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woman with a 20−year history of inter− mittent dysphagia and regurgitation worsening over the past 6 years. The pa− tient underwent balloon dilatation as the first treatment of her disease. A Rigiflex balloon dilator (Boston Scientific, Boston, MA, USA) with a diameter of 30 mm was positioned over a guide wire at the gas− troesophageal junction under endoscopic control. An endoscope was introduced to the stomach next to the balloon and then retroflexed to control the procedure (l" Fig. 1 and l" 2 ). We gradually inflated the balloon to 8 psi within 30 seconds and the pressure was maintained for 1 minute. During the procedure, the esophageal wall was ruptured. The rupture (3.5 cm long) involved the gastrointestinal junc− tion and distal esophagus (l" Fig. 3 and l" 4). Immediately after discovering the complication, we started endoscopic clip− ping. We sealed the rupture with nine clips (l" Fig. 5). Then we placed a naso− gastric tube through a guide wire. Not surprisingly, subcutaneous emphysema developed, but spontaneously regressed within a few days. The day after perfora− tion, the patient had a slight elevation of C−reactive protein, a borderline white cell count, and pleural effusion. Eleven days later, radiography and endoscopy showed no signs of perforation. The pa− tient was discharged on day 11 to receive home care. Endoscopic follow−up 12 weeks later showed a healed perforation site with one clip remaining on site (the “high−resolution“ clip placed as the first one, l" Fig. 6). The cardia is nonspastic, open, and there is only mild reflux esoph− agitis, which has been treated with a pro− ton pump inhibitor. The patient is cur− rently asymptomatic, free of dysphagia and regurgitation. In summary, we have shown that endo− scopic treatment of a large esophageal perforation is a possible and effective al− ternative to standard surgical treatment.

Successful endoscopic treatment (clipping) of esophageal perforation during balloon dilatation in a patient with achalasia