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Wannhoff A, Kouladouros K, Koschny R, Walter B, Zoll Z, Büringer K, Blank S, Schempf U, Caca K, Wichmann D. Endoscopic vacuum therapy for the treatment of Boerhaave syndrome: a multicenter analysis. Gastrointest Endosc 2025; 101:365-374. [PMID: 39218268 DOI: 10.1016/j.gie.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/31/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Boerhaave syndrome, an effort rupture of the esophagus, is a rare but serious condition. Endoscopic vacuum therapy (EVT) is a new therapeutic approach for GI perforation. We aimed to evaluate EVT for treatment of Boerhaave syndrome. METHODS This retrospective study was conducted at 5 tertiary hospitals in southern Germany. All patients treated for Boerhaave syndrome since 2010 were identified and included. Treatment success and outcomes were assessed and compared between the different modes of primary treatment. RESULTS Fifty-seven patients with Boerhaave syndrome were identified (median age, 68 years; n = 16 female). The primary treatment was EVT in 25 cases, surgery in 14, and endoscopic stenting in 15. Primary EVT was successful in 20 (80.0%) of the 25 patients. Two patients were switched to surgical treatment, 1 was switched to esophageal stenting, and 2 patients died. The mortality rate was lower (P = .160) in patients treated primarily with EVT (n = 2 [8.0%]) compared with patients in the non-EVT group (n = 8 [25.0%]). Treatment success was significantly higher (P = .007) for primary EVT (80.0%) than for non-EVT (43.8%). Primary EVT was associated with treatment success in multivariable analysis. CONCLUSIONS EVT showed a high success rate for treatment of Boerhaave syndrome and was associated with treatment success.
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Affiliation(s)
- Andreas Wannhoff
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany.
| | - Konstantinos Kouladouros
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Mannheim, Germany; Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité University Hospital Berlin, Berlin, Germany
| | - Ronald Koschny
- Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Walter
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Zita Zoll
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Karsten Büringer
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
| | - Susanne Blank
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Mannheim, Germany
| | - Ulrike Schempf
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
| | - Karel Caca
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Dörte Wichmann
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
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Mafi D, Legriel S, Charbonnel C, Benghalia K, Zavastin C, Glorion M, Paul M. An Esophagopleural Fistula Related to Cardiopulmonary Resuscitation. JACC: CASE REPORTS 2023; 11:101769. [PMID: 37077442 PMCID: PMC10107006 DOI: 10.1016/j.jaccas.2023.101769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 02/15/2023]
Abstract
We describe a previously unreported and potentially fatal complication of esophageal perforation following cardiopulmonary resuscitation in a 74-year-old man with cardiac arrest subsequent to ventricular tachycardia caused by ischemic heart disease. We discuss the importance of searching for severe traumatic complications. This description emphasizes presenting complaints, early recognition, and management strategies of such cases (Level of Difficulty: Intermediate).
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Charalampakis V, Cardoso VR, Sharples A, Khalid M, Dickerson L, Wiggins T, Gkoutos GV, Tucker O, Super P, Richardson M, Nijjar R, Singhal R. Single-centre review of the management of intra-thoracic oesophageal perforation in a tertiary oesophageal unit: paradigm shift, short- and long-term outcomes over 15 years. Surg Endosc 2023; 37:1710-1717. [PMID: 36207647 PMCID: PMC10017567 DOI: 10.1007/s00464-022-09682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/25/2022] [Indexed: 10/10/2022]
Abstract
BACKGROUND Oesophageal perforation is an uncommon surgical emergency associated with high morbidity and mortality. The timing and type of intervention is crucial and there has been a major paradigm shift towards minimal invasive management over the last 15 years. Herein, we review our management of spontaneous and iatrogenic oesophageal perforations and assess the short- and long-term outcomes. METHODS We performed a retrospective review of consecutive patients presenting with intra-thoracic oesophageal perforation between January 2004 and Dec 2020 in a single tertiary hospital. RESULTS Seventy-four patients were identified with oesophageal perforations: 58.1% were male; mean age of 68.28 ± 13.67 years. Aetiology was spontaneous in 42 (56.76%), iatrogenic in 29 (39.2%) and foreign body ingestion/related to trauma in 3 (4.1%). The diagnosis was delayed in 29 (39.2%) cases for longer than 24 h. There was change in the primary diagnostic modality over the period of this study with CT being used for diagnosis for 19 of 20 patients (95%). Initial management of the oesophageal perforation included a surgical intervention in 34 [45.9%; primary closure in 28 (37.8%), resection in 6 (8.1%)], endoscopic stenting in 18 (24.3%) and conservative management in 22 (29.7%) patients. On multivariate analysis, there was an effect of pathology (malignant vs. benign; p = 0.003) and surgical treatment as first line (p = 0.048) on 90-day mortality. However, at 1-year and overall follow-up, time to presentation (≤ 24 h vs. > 24 h) remained the only significant variable (p = 0.017 & p = 0.02, respectively). CONCLUSION Oesophageal perforation remains a condition with high mortality. The paradigm shift in our tertiary unit suggests the more liberal use of CT to establish an earlier diagnosis and a higher rate of oesophageal stenting as a primary management option for iatrogenic perforations. Time to diagnosis and management continues to be the most critical variable in the overall outcome.
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Affiliation(s)
- Vasileios Charalampakis
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Athens Medical Center, Athens, Greece
| | - Victor Roth Cardoso
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - Alistair Sharples
- Department of Upper GI and Bariatric Surgery, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Maha Khalid
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Luke Dickerson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tom Wiggins
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Georgios V Gkoutos
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
- NIHR Biomedical Research Centre, Birmingham, B15 2TT, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, B15 2TT, UK
| | - Olga Tucker
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Super
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Richardson
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rajwinder Nijjar
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rishi Singhal
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
- Consultant Bariatric and Upper GI Surgeon, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
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Esophageal Perforation following Accidental Ingestion of a Razor Blade. Case Rep Surg 2022; 2022:1974147. [PMID: 35341077 PMCID: PMC8947916 DOI: 10.1155/2022/1974147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/03/2022] [Indexed: 12/22/2022] Open
Abstract
Background Ingestion of sharp foreign bodies is uncommon and often underreported. It can present with esophageal perforation which is a life-threatening complication requiring prompt diagnosis and management. Case Presentation. We report a case of accidental ingestion of a razor blade in a chronic alcoholic who presented with hematemesis after an esophageal perforation, the diagnosis of which was confirmed by radiology. Conclusion Early recognition of esophageal perforation is crucial for early intervention. Proper history taking and radiological investigations are a key to reaching a diagnosis.
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Malfitano MJ, Bui JT, Swier RM, Haithcock BE. The use of grape juice in the detection of esophageal leaks. J Thorac Dis 2022; 13:6323-6330. [PMID: 34992812 PMCID: PMC8662515 DOI: 10.21037/jtd-21-1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/14/2021] [Indexed: 11/22/2022]
Abstract
Background Esophagectomies and repair of esophageal perforations are operations used for a variety of clinical indications. Anastomotic leaks are a major post-operative complication after these procedures. At our institution, we routinely use grape juice to detect esophageal leaks in the post-operative setting in addition to other standard imaging modalities. We hypothesize that grape juice can provide similar diagnostic sensitivity and specificity to other modalities for leak detection. Methods A retrospective review of all patients who underwent an esophagectomy or repair of esophageal perforations from 2013–2019 by the thoracic surgery service at our institution was performed. All patients underwent a barium swallow study, CT imaging or upper endoscopy, as well as ingesting purple grape juice on post-operative day 5 or greater. Purple grape juice observed in the tube thoracostomy drainage system was identified as a positive esophageal leak. Results Sixty-four patients were included in the study period (25% female, 88% white, median age 62 years old). Sixty-three patients had both a barium swallow study and grape juice test, while one patient underwent CT imaging and grape juice study. Grape juice test sensitivity and specificity were found to be 80% and 98.3%, respectively. Conclusions This pilot study demonstrates the effectiveness of using grape juice in detecting esophageal leaks after esophageal operations in patients with tube thoracostomies. Grape juice may be cheaper and potentially less morbid than other studies performed to detect esophageal leaks. Further research is needed to justify the increased use of grape juice in patients who undergo esophageal operations.
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Affiliation(s)
| | | | - Rachel M Swier
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Pickering O, Pucher PH, De'Ath H, Abuawwad M, Kelly J, Underwood TJ, Noble F, Byrne JP. Minimally Invasive Approach in Boerhaave's Syndrome: Case Series and Systematic Review. J Laparoendosc Adv Surg Tech A 2021; 31:1254-1261. [PMID: 33400893 DOI: 10.1089/lap.2020.0751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Boerhaave's syndrome is a life-threatening spontaneous perforation of the esophagus associated with significant morbidity and mortality. Historically, thoracotomy has been the mainstay of treatment, but is associated with high morbidity and pain. Minimally invasive approaches provide alternative treatment possibilities. This systematic review together with inclusion of a case series from a tertiary esophagogastric unit assesses current evidence focused on minimally invasive surgical management of this condition. Methods: A systematic review was conducted in line with MOOSE (Meta-analyses Of Observational Studies in Epidemiology) guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles focusing on the minimally invasive management of Boerhaave's syndrome were identified and scrutinized. We also report demographics and outcomes for a consecutive case series of patients with acute Boerhaave's syndrome managed via thoracoscopy. Results: Fifteen studies were included comprising 5 retrospective cohort studies and 10 case reports. Management strategies were divided into three categories: thoracoscopic, endoscopic, and laparoscopic. Overall mortality rates for each treatment modality were 2%, 13%, and 33%, and treatment success rates 98%, 38%, and 67%, respectively. Postoperative infective complications were seen in 79% of patients, with only 2 patients requiring salvage thoracotomy. In our local case series, we report 4 consecutive patients managed with thoracoscopy, with a 100% treatment success rate. Conclusion: Minimally invasive approaches in the management of Boerhaave's syndrome are safe and effective. We propose a selective management algorithm involving a minimally invasive approach to management of this life-threatening condition. Registered with local clinical outcomes team as service evaluation. (Approval number sev/0171).
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Affiliation(s)
- Oliver Pickering
- Department of General Surgery, St Mary's Hospital, Isle of Wight, Newport, United Kingdom
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Philip H Pucher
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Henry De'Ath
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
- Department of General Surgery, Frimley Park Hospital, Frimley, United Kingdom
| | - Mahmoud Abuawwad
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Jamie Kelly
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Timothy J Underwood
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Fergus Noble
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - James P Byrne
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
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Śnieżyński J, Wilczyński B, Skoczylas T, Wallner GT. Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931629. [PMID: 34385411 PMCID: PMC8370138 DOI: 10.12659/ajcr.931629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 53-year-old
Final Diagnosis: Spontaneous esophageal rupture
Symptoms: Chest pain • dyspena • hydropneumothorax • purulent discharge from the umbilicus • vomiting
Medication: —
Clinical Procedure: Endoscopic stent-grafting • enteral feeding • pleural drainage
Specialty: Gastroenterology and Hepatology • Surgery
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Affiliation(s)
- Jan Śnieżyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Lublin, Poland
| | - Bartosz Wilczyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Lublin, Poland
| | - Tomasz Skoczylas
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Lublin, Poland
| | - Grzegorz T Wallner
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Lublin, Poland
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Vermeulen BD, van der Leeden B, Ali JT, Gudbjartsson T, Hermansson M, Low DE, Adler DG, Botha AJ, D'Journo XB, Eroglu A, Ferri LE, Gubler C, Haveman JW, Kaman L, Kozarek RA, Law S, Loske G, Lindenmann J, Park JH, Richardson JD, Salminen P, Song HY, Søreide JA, Spaander MCW, Tarascio JN, Tsai JA, Vanuytsel T, Rosman C, Siersema PD. Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis. Surg Endosc 2021; 35:3492-3505. [PMID: 32681374 PMCID: PMC8195755 DOI: 10.1007/s00464-020-07806-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave's syndrome (BS). METHODS We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. RESULTS Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8-5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2-7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2-6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1-3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1-3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. CONCLUSIONS This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Gastroenterology and Hepatology (Route 455), Radboud University Medical Center, Geert Grooteplein-Zuid 8, 6500 HB, Nijmegen, The Netherlands.
| | - Britt van der Leeden
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jawad T Ali
- Department of General Surgery, University of Texas at Austin, Dell Medical School, Texas, USA
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Douglas G Adler
- Department of Medicine, Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Abraham J Botha
- Department of General and GI Surgery, Guy's & St Thomas's Hospitals, London, UK
| | - Xavier B D'Journo
- Department of Thoracic Surgery, Aix-Marseille Université, North Hospital, Marseille, France
| | - Atila Eroglu
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Lorenzo E Ferri
- Department of Surgery and Oncology, McGill University, Montreal General Hospital, Montreal, Canada
| | - Christoph Gubler
- Klinik für Gastroenterologie und Hepatologie, Universitäts Spital Zürich, Zurich, Switzerland
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lileswar Kaman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, USA
| | - Simon Law
- Department of Surgery, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Gunnar Loske
- Department for General, Abdominal, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg gGmbH, Hamburg, Germany
| | - Joerg Lindenmann
- Division of Thoracic Surgery and Hyperbaric Surgery, Medical University of Graz, Graz, Austria
| | - Jung-Hoon Park
- Department of Vascular and Interventional Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Ho-Yong Song
- Department of Vascular and Interventional Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jon A Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeffrey N Tarascio
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon A Tsai
- Division of Surgery, Karolinska Institutet, CLINTEC, Stockholm, Sweden
| | - Tim Vanuytsel
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal, KU Leuven, Leuven, Belgium
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Deng Y, Hou L, Qin D, Huang T, Yuan T. Current treatment and outcome of esophageal perforation: A single-center experience and a pooled analysis. Medicine (Baltimore) 2021; 100:e25600. [PMID: 33879724 PMCID: PMC8078246 DOI: 10.1097/md.0000000000025600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/02/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Esophageal perforation has been one of the serious clinical emergencies, because of the high mortality and complication rates. However, the current prognosis of esophageal perforation and the outcomes of available treatment methods are not well defined. This study attempted to pool the immediate outcomes of esophageal perforation in the past 2 decades. METHODS The clinical data of 22 consecutive adult patients with esophageal perforation in our center were analyzed. A pooled analysis was also conducted to summarize results from the literatures published between 1999 and 2020. Studies that met the inclusion criteria were assessed, and their methodological quality was examined. RESULTS The mortality and complication rates in our center were 4.55% and 31.82%, separately. The pooled analysis included 45 studies published between 1999 and 2019, which highlighted an overall immediate mortality rate of 9.86%. Surgical treatments were associated with a pooled immediate mortality of 10.01%, and for conservative treatments of 6.49%. Besides, in the past decade, the mortality and complication rates decreased by 27.12% and 46.75%, respectively. CONCLUSIONS In the past 2 decades, the overall immediate mortality rate of esophageal perforation was about 10% in the worldwide, and the outcomes of esophageal perforation treatment are getting better in the last 10 years. ETHICS REGISTRATION INFORMATION LW2020011.
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Affiliation(s)
| | - Luqi Hou
- Department of Research and Education, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545001, China
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Awofisoye OI, Olalekan OE, Anumenechi N, Onwukpa F. Boerhaave's syndrome after pentazocine-induced vomiting in a 21-year-old male with asthma: a case report. Pan Afr Med J 2021; 38:74. [PMID: 33889240 PMCID: PMC8033192 DOI: 10.11604/pamj.2021.38.74.27031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/13/2021] [Indexed: 11/11/2022] Open
Abstract
Boerhaave's syndrome is an uncommon syndrome characterized by spontaneous rupture of the oesophagus with a high mortality rate. While excessive alcohol intake and binge-eating are the classic precipitants of this syndrome, medication-induced vomiting causing Booerhave's is quite uncommon. Traditionally managed operatively, conservative management is being increasingly reported in selected cases. We report the case of 21-year-old male with who developed sudden onset chest pain and dyspnoea after pentazocine induced vomiting. He was referred after lack of response to initial treatment for acute severe asthma. A chest CT scan showed pneumomediastinum, subcutaneous emphysema and oesophageal tear. He was managed conservatively with oxygen therapy, nil per mouth and antibiotics with improvement of symptoms and discharge after 8 days.
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11
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Hayakawa S, Ogawa R, Ito S, Nakaya S, Okubo T, Sagawa H, Tanaka T, Takahashi H, Matsuo Y, Takiguchi S. Suitable Diagnosis and Treatment of Esophageal Ruptures in Cases of Non-Boerhaave Syndrome: A Comparison With Boerhaave Syndrome. J Investig Med High Impact Case Rep 2021; 9:23247096211014683. [PMID: 33985358 PMCID: PMC8127747 DOI: 10.1177/23247096211014683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/31/2021] [Accepted: 04/10/2021] [Indexed: 11/17/2022] Open
Abstract
Boerhaave syndrome (BS) is frequently reported in cases of esophageal perforation; however, there are relatively few studies on non-Boerhaave syndrome (nBS). This study clarifies the appropriate diagnosis and treatment for patients with nBS among those with esophageal ruptures. Twelve patients with esophageal ruptures who underwent surgery at our department over 14 years were classified into 2 groups: 4 in the nBS group and 8 in the BS group. Patient characteristics, surgical methods, surgical outcomes, and complications were compared between the groups. The chief complaints varied between the groups. The nBS group had significantly higher preoperative C-reactive protein (P = .007) and required 5 days (median) from onset to surgery. Moreover, the perforation diameter was significantly smaller in the nBS group than in the BS group (P = .013). Suturing of the perforation site was performed during the initial surgery in 8 BS group patients (100%) and 1 nBS group patient (25%; P = .018). Only drainage was performed during the initial surgery for 3 nBS group patients (75%). The complications did not significantly differ between the groups (P = 1.000), and no deaths were reported. The chief complaints of patients with nBS are diverse, and esophageal perforation should be cited as a differential diagnosis even in the absence of vomiting or chest pain symptoms. In the initial surgery for patients with nBS, the perforation site does not necessarily need to be closed. It is treatable by second-stage surgery or by natural closing.
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Affiliation(s)
| | - Ryo Ogawa
- Nagoya City University, Nagoya City, Japan
| | - Sunao Ito
- Nagoya City University, Nagoya City, Japan
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Aiolfi A, Micheletto G, Guerrazzi G, Bonitta G, Campanelli G, Bona D. Minimally invasive surgical management of Boerhaave's syndrome: a narrative literature review. J Thorac Dis 2020; 12:4411-4417. [PMID: 32944354 PMCID: PMC7475560 DOI: 10.21037/jtd-20-1020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Treatment of Boerhaave's syndrome is controversial. Formal thoracotomy and laparotomy were considered the gold standard treatment in the past. However, these approaches are associated with significant surgical trauma, stress, and postoperative pain. Recently published studies reported the application of minimally invasive surgery in the setting of such esophageal emergency. However, the application of minimally invasive surgery in the setting of Boerhaave's syndrome is debated and evidence is puzzled. The aim of this study was to summarize the current knowledge on minimally invasive treatment of Boerhaave's syndrome. PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of Boerhaave's syndrome in the setting of minimally invasive surgery (thoracoscopy or laparoscopy) were included. Sixteen studies and forty-eight patients were included. The age of the patient population ranged from 37 to 81 years old and 74% were males. The time shift period from symptoms onset to surgical treatment ranged from 5 to 240 hours with 10 patients (20.8%) having surgery more than 24 hours from symptoms onset. Vomiting (100%), chest/epigastric pain (88%), and dyspnea (62%) were the most commonly reported symptoms. The perforation size ranged from 6 to 30 mm with 96% of patients suffering from distal esophageal tear. Video-assisted thoracoscopy (VATS) was the most commonly reported surgical approach (75%), followed by laparoscopy (16.7%), and combined thoraco-laparoscopy (6.2%). In case of VATS, a left approach was adopted in 91% of patients with selective lung ventilation. Primary suture was the most commonly performed surgical procedure (60%) with interrupted single or dual-layer repair. Surgical debridement (25%), primary repair reinforced with gastric or omental patch (8%), esophageal repair over T-tube (6%), and endoscopic stenting combined with laparoscopic debridement (2%) were also reported. The postoperative morbidity was 64.5% with pneumonia (42%), pleural empyema (26%), and leak (19%) being the most commonly reported complications. The overall mortality was 8.3%. Boerhaave's syndrome is a rare entity. Minimally invasive surgical treatment seems promising, feasible, and safe in selected patients with early presentation and stable vital signs managed in referral centers. In the management algorithm of Boerhaave's syndrome, a definitive indication to adopt minimally invasive surgery is lacking and its potential role mandates further analysis.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
| | - Giancarlo Micheletto
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
| | - Guglielmo Guerrazzi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
| | - Giampiero Campanelli
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.,Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Varese, Italy
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13
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Yan XL, Jing L, Guo LJ, Huo YK, Zhang YC, Yan XW, Deng YZ. Surgical management of Boerhaave's syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:669-674. [PMID: 32496118 DOI: 10.17235/reed.2020.6746/2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND spontaneous esophageal rupture (Boerhaave's syndrome) is a rare and challenging clinical condition. OBJECTIVE to evaluate the outcome of different surgical treatments for patients with Boerhaave's syndrome with an early diagnosis (< 24 h) and delayed diagnosis (> 24 h), using a retrospective cohort study in a tertiary referral center. PATIENTS AND METHODS eighty-eight patients with Boerhaave's syndrome who underwent surgical treatment were identified from March 1994 to March 2019 in the First Hospital of Shanxi Medical University. Subsequently, they were retrospectively divided into two groups according to time from symptom onset to diagnosis (group 1, < 24 h, n = 16; group 2, > 24 h, n = 72). Primary suture repair was used in group 1 and reinforcement with a vascular muscle flap was used in group 2, in order to reduce the incidence of fistula. Patients in group 2 were further divided into two subgroups according to reinforcement using diaphragmatic flaps (subgroup 1) or intercostal muscle flaps (subgroup 2). RESULTS the duration of hospitalization and stay in Intensive Care Unit (ICU) was significantly shorter in group 1 (p = 0.027 and p = 0.001). Group 1 had fewer postoperative esophageal leaks (p = 0.037) compared to group 2. Various aspects were compared in the two subgroups and the differences were not statistically significant (p > 0.05). CONCLUSIONS it is very important to establish an early diagnosis for patients with Boerhaave's syndrome. Early (< 24 h) and primary suture repair is superior to delayed (> 24 h) primary repair, even for those reinforced with vascular muscle flaps. Furthermore, repair reinforcement with different muscle flaps appears to render similar results for patients with delayed diagnosis.
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Affiliation(s)
- Xiao-Liang Yan
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University, china
| | - Li Jing
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Lin-Jing Guo
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Yun-Kui Huo
- Cardiovascular Surgery, The First Hospital of Shanxi Medical University,
| | - Yong-Cai Zhang
- Cardiovascular Surgery, The First Hospital of Shanxi Medical University,
| | - Xiu-Wen Yan
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Yong-Zhi Deng
- Cardiovascular Surgery, The Affiliated Cardiovascular Hospital of Shanxi Medical University,
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14
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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15
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Dosis A, Casey P, Turner P, Shetty V, Ward J, Pursnani K. Transhiatal Approach for the Management of Esophageal Perforations. Am Surg 2020. [DOI: 10.1177/000313482008600310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alexios Dosis
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
| | - Patrick Casey
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
| | - Paul Turner
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
| | - Vinutha Shetty
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
| | - Jeremy Ward
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
| | - Kishore Pursnani
- Lancashire Teaching Hospital NHS Foundation Trust Preston, Lancashire, United Kingdom
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16
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Aref H, Yunus T, Alhallaq O. Laparoscopic Management of Boerhaave's syndrome: a case report with an intraoperative video. BMC Surg 2019; 19:109. [PMID: 31409335 PMCID: PMC6693239 DOI: 10.1186/s12893-019-0576-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022] Open
Abstract
Background Boerhaave’s syndrome involves a sudden elevation in the intraluminal pressure of the esophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Its treatment is challenging, and early surgical intervention is the most crucial prognostic element. Case presentation We present a case of a 32 year-old male who presented after severe emesis with an acute onset of epigastric pain. He was diagnosed with Boerhaave’s syndrome. Displaying signs of shock mandated immediate surgical exploration with laparoscopic primary repair. Conclusion The golden period of the first 24 hrs of the event still applies to cases of esophageal perforation. The scarcity of these cases makes a comparison between the various treatment methods difficult. Our data support the use of laparoscopic intervention with primary repair as the mainstay of treatment for the management of esophageal perforation. Electronic supplementary material The online version of this article (10.1186/s12893-019-0576-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hager Aref
- Department of Surgery, International Medical Center, P.O. Box 2172, Jeddah, 21451, Saudi Arabia.
| | - Tahir Yunus
- Department of Surgery, International Medical Center, P.O. Box 2172, Jeddah, 21451, Saudi Arabia
| | - Obadah Alhallaq
- Department of Surgery, International Medical Center, P.O. Box 2172, Jeddah, 21451, Saudi Arabia
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17
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Vermeulen BD, Siersema PD. Diagnosis and endoscopic treatment of esophageal leakage: a systematic review. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Abstract
Well-timed diagnostics of a spontaneous nontraumatic rupture of esophagus or Boerhaave’s syndrome, presents great difficulties because of his rarity and a variety of clinical implications. Esophagus ruptures may feign various organs pathology [2] that most often demands differential diagnostics with a stomach ulcer perforation, acute myocardial infarction, pulmonary artery embolism, aortic dissection and pancreatitis [16, 17]. The treatment can include conservative and surgical tools, but still accompanied by high mortality (up to 35%) [7]; results largely defined by the time between the moment of a rupture and start of the treatment. In addition to the review, described the experience of successful treatment of a patient with Boerhaave’s syndrome in the light of the generalized today data of world medical literature on this problem.
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19
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Munro CE, Stamp GFW, Phillips AW, Griffin SM. A tale of three stents: aortic stenting prior to oesophagectomy after oesophageal stents. Ann R Coll Surg Engl 2018; 100:e78-e80. [PMID: 29364021 PMCID: PMC5958853 DOI: 10.1308/rcsann.2018.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2017] [Indexed: 11/22/2022] Open
Abstract
The use of endoluminal stents to treat anastomotic leaks post oesophagogastric resection remains controversial. While some advocate stents to expedite recovery, others advise caution due to the risk of major morbidity and mortality. We describe a case of anastomotic leak following total gastrectomy for adenocarcinoma treated with a self-expanding metallic stent. Complications with the initial stent were treated with a further stent, which compromised the function of the oesophagus and eroded into the aorta, necessitating a colonic reconstruction and endovascular aortic stenting.
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Affiliation(s)
- CE Munro
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - GFW Stamp
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - AW Phillips
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - SM Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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20
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Persson S, Rouvelas I, Irino T, Lundell L. Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review. Dis Esophagus 2017; 30:1-10. [PMID: 28881894 DOI: 10.1093/dote/dox108] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 07/28/2017] [Indexed: 12/11/2022]
Abstract
Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.
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Affiliation(s)
- S Persson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Irino
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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21
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Abou-Mourad OM, Andrade FMD, Júdice LF, Júdice Â, Carvalho ABCB, Morard MRS, Fiorelli RKA. Video-thoracoscopic approach, without suture, of late thoracic esophageal perforations. Rev Col Bras Cir 2017; 44:354-359. [PMID: 29019538 DOI: 10.1590/0100-69912017004009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/30/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to evaluate the use of video-thoracoscopy, in the treatment of late perforations of the thoracic esophagus, without suture or organ resection. METHODS retrospective analysis of patients with late diagnosis (> 12 hours) of thoracic esophageal perforation treated by video-thoracoscopy, without suture or organ resection, over a 15-year period. RESULTS sixteen patients were operated on, ten men and six women, aged between 48 and 66 years, with time between the diagnosis of the perforation and the surgery ranging from 16 to 26 hours. All patients underwent video-thoracoscopy, with pulmonary decortication, pleural loculations approach, opening of the mediastinal pleura near the perforation site and debridement of the devitalized tissues, followed by double drainage of the pleural cavity. No esophageal suture or resection was performed, and the patients evolved with complete closure of the lesions, without deaths. CONCLUSION the video-thoracoscopic surgical approach was able to control pleural infection, pulmonary expansion and enable complete regeneration of the esophagus with late-diagnosed perforation.
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Affiliation(s)
- Omar Moté Abou-Mourad
- Universidade Federal Fluminense, Departamento de Cirurgia, Divisão de Cirurgia Torácica, Niterói, RJ, Brasil
| | - Filipe Moreira de Andrade
- Universidade Severino Sombra, Departamento de Cirurgia, Vassouras, RJ, Brasil.,Universidade Federal de Viçosa, Departamento de Medicina, Viçosa, MG, Brasil.,Faculdade Governador Ozanam Coelho, Departamento de Medicina, Ubá, MG, Brasil
| | - Luiz Felippe Júdice
- Universidade Federal Fluminense, Departamento de Cirurgia, Divisão de Cirurgia Torácica, Niterói, RJ, Brasil
| | - Ângelo Júdice
- Universidade Federal Fluminense, Departamento de Cirurgia, Divisão de Cirurgia Torácica, Niterói, RJ, Brasil
| | | | | | - Rossano Kepler Alvim Fiorelli
- Universidade Severino Sombra, Departamento de Cirurgia, Vassouras, RJ, Brasil.,Universidade Federal do Estado do Rio de Janeiro, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil
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22
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Tellechea JI, Gonzalez JM, Miranda-García P, Culetto A, D'Journo XB, Thomas PA, Barthet M. Role of Endoscopy in the Management of Boerhaave Syndrome. Clin Endosc 2017; 51:186-191. [PMID: 28928355 PMCID: PMC5903076 DOI: 10.5946/ce.2017.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 06/23/2017] [Accepted: 07/03/2017] [Indexed: 11/14/2022] Open
Abstract
Boerhaave syndrome (BS) is a spontaneous esophageal perforation which carries high mortality. Surgical treatment is well established, but the development of interventional endoscopy has proposed new therapies. We expose our experience in a Gastrointestinal and Endoscopy Unit. With a retrospective, observational, open-label, single center, consecutive case series. All patients diagnosed with BS who were managed in our center were included. Treated conservatively, endoscopically or surgically, according to their clinical condition and lesion presentation. Fourteen patients were included. Ten were treated with primary surgery. One conservatively. In total, 7/14 patients required an endoscopic treatment. All required metallic stents deployment, 3 cases over-the-scope-clips concomitantly and one case a novel technique an internal drain. 6/7 cases endoscopically treated achieved complete esophageal healing. In conclusion, endoscopy is an useful tool at all stages BS management: difficult diagnosis, primary treatment in selected patients and as salvage when surgery fails. With mortality rates and outcomes comparables to surgery.
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Affiliation(s)
- Juan Ignacio Tellechea
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Jean-Michel Gonzalez
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Pablo Miranda-García
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Adrian Culetto
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Xavier Benoit D'Journo
- Department of Thoracic Surgical, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgical, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, North Hospital, University of Mediterranean, Chemin des Bourrely, Marseille, France
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23
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Mirus M, Heller AR. [Diagnostic investigation in emergency medicine: Why case history is crucial]. Anaesthesist 2017; 66:256-264. [PMID: 28194478 DOI: 10.1007/s00101-017-0280-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 12/09/2016] [Accepted: 01/26/2017] [Indexed: 11/29/2022]
Abstract
We present the preclinical case of a patient reporting chest pain. Pain impeded physical examination. Reviewing the patient's detailed medical history after analgesia revealed a connection between the reported pain and vomiting. This led to a suspicion of organ perforation. Thus, the patient was admitted to a surgical emergency room (ER) and Boerhaave's Syndrome was diagnosed. After deterioration in the ER, cardiopulmonal reanimation (CPR), and successful surgical treatment, the patient was transferred to the intensive care unit (ICU) seven hours after first contact.
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Affiliation(s)
- M Mirus
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - A R Heller
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland
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24
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Atie M, Dunn G, Falk GL. Delayed presentation of Boerhaave's syndrome. BMJ Case Rep 2016; 2016:bcr-2016-217391. [PMID: 27737871 DOI: 10.1136/bcr-2016-217391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mohamad Atie
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Graham Dunn
- Department of Radiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Gregory L Falk
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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25
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Kimura-Kataoka K, Fujihara J, Kurata S, Takinami Y, Inoue K, Yasuda T, Takeshita H. An autopsy case of spontaneous esophageal perforation (Boerhaave syndrome). Leg Med (Tokyo) 2016; 23:5-9. [PMID: 27890104 DOI: 10.1016/j.legalmed.2016.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/23/2016] [Accepted: 08/25/2016] [Indexed: 11/24/2022]
Abstract
A 45-year-old male, an alcohol addict with asthma, was found dead in his home, after several days of continued drinking. A forensic autopsy was performed 3days after the discovery of his death in order to specify the cause of death. A longitudinal perforation penetrating all layers of the esophagus measuring 1.8cm was present on the left wall approximately 2.0cm from the gastroesophageal junction. There were 1900mL of greenish to brownish turbid liquid in the left pleural cavity and 150mL of greenish viscous liquid in the stomach. Histopathologically, an infiltration of numerous neutrophils was evident in the submucosa layer, proper muscular layer, and serous membrane of the esophagus, corresponding to the esophageal laceration. The serum C-reactive protein (CRP) concentration was determined to be 3.1mg/dL. The alcohol concentrations were determined to be 1.49mg/g in the right cardiac blood, 1.31mg/g in the left cardiac blood, and 2.48mg/g in urine. Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation. This was the first report of a spontaneous esophageal perforation eventually causing respiratory failure.
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Affiliation(s)
- Kaori Kimura-Kataoka
- Department of Legal Medicine, Shimane University School of Medicine, Izumo, Shimane, Japan.
| | - Junko Fujihara
- Department of Legal Medicine, Shimane University School of Medicine, Izumo, Shimane, Japan
| | | | - Yoshikazu Takinami
- Department of Emergency and Critical Care Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Ken Inoue
- Department of Public Health, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Toshihiro Yasuda
- Division of Medical Genetics and Biochemistry, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Haruo Takeshita
- Department of Legal Medicine, Shimane University School of Medicine, Izumo, Shimane, Japan
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26
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Davies J, Spitzer D, Phylactou M, Glasser M. Cardiac arrest due to a missed diagnosis of Boerhaave's syndrome. BMJ Case Rep 2016; 2016:bcr-2014-208659. [PMID: 27154984 DOI: 10.1136/bcr-2014-208659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 91-year-old presented with a rare cause of cardiac arrest. He was initially admitted with severe back pain following vomiting and diagnosed with probable aspiration pneumonia. On day 3 of admission, he was discovered in cardiac arrest and cardiopulmonary resuscitation was started. On intubation, a left-sided pneumothorax and subcutaneous emphysema were noted. Needle decompression showed gastric fluid leaking from the cannula. The patient regained a cardiac output, and a subsequent CT scan confirmed a large pneumomediastinum with air tracking to the neck and chest, and bilateral pneumothoraces. A diagnosis of Boerhaave's syndrome was made. The patient was transferred to the intensive care unit but did not survive. This case demonstrates the importance of looking for and treating the rarer reversible causes of cardiac arrest, and of maintaining a high index of suspicion for Boerhaave's syndrome. Despite its rarity, Boerhaave's syndrome is often misdiagnosed on initial presentation, leading to delayed treatment and poor outcomes.
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Affiliation(s)
| | | | - Maria Phylactou
- Department of Endocrinology, Hillingdon Hospital, Uxbridge, Middlesex, UK
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27
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Dent B, Griffin SM, Jones R, Wahed S, Immanuel A, Hayes N. Management and outcomes of anastomotic leaks after oesophagectomy. Br J Surg 2016; 103:1033-8. [PMID: 27146631 DOI: 10.1002/bjs.10175] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/02/2015] [Accepted: 02/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality. METHODS All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database. RESULTS A total of 390 oesophagectomies were performed (median age 65 (range 32-81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52-80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15-159) days; none of these patients died. CONCLUSION Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.
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Affiliation(s)
- B Dent
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - R Jones
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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28
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Treatment of Boerhaave’s Syndrome: Specialized Esophago-Gastric Unit Experience on Twelve Patients. Eur Surg 2016. [DOI: 10.1007/s10353-016-0392-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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29
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Skaug B, Taylor KR, Chandrasekaran S. Oesophageal rupture masquerading as STEMI. BMJ Case Rep 2016; 2016:10.1136/bcr-2016-214906. [PMID: 27068730 DOI: 10.1136/bcr-2016-214906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old man presented to the emergency department, with acute onset of chest pain. Based on ECG changes suggestive of ST elevation myocardial infarction (STEMI), he was taken emergently to the cardiac catheterisation laboratory for coronary angiography. There he was found to have only non-obstructive coronary disease. Subsequent physical examination and review of his chest radiograph revealed subcutaneous emphysema, and CT scan revealed a distal oesophageal rupture and pneumomediastinum. After stabilisation in the intensive care unit (ICU), he was taken to the operating room for thoracotomy, chest tube placement and stenting of his oesophagus. He survived the incident and, after several weeks of ICU stay, recovered to a large extent. His case highlights the importance of considering oesophageal rupture in the differential diagnosis for acute onset of chest pain.
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Affiliation(s)
- Brian Skaug
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Kenneth R Taylor
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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30
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Abstract
Acute oesophageal symptoms include acute dysphagia or food bolus impaction (most commonly due to strictures, Schatzki ring and eosinophilic oesophagitis), acute chest pain with odynophagia due to oesophageal infections, motility disorders and acute oesophageal rupture (of which oesophageal intramural haematoma is a subtype). Acute full thickness oesophageal rupture carries a high mortality if not recognised early; the clinical features and conditions with which this may be confused are presented and discussed.
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31
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Anderson RE, Wilcox S, Miller ES. A Rare but Lethal Cause of Chest Pain. J Emerg Med 2015; 49:698-702. [PMID: 26281817 DOI: 10.1016/j.jemermed.2015.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022]
Affiliation(s)
- R Eleanor Anderson
- Department of Emergency Medicine, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Susan Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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32
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Mangiavillano B, Pagano N, Arena M, Miraglia S, Consolo P, Iabichino G, Virgilio C, Luigiano C. Role of stenting in gastrointestinal benign and malignant diseases. World J Gastrointest Endosc 2015; 7:460-480. [PMID: 25992186 PMCID: PMC4436915 DOI: 10.4253/wjge.v7.i5.460] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 01/08/2015] [Accepted: 01/30/2015] [Indexed: 02/05/2023] Open
Abstract
Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.
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33
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Anwuzia-Iwegbu C, Al Omran Y, Heaford A. Against all odds. Conservative management of Boerhaave's syndrome. BMJ Case Rep 2014; 2014:bcr-2013-200485. [PMID: 24850546 DOI: 10.1136/bcr-2013-200485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Spontaneous oesophageal perforation or Boerhaave's syndrome is a life-threatening condition that usually requires early diagnosis and early surgical management. A 79-year-old man presented to the accident and emergency department with an ischaemic left big toe. He reported a 2-week history of worsening symptoms and a claudication distance in his left leg of 20-30 m. Three days post-revascularisation of the leg, the patient reported chest pain radiating to the back. CT angiography of the aorta indicated Boerhaave's syndrome. Following 35 days of conservative management in the intensive care unit and high dependency unit, the patient was stepped down to a surgical ward. A water-soluble contrast study demonstrated minimal leak through the perforated oesophagus. The patient was started on oral intake, which was well tolerated. This case highlights that conservative management may be appropriate.
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Affiliation(s)
| | - Yasser Al Omran
- Barts and The London School of Medicine & Dentistry, London, UK
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34
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Dent B, Immanuel A, Griffin SM. Minimally invasive endoscopic therapy for the management of Boerhaave's syndrome. Ann R Coll Surg Engl 2014; 96:253-4. [PMID: 24780812 PMCID: PMC4474081 DOI: 10.1308/003588414x13814021678754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Darrien JH, Kasem H Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome. Ann R Coll Surg Engl 2013; 95 : 552–556 doi 10.1308/003588413X13629960049315
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Affiliation(s)
- B Dent
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK.
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35
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Wahed S, Dent B, Jones R, Griffin SM. Spectrum of oesophageal perforations and their influence on management. Br J Surg 2013; 101:e156-62. [DOI: 10.1002/bjs.9338] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 01/23/2023]
Abstract
Abstract
Background
Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.
Methods
All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.
Results
There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days.
Conclusion
The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.
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Affiliation(s)
- S Wahed
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - B Dent
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - R Jones
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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36
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Connelly CL, Lamb PJ, Paterson-Brown S. Outcomes following Boerhaave's syndrome. Ann R Coll Surg Engl 2013; 95:557-60. [PMID: 24165336 PMCID: PMC4311529 DOI: 10.1308/rcsann.2013.95.8.557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2013] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit. METHODS Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay. RESULTS Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days. CONCLUSIONS Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.
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Affiliation(s)
- C L Connelly
- The Royal Infirmary of Edinburgh, 72/3 Marchmont Road, Edinburgh EH9 1HS, UK.
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37
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Darrien JH, Kasem H. Minimally invasive endoscopic therapy for the management of Boerhaave's syndrome. Ann R Coll Surg Engl 2013; 95:552-6. [PMID: 24165335 PMCID: PMC4311528 DOI: 10.1308/rcsann.2013.95.8.552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2013] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Boerhaave's syndrome represents the most lethal of all gastrointestinal perforations. In 2009 a treatment algorithm was published based on current level 4 evidence indicating that all septic patients should be treated surgically, early presentations without sepsis endoscopically and delayed presentations without sepsis conservatively. No provision was made for septic patients unfit for surgical intervention. Using a case series, we demonstrate how minimally invasive endoscopic therapies can be used successfully to manage such a cohort. METHODS Between September 2008 and January 2010, five patients presented to Wishaw General Hospital with Boerhaave's syndrome, all with an associated septic profile and none fit for surgery. They were managed using minimally invasive endoscopic therapies including endoscopic placement of oesophageal stents, elimination of mediastinal/pleural contamination using video assisted thorascopic lavage, management of subsequent collections using sinus tract endoscopy and mini-laparotomy with transhiatal endoscopic drainage, and closure of oesophagocutaneous fistulas using the Surgisis® (Cook Surgical, Bloomington, IN, US) anal fistula plug sited endoscopically with a rendezvous technique. RESULTS Oesophageal re-epithelialisation and resolution of sepsis was achieved in all five cases on days 50, 50, 51, 59 and 103. Four patients are alive today. The fifth died on day 109 in hospital as a consequence of co-morbidity. Two patients required oesophageal dilatation for benign oesophageal strictures. CONCLUSIONS Minimally invasive endoscopic therapy can be used successfully to achieve oesophageal re-epithelialisation and resolution of sepsis in patients unfit for surgical intervention. It offers a feasible treatment for patients not accounted for in today's literature and expands on currently described endoscopic therapies.
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Affiliation(s)
- J H Darrien
- NHS Lanarkshire, c/o Hasan Kasem at Wishaw General Hospital, 50 Netherton Street, Wishaw, North Lanarkshire ML2 0DP, UK.
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38
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Biancari F, D'Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, Saarnio J, Lucenteforte E. Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013; 37:1051-9. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 Oulu, Finland.
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Moriarity AR, Larkin JO, O’Sullivan KE, Ravi N, Reynolds JV. Spontaneous Perforation of the Esophagus in a Patient With Achalasia. Ann Thorac Surg 2013; 96:1456-1457. [DOI: 10.1016/j.athoracsur.2013.01.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 01/20/2013] [Accepted: 01/28/2013] [Indexed: 01/19/2023]
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Bona D, Aiolfi A, Rausa E, Bonavina L. Management of Boerhaave's syndrome with an over-the-scope clip. Eur J Cardiothorac Surg 2013; 45:752-4. [PMID: 23868954 DOI: 10.1093/ejcts/ezt363] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Boerhaave's syndrome is a spontaneous barotraumatic disruption of the distal oesophagus secondary to an abrupt increase in intraoesophageal pressure during vomiting. Management ranges from a conservative approach to an oesophagectomy. The over-the-scope-clip (OTSC, Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed clipping method for tissue mechanical compression in the gastrointestinal tract. We report the case of a patient referred with a delayed diagnosis of Boerhaave's syndrome and successfully treated by OTSC application followed by lung decortication.
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Affiliation(s)
- Davide Bona
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan Medical School, IRCCS Policlinico San Donato, Milan, Italy
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41
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Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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42
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Søreide JA, Konradsson A, Sandvik OM, Øvrebø K, Viste A. Esophageal perforation: clinical patterns and outcomes from a patient cohort of Western Norway. Dig Surg 2013; 29:494-502. [PMID: 23392348 DOI: 10.1159/000346479] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 12/10/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Esophageal perforation is a rare, often life-threatening condition, and management remains challenging. METHODS Retrospective review of consecutive patients with esophageal perforation treated at two university hospitals between 2000 and 2010. Pertinent data from hospital records were retrieved for statistical calculations and evaluation of perforation score. RESULTS Forty-seven patients [47% female, median age 62 years (range 15-88)] were included. The annual incidence was 4.7/1,000,000. Perforations were spontaneous in 14 patients (30%), iatrogenic in 25 (53%), and caused by trauma and foreign body impaction in 8 patients (17%). ASA score (p = 0.004), perforation localization (p = 0.001), diagnostic delay (p = 0.002), and perforation score (p < 0.001) differed significantly between patient groups with different etiology, but not between groups with different outcomes. Early diagnosis (≤24 h) was significantly associated with a low perforation score (p = 0.033). A non-operative approach was employed in 26 patients (55%) - more commonly for proximally localized perforations (p = 0.045). The non-operative group showed lower severe complication rates (p = 0.033), shorter ICU stays (p < 0.001) and durations of mechanical ventilation (p = 0.022). The overall 30-day mortality was 23.4%. CONCLUSION Careful clinical evaluation and appropriate, individualized treatment are important. The high mortality may be partly explained by the underlying disease and the complexity of the clinical condition in many patients.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastroenterologic Surgery, Stavanger University Hospital, Stavanger, Norway.
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Sulpice L, Dileon S, Rayar M, Badic B, Boudjema K, Bail JP, Meunier B. Conservative surgical management of Boerhaave's syndrome: experience of two tertiary referral centers. Int J Surg 2012; 11:64-7. [PMID: 23219866 DOI: 10.1016/j.ijsu.2012.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 11/21/2012] [Accepted: 11/22/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgery is generally proposed for Boerhaave's syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers. METHODS From June 1985 to November 2010, among 53 patients presenting with Boerhaave's syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S). RESULTS Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021). CONCLUSIONS These findings from the largest reported cohort of Boerhaave's syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.
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Affiliation(s)
- L Sulpice
- Service de chirurgie hépatobiliaire et digestive, CHU Rennes, Université de Rennes 1, France.
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Elsayed H, Shaker H, Whittle I, Hussein S. The impact of systemic fungal infection in patients with perforated oesophagus. Ann R Coll Surg Engl 2012; 94:579-84. [PMID: 23131229 PMCID: PMC3954285 DOI: 10.1308/003588412x13373405388095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2012] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre. METHODS A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008). RESULTS We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications. CONCLUSIONS Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.
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Affiliation(s)
- H Elsayed
- Liverpool Heart and Chest Hospital NHS Foundation Trust, UK.
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[Esophageal injury following blunt thoracic trauma. A case report and review of the literature]. Unfallchirurg 2012; 115:1123-5. [PMID: 23052701 DOI: 10.1007/s00113-012-2256-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of this article was to raise the awareness of the difficulties physicians face in the diagnosis and treatment of esophageal perforation following blunt thoracic trauma. We present a case of esophagus perforation following blunt chest trauma in the course of a motorcycle accident. Within 24 h the patient was admitted to the University hospital, and presented with progressive pain, subfebrile temperature, leukocytosis and pneumomediastinum. Emergency surgery revealed extensive esophageal lesions. A two-stage surgical approach was chosen with initial resection and temporary closure of the esophagus. After 2 months the integrity of the esophagus could be restored without complications.
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Sulpice L, Rayar M, Laviolle B, Cunin D, Merdrignac A, Boudjema K, Meunier B. Surgical treatment of esophageal perforations: the importance of a primary repair. Surg Today 2012; 43:727-31. [PMID: 22987277 DOI: 10.1007/s00595-012-0328-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/09/2012] [Indexed: 01/04/2023]
Abstract
PURPOSE The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis. METHODS All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients. RESULTS The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19). CONCLUSIONS Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.
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Affiliation(s)
- L Sulpice
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire, Université de Rennes 1, Rennes, France
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Abstract
A physiologically fit 91-year-old gentleman presented with sudden onset chest pain, breathlessness and cardiovascular compromise associated with vomiting. He was treated for renal colic, community-acquired pneumonia and pulmonary embolism before a formal diagnosis of Boerhaave's syndrome was made. The patient was prepared for emergency surgery, unfortunately his condition deteriorated rapidly and he was subsequently managed conservatively. He died 2 days later. Diagnosis and treatment of Boerhaave's syndrome are often delayed. Treatment options for Boerhaave's syndrome include conservative measures, endoscopic interventions and surgery. Chest pain is a common presentation on the acute medical take. Boerhaave's syndrome is a rare cause of chest pain, which may mimic other conditions but should not be missed due a high death rate.
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Affiliation(s)
- Sarah White
- Department of Geriatric Medicine, Bristol Royal Infirmary, University Hospitals Bristol, Bristol, UK.
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Abstract
Boerhaave's syndrome is oesophageal rupture as a result of forceful vomiting or retching against a closed cricopharyngeus. We report the case of an 81-year-old man with oesophageal rupture secondary to volvulus of an intrathoracic stomach who underwent laparotomy with a repair of the oesophageal perforation and intrathoracic stomach, making a good recovery. This case demonstrates another life-threatening complication of an intrathoracic stomach and highlights the importance of an early diagnosis and the advantages of using a transabdominal approach in this situation.
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Affiliation(s)
- A Paily
- Department of Surgery, The Royal Infirmary, Edinburgh, Scotland, UK
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Lyman D. Spontaneous esophageal perforation in a patient with mixed connective tissue disease. Open Rheumatol J 2012; 5:138-43. [PMID: 22279514 PMCID: PMC3263470 DOI: 10.2174/1874312901105010138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/28/2011] [Accepted: 10/31/2011] [Indexed: 11/22/2022] Open
Abstract
Spontaneous esophageal perforation is a rare and life-threatening disorder. Failure to diagnosis within the first 24-48 hours of presentation portends a poor prognosis. A patient with mixed connective tissue disease (MCTD) on low-dose prednisone and methotrexate presented moribund with chest and shoulder pain, a left hydropneumothorax, progressive respiratory failure and shock. Initial management focussed on presumed community acquired pneumonia (CAP) in a patient on immunosuppressants. Bilateral yeast empyemas were treated and attributed to immunosuppression. On day 26, the patient developed mediastinitis, and the diagnosis of esophageal perforation was first considered. A review of the literature suggests that the diagnosis and management of spontaneous esophageal perforation could have been more timely and the outcome less catastrophic.
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Affiliation(s)
- David Lyman
- Cherry Street Health Services, 100 Cherry Street SE, Grand Rapids, Michigan, 49053, USA
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Suzuki M, Sato N, Matsuda J, Niwa N, Murai K, Yamamoto T, Takeda S, Shigehara K, Nomura T, Gamma A, Tanaka K. A case of rapid diagnosis of Boerhaave syndrome by thoracic drainage. J Emerg Med 2011; 43:e419-23. [PMID: 22197195 DOI: 10.1016/j.jemermed.2011.05.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 10/21/2010] [Accepted: 05/20/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Boerhaave syndrome is a rare and often fatal syndrome. Delayed diagnosis and treatment is closely associated with prolonged morbidity and increased mortality. In general, esophagography is usually chosen as the diagnostic procedure, but it has a relatively high false-negative rate. There are no reports, to our knowledge, regarding the efficacy of thoracic drainage, although it is easier to perform and more immediate than esophagography in the emergency department. OBJECTIVES To report the efficacy of thoracic drainage for rapid diagnosis and treatment of Boerhaave syndrome. CASE REPORT An 80-year-old woman was admitted with vomiting and sudden onset of postprandial chest pain radiating to the back. Initially, myocardial infarction or aortic dissection was suspected, but was excluded by point-of-care tests and computed tomography (CT) scan, which revealed a left-sided pneumothorax, heterogeneous left pleural effusion, and pneumomediastinum at the lower level of the esophagus. Boerhaave syndrome was suspected and confirmed by thoracic drainage, which drained off bloody fluid and residual food such as broccoli. Emergency thoracotomy was performed within 4 h after onset of symptoms. The patient made an uneventful recovery. CONCLUSION Findings in this case indicate that chest pain, left-sided massive effusion on chest radiography, and left-sided massive heterogeneous effusion on CT scan are important for the diagnosis of Boerhaave syndrome. Subsequent thoracic drainage is useful for confirming Boerhaave syndrome, and such a strategy might lead to a good prognosis for patients with this rare but critical disease.
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Affiliation(s)
- Manabu Suzuki
- Intensive and Cardiac Care Unit, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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