Esophageal perforation is a rare but serious complication of pneumatic dilation for achalasia, occurring in 1%–3% of procedures. Early recognition and rapid endoscopic management are crucial to prevent severe consequences such as mediastinitis or sepsis. We report a case of iatrogenic perforation diagnosed immediately after dilation and successfully managed with endoscopic stenting.

A 58-year-old woman with type II achalasia underwent her first pneumatic dilation using a 30-mm balloon inflated for one minute under sedation. Post-dilation endoscopic assessment revealed a 3-cm anterolateral tear. Shortly afterward, the patient developed severe epigastric pain. A thoraco-abdominal CT scan confirmed a 10-mm esophageal defect with mediastinal fat infiltration, consistent with perforation.

An early endoscopic intervention was performed, consisting of the placement of a fully covered self-expandable metal stent (SEMS) across the tear, secured with two clips to avoid migration. Supportive care included enteral feeding via a nasogastric tube, intravenous antibiotics, and proton pump inhibitors.

The patient remained clinically stable, without signs of sepsis or subcutaneous emphysema. A control CT scan at 48 hours showed correct stent positioning and absence of mediastinal leakage. Oral intake was progressively resumed after one week. The stent was removed two weeks later, and follow-up endoscopy confirmed complete healing of the perforation.

This case highlights the importance of systematic post-dilation endoscopy and prompt imaging in symptomatic patients, allowing early diagnosis of perforation. Endoscopic stent placement with secure fixation is an effective, minimally invasive therapeutic option that can prevent surgical intervention and reduce morbidity. Early detection and rapid endoscopic management remain key factors in achieving favorable outcomes in iatrogenic esophageal perforation following pneumatic dilation.