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dysphagia over a 2-month period. Transnasal endoscopy with an ultrathin endoscope (Fujinon EG-530N; Fujinon, Wayne, New Jersey, USA) was used. An ulcerative tumor was found in the middle esophagus (●" Fig. 1), and the biopsy revealed squamous cell carcinoma. A feeding tube was placed over a guidewire. A chest computed tomography (CT) scan was performed the next day to evaluate the esophageal cancer. Pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema (●" Figs. 2–4) were found, and no fluid collection was seen. The patient received intravenous antibiotic therapy and nutritional support. An esophageal Niti-S stent (Taewoong Medical, Seoul, Korea) was placed into the patient’s esophagus (●" Fig. 5). Thepatientdidnotdevelop clinical signs of sepsis andwasplaced on a restricted diet 1 week later. She was discharged with the ability to consume semi-solid food and was referred to an oncology clinic. Perforation of the gastrointestinal tract during endoscopic examination is a rare but serious complication. Perforation with the presence of pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema has been reported in association with endoscopic retrograde cholangiopancreatography [1,2] and colonoscopy [3]. To our knowledge, this is the first case of such Pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ultrathin endoscopy