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Saleem MM, Pervaiz M, Mazhar I, Shoaib U, Osama M, Ahmad A, Khauteja Khan S, Tahir MI, Sami KH, Muazzam M. Non-surgical Management of Neonatal Esophageal Perforation: A Rare Case. Cureus 2025; 17:e77289. [PMID: 39931598 PMCID: PMC11809944 DOI: 10.7759/cureus.77289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2025] [Indexed: 02/13/2025] Open
Abstract
Iatrogenic esophageal perforation in neonates, though rare, is a serious condition with high mortality. It is almost exclusively secondary to invasive instrumentation complications in intensive care settings. Forceful or repeated orogastric (OG) or nasogastric (NG) tube insertion, vigorous suctioning to clear the airway, and trauma during airway intubation are the leading causes. Being rare in occurrence, a high index of suspicion should be maintained for early diagnosis and prompt treatment to prevent mortality. We present a similar case in a 2.6 kg male neonate who developed this complication from OG tube placement in the neonatal intensive care unit during the treatment of respiratory distress and parapneumonic effusion.
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Affiliation(s)
| | - Mishal Pervaiz
- Anesthesiology, Combined Military Hospital (CMH), Lahore, PAK
| | - Ismail Mazhar
- Pediatric Surgery, Combined Military Hospital (CMH), Lahore, PAK
- Internal Medicine, Combined Military Hospital (CMH) Lahore Medical College, Institute of Dentistry, Lahore, PAK
| | - Uswah Shoaib
- Pediatric Surgery, Combined Military Hospital (CMH), Lahore, PAK
| | - Muhammad Osama
- Pediatric Surgery, Combined Military Hospital (CMH), Lahore, PAK
| | - Amaan Ahmad
- Pediatric Surgery, Combined Military Hospital (CMH) Lahore Medical College, Institute of Dentistry, Lahore, PAK
| | | | | | - Khawaja Haider Sami
- Pediatric Surgery, Combined Military Hospital (CMH) Lahore Medical College, Institute of Dentistry, Lahore, PAK
| | - Maida Muazzam
- General Surgery, Shifa Tameer-E-Millat University Shifa College of Medicine, Islamabad, PAK
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2
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Günendi T, Kocaman OH, Dörterler ME, Kaya V, Efe C, Boleken ME. Non-operative management of iatrogenic esophageal perforation in a 6-year-old child. Acta Chir Belg 2023; 123:682-686. [PMID: 35838032 DOI: 10.1080/00015458.2022.2101748] [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: 11/14/2021] [Accepted: 07/11/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Esophageal perforations are rare, the most common encountered esophageal perforation is iatrogenic in origin. It can be life-threatening if not diagnosed and treated early. Medical treatment has been recommended primarily in hemodynamically stable children. Drainage of intrathoracic or periesophageal fluid formation should be reserved to patients with hemodynamic instability. Surgical intervention may seldomly be required, depending on the localization and size of the defect. CASE REPORT A 6-year-old male patient was referred to our clinic due to an esophageal perforation whilst removing the foreign body from upper esophagus under direct vision of a rigid esophagoscope. A radiologic appearance similar to esophageal duplication was detected along the esophagus in the esophagogram. A secondary esophagoscopy was carried out by our clinic, laceration at the esophagopharyngeal junction and dissection along the esophagus were observed and the foreign body was propelled into the stomach. The patient, whose clinical condition was stable, was managed medically without the need for a surgical intervention. CONCLUSIONS Esophageal perforation is rare, yet perilous if not handled properly. We do not encounter this clinical entity frequently. Despite its rarity it can arise either iatrogenically or while managing a previous complication such as a simple nasogastric tube insertion in an infant or during an endoscopy for an esophageal foreign body. Its management is challenging, and we believe that non-operative treatment is still an important option in childhood esophageal perforations.
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Affiliation(s)
- Tansel Günendi
- Department of Pediatric Surgery, Harran University Medical Faculty, Şanlıurfa, Turkey
| | - Osman Hakan Kocaman
- Department of Pediatric Surgery, Harran University Medical Faculty, Şanlıurfa, Turkey
| | | | - Veysel Kaya
- Department of Radiology, Harran University Medical Faculty, Şanlıurfa, Turkey
| | - Cumali Efe
- Department of Gastroenterology, Harran University Medical Faculty, Şanlıurfa, Turkey
| | - Mehmet Emin Boleken
- Department of Pediatric Surgery, Harran University Medical Faculty, Şanlıurfa, Turkey
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3
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Borries T, Eldore LW, Burris J, Shah Z, Ford K. Esophageal Perforation of a Neonate Following Placement of an Oral Gastric Tube. Cureus 2023; 15:e44461. [PMID: 37791196 PMCID: PMC10544182 DOI: 10.7759/cureus.44461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
We present a case of neonatal esophageal perforation following routine oral gastric (OG) tube placement in the neonatal intensive care unit. This is a rare complication primarily affecting premature infants and can have significant morbidity and mortality. This case demonstrates the initial radiographic presentation of esophageal perforation and the subsequent imaging to confirm the diagnosis. Clinical management of this condition in the neonatal patient is also discussed. A unique highlight of this case is the difference in radiographic presentation on the initial study as compared to the later study.
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Affiliation(s)
- Trevor Borries
- Diagnostic Radiology Residency, Baylor University Medical Center, Dallas, USA
| | - Luke W Eldore
- Medical School, Texas A&M College of Medicine, Dallas, USA
- Radiology, Baylor University Medical Center, Dallas, USA
| | - John Burris
- Radiology, Baylor University Medical Center, Dallas, USA
| | - Zubin Shah
- Radiology, Baylor University Medical Center, Dallas, USA
| | - Kenneth Ford
- Radiology, Baylor University Medical Center, Dallas, USA
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4
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von Beck K, Robinson T, Nguyen CN, Perez TH, Olson J, Lovvorn HN, Baron CM, Zamora IJ. Use of a self-expanding metal stent to treat acute esophageal perforation in a 4-year-old child. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Salış M, Arda MS, Tokar B. Management of Pediatric Trauma: General View. PEDIATRIC ENT INFECTIONS 2022:1107-1120. [DOI: 10.1007/978-3-030-80691-0_92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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El-Asmar KM, Elghandour MM, Allam AM. Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage. J Pediatr Surg 2021; 56:692-696. [PMID: 32622547 DOI: 10.1016/j.jpedsurg.2020.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Iatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program. PATIENTS AND METHODS From January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported. RESULTS 24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement. CONCLUSION Preserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life. Level IV of evidence.
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Affiliation(s)
| | | | - Ayman M Allam
- Pediatric Surgery Department, Ain Shams University, Cairo, Egypt
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7
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Elgendy MM, Othman H, Aly H. Esophageal perforation in very low birth weight infants. Eur J Pediatr 2021; 180:513-518. [PMID: 33410940 DOI: 10.1007/s00431-020-03894-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
We aimed to assess the prevalence and outcomes of esophageal perforation in very low birth weight infants. This retrospective cohort study utilized the US National Inpatient Sample dataset for the years 2000 to 2017. A total of 1,755,418 very low birth weight infants were included; of them, 861 (0.05%) were diagnosed with esophageal perforation. The majority (77.9%) of infants were in the birth weight category < 1000 g and 77.7% in infants ≤ 28 weeks of gestation. The majority (73%) of infants were tracheally intubated and received mechanical ventilation; of them, 24 infants (2.8%) had tracheostomy. Mortality associated with esophageal perforation was 25.8%. Regression analysis did not show an association between esophageal perforation and increased mortality in preterm infants (aOR = 1.0, CI: 0.83-1.20, p = 0.991). Procedures encountered in these infants include thoracentesis (10.8%), laparotomy (4.1%), percutaneous abdominal drainage (4.1%), and gastrostomy tube insertion (6.2%), whereas the rest of the infants were managed conservatively. There was a significant trend for increasing prevalence of esophageal perforation over the years.Conclusion: Esophageal perforation does not independently increase the risk for mortality in very low birth weight infants. The increasing prevalence is possibly related to increased care offered to infants at limits of viability in recent years. What is Known: • Knowledge about esophageal perforation is derived from anecdotal single-center case reports. • Esophageal perforation in neonates is mostly iatrogenic. • It is considered a critical complication that is associated with high mortality. What is New: • This is the first and largest national study on prevalence of esophageal perforation in preterm infants. • Esophageal perforation does not independently increase the risk for mortality. • Septicemia and pneumothorax are frequent complications to esophageal perforation.
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Affiliation(s)
- Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA.
| | - Hasan Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, MI, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA
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8
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Fan W, Huang J. Experience on Using Thoracoscope in Diagnosis and Treatment of Neonatal Idiopathic Esophageal Perforation. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02075-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AbstractIdiopathic esophageal perforation in the neonatal is a rare entity. The presentation is usually with mediastinal inflammation, icherrhemia, and infectious shock, all of which are potentially life-threatening. We present a case with an unusual right side pneumothorax chest and esophagography suggesting an esophageal perforation. With thoracoscope, the esophageal perforation was sutured. The child recovered well from the procedure.
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9
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Matsumoto R, Sasaki K, Omoto I, Noda M, Uchikado Y, Arigami T, Kita Y, Mori S, Maemura K, Natsugoe S. Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report. Surg Case Rep 2019; 5:152. [PMID: 31650260 PMCID: PMC6813377 DOI: 10.1186/s40792-019-0717-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/27/2019] [Indexed: 01/11/2023] Open
Abstract
Background Spontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients. Case presentation A 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH2O and at − 20 cmH2O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day. Conclusion Conservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.
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Affiliation(s)
- Ryu Matsumoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
| | - Itaru Omoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Masahiro Noda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
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10
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Pediatric esophageal perforation due to firearm injuries during the Syrian war and a new suture technique. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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11
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Govindarajan KK. Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation. KOREAN JOURNAL OF PEDIATRICS 2018; 61:175-179. [PMID: 29963100 PMCID: PMC6021361 DOI: 10.3345/kjp.2018.61.6.175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/06/2018] [Accepted: 04/29/2018] [Indexed: 01/08/2023]
Abstract
Perforation of the esophagus is an uncommon problem with significant morbidity and mortality. In children undergoing endoscopy, the risk of perforation is higher when interventional endoscopy is performed. The clinical features depend upon the site of esophageal perforation. Opinions vary regarding the optimal treatment protocol, and the role of conservative management in this context is not well established. Esophageal perforation that occurs as a consequence of endoscopy in children requires careful evaluation and management, as outlined in this article.
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Affiliation(s)
- Krishna Kumar Govindarajan
- Department of Pediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
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12
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Abstract
Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.
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13
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Abstract
Esophageal perforation (EP) is a rare complication that is often iatrogenic in origin. In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has become a common therapeutic approach for EP in neonates and children. Principles of management pediatric EP includes rapid diagnosis, appropriate hemodynamic monitoring and support, antibiotic therapy, total parenteral nutrition, control of extraluminal contamination, and restoration of luminal integrity either through time or operative approaches.
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children׳s Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
| | - Shawn D St Peter
- Deparment of Surgery, Children׳s Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
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14
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Herb B, Meltzer J, Lim CA. Dysphagia in a Teenager With Neck Trauma. Clin Pediatr (Phila) 2017; 56:301-304. [PMID: 27107007 DOI: 10.1177/0009922816645523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Brandon Herb
- 1 Albert Einstein College of Medicine, Bronx, NY, USA
| | - James Meltzer
- 1 Albert Einstein College of Medicine, Bronx, NY, USA.,2 Jacobi Medical Center, Bronx, NY, USA
| | - C Anthoney Lim
- 1 Albert Einstein College of Medicine, Bronx, NY, USA.,2 Jacobi Medical Center, Bronx, NY, USA
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15
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Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children. J Pediatr Gastroenterol Nutr 2017; 64:e38-e43. [PMID: 28107284 DOI: 10.1097/mpg.0000000000001235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Surgery and conservative treatment of esophageal or gastric perforations are both often associated with poor results and carry a high morbidity and mortality rate. The aim of the present study was to evaluate the effectiveness and safety of using fully covered self-expending metallic stents (SEMS) in children with upper digestive leaks. METHODS This retrospective study reviewed all children with esophageal or gastric perforation who were treated with placement of an SEMS from January 2011 to January 2015. Closure of the perforation was the primary outcome measured. Secondary outcomes were the duration of antibiotic therapy and parenteral nutrition, adverse events, and length of hospitalization. RESULTS A total of 19 SEMS were placed in 10 patients (median age: 5.5 years; 5 girls) treated for postanastomotic leaks of esophageal atresia (n = 3), esophagogastroplasty (n = 4), resection of esophageal duplication (n = 1) or perforation during Toupet surgical dismantling (n = 1), and gastric rupture after Nissen surgery (n = 1). The perforation closed in 9 out of 10 patients in a mean of 36 days after stenting (range: 13-158 days). All patients received antibiotic therapy for an average of 17.5 days (3-109 days) and parenteral nutrition for 49 days (17-266 days). During a median follow-up of 8.9 months, 4 out of 9 sealed perforations developed stenosis, which was efficiently treated by endoscopic dilations in 2 patients and surgical redo in 2 patients with dilation-resistant stenosis. CONCLUSIONS Covered stents appear to be beneficial in closing esophageal perforations in children and can avoid the high morbidity of a surgical repair. Stenosis, however, occurred frequently after larger leakages.
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16
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Abstract
Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.
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Affiliation(s)
- Erik G Pearson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew T Santore
- Section of Pediatric Surgery, Department of Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Third Floor Surgical Offices, 1405 Clifton Rd, Atlanta, Georgia 30322.
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17
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Okumura H, Uchikado Y, Kita Y, Omoto I, Hayashi N, Matsumoto M, Sasaki K, Setoyama T, Arigami T, Uenosono Y, Matsushita D, Desaki R, Noda M, Higo N, Okubo K, Urata M, Yamasaki Y, Owaki T, Ishigami S, Natsugoe S. Clinical analysis of the diagnosis and treatment of esophageal perforation. Esophagus 2016; 13:146-150. [DOI: 10.1007/s10388-015-0504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
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18
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 11/28/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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Abstract
Thoracic injury in children deserves special attention because, although it accounts for less than 10% of traumatic injuries in children, there is a significant associated morbidity and mortality. This review discusses the anatomic and physiologic factors resulting in such injury severity with blunt thoracic trauma in children. Specific organ injuries, including most common chest wall injuries, hemo- and pneumothoraces, and pulmonary parenchymal injuries, are discussed, encompassing epidemiology, presentation, diagnosis, and management. Rare injuries including tracheobronchial tree injuries, cardiovascular injuries, esophageal injuries, and diaphragmatic injuries are also briefly discussed.
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Affiliation(s)
- Hanna Alemayehu
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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20
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Hesketh AJ, Behr CA, Soffer SZ, Hong AR, Glick RD. Neonatal esophageal perforation: nonoperative management. J Surg Res 2015; 198:1-6. [PMID: 26055213 DOI: 10.1016/j.jss.2015.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/07/2015] [Accepted: 05/12/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Esophageal perforation is a rare complication of enteric instrumentation in neonates. Enteric tube placement in micro-preemies poses a particular hazard to the narrow lumen and thin wall of the developing esophagus. The complication may be difficult to recognize or misdiagnosed as esophageal atresia, and is associated with considerable mortality. Historically, management of this life-threatening iatrogenic disease was operative, but trends have shifted toward nonoperative treatment. Here, we review neonatal esophageal perforation at our own institution for management techniques, risk factors, and outcomes. MATERIALS AND METHODS Seven neonatal patients with esophageal perforation were identified and charts reviewed for demographics, comorbidities, etiology of perforation, diagnostic modalities, management decisions, complications, and outcomes. RESULTS Mean gestational age was 27.2 ± 4.0 wk, and weight at diagnosis was 892 ± 674 g. All seven patients had esophageal perforation resulting from endotracheal or enterogastric intubation and were managed nonoperatively. Treatment included removal of the offending tube, nil per os, and antibiotics. Five patients required additional interventions: four tube thoracostomies for pneumothoraces and one peritoneal drain for pneumoperitoneum. Three patients died because of sequelae of prematurity (intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). One patient was diagnosed as having esophageal atresia; esophagoscopy before surgical repair established the correct diagnosis. CONCLUSIONS Neonates, particularly those under 1500 g, are at substantial risk for iatrogenic esophageal perforation during enterogastric intubation. Nonoperative management may be a safe initial strategy in the neonatal setting, but more aggressive interventions may ultimately be required. Despite recent improvement in early recognition of this injury, misdiagnosis still occurs.
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Affiliation(s)
- Anthony J Hesketh
- Division of Pediatric Surgery, Department of Surgery, Hofstra North Shore - LIJ School of Medicine, New Hyde Park, New York.
| | - Christopher A Behr
- Division of Pediatric Surgery, Department of Surgery, Hofstra North Shore - LIJ School of Medicine, New Hyde Park, New York
| | - Samuel Z Soffer
- Division of Pediatric Surgery, Department of Surgery, Hofstra North Shore - LIJ School of Medicine, New Hyde Park, New York
| | - Andrew R Hong
- Division of Pediatric Surgery, Department of Surgery, Hofstra North Shore - LIJ School of Medicine, New Hyde Park, New York
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Hofstra North Shore - LIJ School of Medicine, New Hyde Park, New York
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21
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Mishra B, Singhal S, Aggarwal D, Kumar N, Kumar S. Non operative management of traumatic esophageal perforation leading to esophagocutaneous fistula in pediatric age group: review and case report. World J Emerg Surg 2015; 10:19. [PMID: 25866555 PMCID: PMC4393641 DOI: 10.1186/s13017-015-0012-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 02/25/2015] [Indexed: 01/21/2023] Open
Abstract
Management of delayed presenting esophageal perforations has long been a topic of debate. Most authors consider definitive surgery being the management of choice. Management, however, differs in pediatric patients in consideration with better healing of younger tissues. We extensively review the role of aggressive non-operative management in pediatric esophageal perforations, especially with delayed presentation and exemplify with case of a young boy with esophageal perforation and esophago-cutaneous fistula. We also lay down the protocol to manage such patients based on our institutional recommendations.
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Affiliation(s)
- Biplab Mishra
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | | | - Divya Aggarwal
- University College of Medical Sciences, New Delhi, India
| | - Nitesh Kumar
- All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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22
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Sarıkaş NG, Korkmaz T, Kahramansoy N, Kılıçgün A, Boran Ç, Boztaş G. The effects of ankaferd blood stopper on the recovery process in an experimental oesophageal perforation model. Balkan Med J 2015; 32:96-100. [PMID: 25759779 DOI: 10.5152/balkanmedj.2015.15459] [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: 06/01/2014] [Accepted: 10/28/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Oesophageal perforation is a life-threatening pathology that is generally treated conservatively; however, surgical procedures are frequently performed. A topical haemostatic agent, Ankaferd Blood Stopper (ABS), also has beneficial wound-healing effects. AIMS This study aimed to determine the effects of ABS following experimental oesophageal perforations. STUDY DESIGN Animal experiment. METHODS The experimental rats were classified into 6 groups (with 7 rats in each group). Pairs of groups (primary repair alone and primary repair + ABS) were terminated in the 1(st), 2(nd), and 3(rd) weeks following injury. The oesophageal perforations, which were 8-10 mm in length, were created using a nasogastric tube. The perforation sites were repaired with a 6-0 polyglactine thread in the primary repair groups. Additionally, ABS was sprayed over the perforation site in the treatment groups. Each oesophagus was evaluated histopathologically. RESULTS There were fewer microabscesses and areas of necrosis in the ABS groups compared with the primary repair groups. The histopathological evaluation revealed that the ABS groups had less inflammation and more re-epithelisation compared to the primary repair groups (p=0.002 and p=0.003, respectively). Fibrosis in the ABS groups was moderate in the 2(nd) week and mild in the 3(rd) week. Comparing the groups with respect to the time intervals, only the 1(st) week groups showed a significant difference in terms of re-epithelialisation (p=0.044). CONCLUSION Topical ABS application on the repaired experimental oesophageal perforation regions led to positive wound-healing effects compared with the rats that were administered the primary repair alone.
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Affiliation(s)
- Necla Gürbüz Sarıkaş
- Department of Pediatric Surgery, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Tanzer Korkmaz
- Department of Emergency Medicine, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Nurettin Kahramansoy
- Department of General Surgery, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Ali Kılıçgün
- Department of Thoracic Surgery, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Çetin Boran
- Department of Pathology, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
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23
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Sabuncuoglu MZ, Benzin MF, Dandin O, Cakir T, Sozen I, Sabuncuoglu A, Teomete U. Rare cause of oesophagus perforation. Int J Surg Case Rep 2014; 6C:138-40. [PMID: 25541369 PMCID: PMC4334877 DOI: 10.1016/j.ijscr.2014.11.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/30/2014] [Accepted: 11/18/2014] [Indexed: 01/04/2023] Open
Abstract
Oesophagus perforation is a very serious clinical event. Mortality rates increase because inexperienced physicians cannot make a diagnosis. Although there is no consensus in literature on surgical treatment choices. INTRODUCTION Oesophagus perforations, which are generally caused by iatrogenic injuries, are a serious clinical event. There are still high rates of mortality and morbidity and there is no gold standard of surgical treatment. PRESENTATION OF CASE The case is here presented of a 54-year old female with complaints of dysphagia after having swallowed a bone in food, who was determined with oesophagus perforation on CT examination. DISCUSSION Oesophagus perforation generally occurs secondary to interventional procedures and rarely develops associated with foreign bodies. Treatment depends on the perforation site and dimension. CONCLUSION While conservative primary surgical repair may be chosen for cervical lesions, more aggressive approaches such as resection and delayed reconstruction are recommended for thoracic lesions. Early determination and appropriate treatment are life-saving.
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Affiliation(s)
| | - Mehmet Fatih Benzin
- Yozgat Akdagmadeni State Hospital, General Surgery Department, Yozgat, Turkey
| | - Ozgur Dandin
- University of Miami Miller School of Medicine, Department of Surgery, Ryder Trauma Center, Miami, FL, USA
| | - Tugrul Cakir
- Antalya Education and Research Hospital, General Surgery Department, Antalya, Turkey
| | - Isa Sozen
- Ankara Numune Education and Research Hospital, General Surgery Department, Ankara, Turkey
| | - Aylin Sabuncuoglu
- Isparta State Hospital Anesthesia and Critical Care Unit, Isparta, Turkey
| | - Uygar Teomete
- University of Miami Miller School of Medicine, Department of Radiology, Miami, FL, USA
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24
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Abstract
Esophageal perforation is uncommon but carries a high morbidity and mortality, particularly if the injury is not detected early before the onset of systemic signs of sepsis. The fact that it is an uncommon problem and it produces symptoms that can mimic other serious thoracic conditions, such as myocardial infarction, contributes to the delay in diagnosis. Patients at risk for iatrogenic perforations (esophageal malignancy) frequently have comorbidities that increase their perioperative morbidity and mortality. The optimal treatment of esophageal perforation varies with respect to the time of presentation, the extent of the perforation, and the underlying esophageal pathologic conditions.
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Affiliation(s)
- Raminder Nirula
- Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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25
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Abstract
Chest trauma in children is caused by high-energy blows, due in general to traffic accidents, that involve several other body regions. They occur mainly in the first decade of life and can be penetrating but are more often non-penetrating. Rib fractures and lung contusions, sometimes associated with pneumothorax or haemothorax, are the more usual injuries, but tracheobronchial rupture, cardiac, oesophageal or diaphragmatic injuries may also occur. These injuries are treated with supportive respiratory and haemodynamic measures, drainage of air or blood from the pleural space and, at times, surgical repair of the injured organ(s). Ruptures of the airway may be difficult to treat and occasionally require suture, anastomosis or resection. Oesophageal injuries can be treated conservatively with antibiotics, drainage and parenteral nutrition. Diaphragmatic tears should be repaired operatively. Overall mortality ranges from 6 to 20%. Mortality is high but this is mainly due to the associated presence of extra-thoracic trauma, and particularly to head injuries.
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Affiliation(s)
- Juan A Tovar
- Department of Paediatric Surgery, Hospital Universitario La Paz and Department of Paediatrics, Universidad Autonoma de Madrid, Madrid, Spain.
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26
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Rollins MD, Barnhart DC. Treatment of persistent esophageal leaks in children with removable, covered stents. J Pediatr Surg 2012; 47:1843-7. [PMID: 23084195 DOI: 10.1016/j.jpedsurg.2012.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 04/23/2012] [Accepted: 05/01/2012] [Indexed: 12/25/2022]
Abstract
Removable, fully covered, expandable metal esophageal stents are routinely used in adults for both malignant and benign esophageal disease. Several case reports have demonstrated the use of these stents in the management of caustic esophageal strictures in children. Most iatrogenic esophageal perforations and esophageal anastomotic leaks in children may be expected to heal with nonoperative treatment, although, in a small percentage, the leak may persist. We report 3 patients with complicated esophageal perforations refractory to nonoperative therapy who were successfully managed using covered esophageal stents.
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Affiliation(s)
- Michael D Rollins
- Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT 84113, USA.
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27
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Abstract
OPINION STATEMENT Esophageal perforation is an uncommon, potentially disastrous occurrence with high mortality rates even when managed with surgery. Over the past few decades, several case series have shown that nonoperative management is a feasible option in some patients, although the criteria for selecting such patients are neither firmly established nor accepted by all those who manage these critical patients. The decision to manage a patient without surgery should be made collaboratively with a surgeon. No single criterion, with the possible exception of sepsis and shock, mandates surgical management. Randomized, prospective studies comparing surgical and nonsurgical therapy have not been performed. Factors that can affect the decision to proceed nonoperatively include the perforation's site and size, the patient's underlying comorbidities, and the patient's hemodynamic status on presentation. Healthy patients with small, contained perforations who present without sepsis tend to be the best candidates for nonoperative management. Intravenous antibiotics and cessation of oral intake should be instituted immediately, even before confirming the diagnosis. Mediastinal fluid collections and pleural effusions often coexist with esophageal perforations and must be managed concomitantly. Percutaneously placed drains are an important adjunct to therapy when collections are identified. Endoscopic stenting has been introduced as a means to seal the perforation. After embarking on a nonoperative course, patients still may deteriorate and require surgery, so close follow-up is warranted for every patient. When proper nonoperative management strategies are followed, outcomes have been shown to be at least equivalent to those of surgical management in most series. In this review, the principles of patient selection and medical therapy for iatrogenic esophageal perforations are discussed.
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Affiliation(s)
- Ryan D Madanick
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing (CEDAS), University of North Carolina School of Medicine, 130 Mason Farm Road, Campus Box #7080 Bioinformatics 4142, Chapel Hill, NC, 27599, USA.
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28
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Roebuck DJ, Hogan MJ, Connolly B, McLaren CA. Interventions in the Chest in Children. Tech Vasc Interv Radiol 2011; 14:8-15. [DOI: 10.1053/j.tvir.2010.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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29
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Esophageal perforation in children: a review of one institution's experience. J Surg Res 2010; 164:13-7. [PMID: 20850782 DOI: 10.1016/j.jss.2010.05.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 04/21/2010] [Accepted: 05/20/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The current approach to esophageal perforation treatment in children has shifted towards conservative management. However, the consensus of what constitutes conservative management is unclear, with various therapies and protocols described, including the need for various decompression and drainage procedures. Our institution utilizes conservative management with minimal intervention guided by the patient's clinical course. The purpose of this study is to report our management and add to the growing evidence for conservative management of esophageal perforation in children. METHODS We performed a retrospective chart review of all patients with an ICD-9 diagnosis of esophageal perforation from January 1995 to July 2009. Patients with postoperative anastomotic leaks with drains in place were excluded, although patients with anastomotic leaks that were not controlled by drains were included. Data collected included patient demographics, etiology, diagnosis, treatment, complications, and outcome. RESULTS Eight patients were identified who met inclusion criteria. Mean age was 28 mo (1 d-10 y), and the average time from causative event to diagnosis was 1.4 d (0-2 d). The etiology for esophageal perforation included esophagoscopy with dilation (n = 4), button battery ingestion (n = 1), coin ingestion (n = 1), nasogastric tube placement (n = 1), and leak after stricture resection (n = 1). All the patients were treated conservatively without primary surgery or thoracic drainage, and the mean time to perforation healing was 10.2 d (1-24 d). The average length of antibiotic therapy was 10 d (0-26 d). Enteral nutrition was utilized in five patients, and total parenteral nutrition (TPN) was utilized in five patients. No patient developed a new-onset esophageal stricture. CONCLUSION Conservative management, guided by the patient's clinical course, with antibiotics and nutritional support is a safe and effective treatment for esophageal perforations in children.
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30
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Vallböhmer D, Hölscher AH, Hölscher M, Bludau M, Gutschow C, Stippel D, Bollschweiler E, Schröder W. Options in the management of esophageal perforation: analysis over a 12-year period. Dis Esophagus 2010; 23:185-90. [PMID: 19863642 DOI: 10.1111/j.1442-2050.2009.01017.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.
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Affiliation(s)
- D Vallböhmer
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
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31
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Mukherjee K, Isbell JM, Yang E. Blunt posterior tracheal laceration and esophageal injury in a child. J Pediatr Surg 2009; 44:1292-4. [PMID: 19524756 DOI: 10.1016/j.jpedsurg.2009.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 01/15/2009] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
Blunt force trauma to the neck can result in the unusual injury pattern of laceration of the posterior tracheal wall in combination with esophageal injury. We present the report of a 10-year-old child who had blunt cervical trauma because of a bicycle accident and subsequently presented with profound subcutaneous emphysema. This case was addressed with operative management with a good result. The essential management principles for this rare constellation of injuries include a high index of suspicion, early control of the airway, endoscopic and radiographic diagnosis, and use of a buttressing strap muscle flap in the event of operative management to prevent delayed complications, including leak and tracheoesophageal fistula.
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Affiliation(s)
- Kaushik Mukherjee
- Monroe Carell Jr, Children's Hospital at Vanderbilt, Nashville, Tenn 37232, USA
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32
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Abstract
Esophageal perforation is most commonly iatrogenic in origin with nasogastric tube insertion, stricture dilation, and endotracheal intubation, being the most frequent sources of the injury in infants and children. Clinical presentation depends on whether the cervical, thoracic, or abdominal esophagus is injured. Any patient complaining of chest pain after an upper endoscopy has esophageal perforation until proven otherwise. In infants and children, plain chest films and esophagography may assist in making the diagnosis. Hemodynamically stable patients with a contained perforation may be managed medically. Free perforation and hemodynamic lability mandates a more aggressive surgical approach for wide drainage of the mediastinum and pleural spaces. Exploration of the chest for attempted direct repair of the injury is now only rarely indicated. Mortality rates have been reported between 20 and 28% with delays in diagnosis and treatment appearing to be most strongly correlated with poor outcomes.
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Affiliation(s)
- Jeffrey W Gander
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA
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33
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Abstract
Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis are easily underestimated, delayed or missed. This is the second of a 2 part article reviewing Paediatric chest trauma and its current management. The injuries are usefully classified into 6 lethal injuries that need excluding in the primary survey and 6 hidden injuries that must be considered in the secondary survey. The 6 lethal injuries are covered in the first part of this article along with biomechanics and mechanisms of injury. This article looks in depth at the 6 hidden injuries, along with a review of chest trauma in non-accidental injury.
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Affiliation(s)
- Maya Kerr
- Paediatric A&E SpR, St Mary's Hospital,
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34
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Eliçevik M, Alim A, Tekant GT, Sarimurat N, Adaletli I, Kurugoglu S, Bakan M, Kaya G, Erdogan E. Management of esophageal perforation secondary to caustic esophageal injury in children. Surg Today 2008; 38:311-5. [DOI: 10.1007/s00595-007-3638-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 06/27/2007] [Indexed: 11/27/2022]
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Rico FR, Panzer AM, Kooros K, Rossi TM, Pegoli W. Use of Polyflex Airway stent in the treatment of perforated esophageal stricture in an infant: a case report. J Pediatr Surg 2007; 42:E5-8. [PMID: 17618872 DOI: 10.1016/j.jpedsurg.2007.04.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anastomotic stricture is a common sequela after primary repair of esophageal atresia with esophagoesophagostomy. Esophageal perforation secondary to dilatation of the stricture, and refractory stricture are not uncommon. We present a case using a Polyflex Airway stent (Boston Scientific, Natick, MA) as an alternative treatment of esophageal stricture and perforation in an infant.
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Affiliation(s)
- Ferdinand R Rico
- Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA
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36
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Margau R, Amaral JG, Chait PG, Cohen J. Percutaneous Thoracic Drainage in Neonates: Catheter Drainage versus Treatment with Aspiration Alone. Radiology 2006; 241:223-7. [PMID: 16928976 DOI: 10.1148/radiol.2411050966] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively compare thoracic drainage in neonates by using catheter and aspiration techniques. MATERIALS AND METHODS Approval was obtained from the institutional research ethics board; informed consent from parents was waived. Retrospective review of 21 neonates (19 boys, two girls; mean gestational age, 39.3 weeks) who underwent percutaneous thoracic drainage during a 9-year period was performed. Data such as indication for drainage, type of drainage, age and weight at birth, corrected age and weight at the time of drainage, use of mechanical ventilation at the time of drainage, and outcomes were collected. Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. Fisher exact test and two-tailed unpaired student t test with a confidence level of 95% (unequal variances assumed) were used to compare neonates treated with a catheter and those treated with aspiration. RESULTS Image-guided therapy was used to treat pleural effusion (29%, n = 6), chylothorax (24%, n = 5), empyema (19%, n = 4), pneumothorax (14%, n = 3), mediastinal seroma (10%, n = 3), and congenital cystic adenomatoid malformation (5%, n = 1). Sixteen (76%) infants were treated with catheter placement, with a success rate of 81% (13 of 16). Five (24%) infants were treated with simple aspiration with no success. The difference in success rates was significant (P = .003). There was no significant difference between the catheter placement and aspiration groups in terms of average age, average weight, and percentage dependent on mechanical ventilation. One complication (cellulitis) was directly related to catheter drainage. In cases where treatment was successful, the mean length of the chest tube placement was 13.5 days, and there were no deaths at follow-up. In cases where treatment failed, the long-term mortality rate was 50% (four of eight). CONCLUSION Image-guided percutaneous thoracic drainage success rates are improved if drainage catheters are placed rather than if aspiration alone is performed.
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Affiliation(s)
- Ryan Margau
- Department of Radiology, the Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada.
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37
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van der Zee DC, Bax NMA, de Schryver JEAR, Beek FJA. Indwelling balloon dilatation for esophageal stenosis in infants. J Pediatr Gastroenterol Nutr 2006; 42:437-9. [PMID: 16641584 DOI: 10.1097/01.mpg.0000189343.46257.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- David C van der Zee
- Department of Pediatric Surgery, University Medical Center, Utrecht, The Netherlands.
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38
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Lee TC, Dreyer ZE, Brandt ML. Conservative surgical treatment of a profoundly immunosuppressed pediatric patient with Boerhaave syndrome. J Pediatr Hematol Oncol 2005; 27:616-7. [PMID: 16282895 DOI: 10.1097/01.mph.0000188113.42576.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Boerhaave syndrome is a condition described as spontaneous rupture of the esophagus that often results in mediastinitis, sepsis, and death. The authors report a case of Boerhaave syndrome in a child with acute lymphoblastic leukemia. At the time of diagnosis (10 days after rupture), the patient had an absolute neutrophil count of 0 and was treated with T-tube drainage of the perforation. The T-tube was removed 2 months after the operation. The patient has required three endoscopic esophageal dilatations of a mild esophageal stricture. He remains in remission from his leukemia, has normal growth and development, and is on a regular diet.
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Affiliation(s)
- Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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39
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Vogel SB, Rout WR, Martin TD, Abbitt PL. Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality. Ann Surg 2005; 241:1016-21 ;discussion 1021-3. [PMID: 15912051 PMCID: PMC1357179 DOI: 10.1097/01.sla.0000164183.91898.74] [Citation(s) in RCA: 217] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation. SUMMARY BACKGROUND DATA The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress. METHODS From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement. RESULTS Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2. CONCLUSIONS Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.
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Affiliation(s)
- Stephen B Vogel
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610, USA.
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Demirbag S, Tiryaki T, Atabek C, Surer I, Ozturk H, Cetinkursun S. Conservative approach to the mediastinitis in childhood secondary to esophageal perforation. Clin Pediatr (Phila) 2005; 44:131-4. [PMID: 15735830 DOI: 10.1177/000992280504400204] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate the safety and efficacy of nonoperative treatment of esophageal perforation (EP) in children. Between 1999 and 2004, 13 episodes in 12 patients were evaluated. The treatment program consisted of broad-spectrum antibiotics, nasopharyngeal aspiration, parenteral and/or enteral nutrition by gastrostomy, and pleural effusion or mediastinal abscess drainage when required. Mean age of the patients was 3.75 +/- 1.13 (range 3-7 years). Two patients (16.7%) were girls and 10 patients (83.3%) were boys. Chest pain was found 76.9% of all EP episodes (10 of 13 perforations), followed by dyspnea in 69.2% (9 of 13), vomiting in 46.1% (6 of 13), fever in 46.1% (6 of 13), and epigastric pain in 7.6% (1 of 13). No deaths occurred. In children, in contrast with the adults, EP can be treated safely by nonoperative methods.
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Affiliation(s)
- Suzi Demirbag
- Department of Pediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
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