Navigating Complex Esophageal Perforations: A Case-Specific Approach to Successful Outcomes.

Description Esophageal perforation is a life-threatening condition requiring prompt diagnosis and effective management. While self-expanding metal stents (SEMS) are a first-line treatment, persistent leaks often necessitate adjunctive endoscopic interventions. A structured, multimodal approach is critical for optimizing outcomes and avoiding surgical intervention. A 44-year-old man developed an iatrogenic esophageal perforation following surgical leiomyoma enucleation. Initial treatment with overlapping fully covered self-expanding metal stents (FC-SEMS) failed to achieve closure, necessitating endoscopic suturing for defect reinforcement. Despite suturing, persistent leakage required placement of a larger-diameter FC-SEMS, secured with an endoscopic fixation system to prevent migration. Serial imaging confirmed successful defect closure, allowing the patient to recover without the need for surgical intervention. This case underscores the importance of a stepwise, individualized endoscopic approach in managing complex esophageal perforations. A combination of SEMS, endoscopic suturing, and fixation techniques can enhance closure success and prevent complications, reducing the need for surgery.