Iatrogenic Esophageal Perforation Following Pneumatic Balloon Dilatation for Primary Achalasia Successfully Managed with Endoscopic Stenting and Conservative Therapy: A Case Report
DOI:
https://doi.org/10.52206/jsmc.2026.16.3.1555Abstract
Background: Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of normal esophageal peristalsis. Pneumatic balloon dilatation (PBD) remains one of the most widely employed minimally invasive therapeutic options for achalasia because of its high efficacy and cost-effectiveness. However, esophageal perforation is an uncommon but potentially life-threatening complication that requires prompt diagnosis and multidisciplinary management to minimize morbidity and mortality.
Case Presentation: A man in his fifth decade presented with progressive dysphagia involving both solids and liquids. Diagnostic evaluation, including upper gastrointestinal endoscopy, barium swallow examination, chest radiography, and esophageal manometry, confirmed primary achalasia. Owing to financial considerations and clinical suitability, the patient underwent pneumatic balloon dilatation using a 35-mm balloon. Immediately following the procedure, he developed neck pain, dyspnea, and subcutaneous emphysema. Emergency endoscopy confirmed a 4-cm iatrogenic distal esophageal perforation.
Management & Results: The patient was successfully managed with covered esophageal stent placement, percutaneous endoscopic gastrostomy (PEG) tube insertion for enteral nutrition, chest tube drainage for associated pneumothorax, broad-spectrum antibiotics, proton pump inhibitors, and supportive care. During recovery, he developed a lower respiratory tract infection that responded favorably to intravenous antimicrobial therapy. Follow-up endoscopy demonstrated complete healing of the perforation, permitting successful stent removal. Mild residual dysphagia persisted, consistent with the underlying esophageal aperistalsis associated with achalasia.
Conclusion: Esophageal perforation following pneumatic balloon dilatation is a rare but serious complication requiring early recognition and prompt multidisciplinary intervention. This case demonstrates that carefully selected patients with contained perforations can be successfully managed using endoscopic stenting combined with conservative medical therapy, thereby avoiding surgical repair and achieving favorable clinical outcomes.
Keywords: Achalasia, Endoscopic Stenting, Esophageal Perforation, Lower Esophageal Sphincter, Pneumatic Balloon Dilatation.
References
Sumi K, Inoue H, Nishikawa Y, Yamamoto K, Tanaka I, Tanabe M, et al. An Exploratory Endoscopic Achalasia Phenotype With Visible Squamocolumnar Junction and Distal Esophagogastric Junction Relaxation Failure: Association With Gastroesophageal Reflux Disease After Peroral Endoscopic Myotomy (With Video). Dig Endoscopy. 2026 Apr;38(4):e70149. https://doi.org/10.1111/den.70149
Minakari M, Sedaghat N. Endoscopic clipping of a complicated esophageal perforation following pneumatic dilation for achalasia: A case study and literature review. Clin. Case Rep. 2022 Nov;10(11):e6620. https://doi.org/10.1002/ccr3.6620
Knipe H, Ashraf A, Elfeky Ml. Esophageal perforation. Radiopaedia.org; 2024. https://doi.org/10.53347/rID-26147
Shaqran TM, Engineer R, Abdalla EM. The management of esophageal perforation: a systematic review. Cureus. 2024 Jul 2;16(7):e63651. https://doi.org/10.7759/cureus.63651
Wessels EM, Masclee GM, Bastiaansen BA, Saleh CM, Tack J, Boeckxstaens G, et al. Long-term Outcomes of Peroral Endoscopic Myotomy (POEM) versus Pneumatic Dilation after prior Laparoscopic Heller Myotomy for Achalasia. Clin Gastroenterol Hepatol. 2026 Apr 2. https://doi.org/10.1016/j.cgh.2026.03.024
Sakai Y, Booka E, Haneda R. Esophageal perforation following pneumatic dilation in esophageal achalasia successfully managed with two-stage laparoscopic surgery. Surg Case Rep. 2025;11(1):25-0418. https://doi.org/10.70352/scrj.cr.25-0418
Nachira D, Sassorossi C, Petracca-Ciavarella L, Zanfrini E, Tabacco D, Pogliani L, et al. Management of esophageal perforations and postoperative leaks. Ann Esophagus. 2023;6:0. https://doi.org/10.21037/aoe-2020-23
Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, et al. Surgical repair vs stent for esophageal perforation: a multi-institutional database analysis. Ann Thorac Surg. 2023 Jun 1;115(6):1378-84. https://doi.org/10.1016/j.athoracsur.2022.07.023
Van Boeckel PG, Sijbring A, Vleggaar FP, Siersema PD. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther. 2011 Jun;33(12):1292-301. https://doi.org/10.1111/j.1365-2036.2011.04648.x
Dasari BV, Neely D, Kennedy A, Spence G, Rice P, Mackle E, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann. Surg. 2014 May 1;259(5):852-60. https://doi.org/10.1097/SLA.0000000000000493
Zhang Y, Xiao J, Fang T, Wei L, Cui W, Zhu Y. Degradable biomimetic stent with hydrogel and directional TGF-loaded nano-fiber membrane for the treatment of esophageal fistula. Biomaterials. 2025 Nov 4:123836. https://doi.org/10.1016/j.biomaterials.2025.123836
Kassem MM, Wallen JM. Esophageal perforation and tears. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Aug 19. https://www.ncbi.nlm.nih.gov/books/NBK532298/
Shahriarirad R, Karoobi M, Shekouhi R. Esophageal perforation etiology, outcome, and the role of surgical management – an 18-year experience of surgical cases in a referral center. BMC Surg. 2023;23:177. https://doi.org/10.1186/s12893-023-02080-w
Shaheem S, Panikkaveettil H. Aetiology, clinical manifestations, diagnosis, and treatment of oesophageal perforation: a review. Cureus. 2024 Feb 27;16(2):e55041. https://doi.org/10.7759/cureus.55041
Saxena P, Khashab MA. Endoscopic management of esophageal perforations: who, when, and how? Curr Treat Options Gastroenterol. 2017;15(1):35–45. https://doi.org/10.1007/s11938-017-0117-3
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