the suture was tightened before the push catheter was removed to allow for the suture cinch to secure the tissue and maintain the tension. After the procedure, an oral gastrograph and study confirmed the absence of any leak. The patient was gradually reintroduced to oral liquids while continuing NJFeeds for another week. A follow-up chest X-ray revealed significant improvement, including the resolution of the right-sided hydra pneumothorax. The patient reported no new complaints, and his condition showed substantial recovery. This case underscores the challenges encountered in managing a complex esophageal perforation in a patient with multiple comorbidities for whom surgical treatment was not an option. The multifaceted approach, including the use of an indigenous endosponge and TAC and suture device, successfully closed the defect and emphasizes the complexity of the case.

esophageal perforation

endoluminal vacuum therapy

non-surgical approach

tissue anchors

high-risk patients