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Ashbrook MJ, Theeuwen HA, Cheng V, Harano T, Wightman SC, Atay SM, Rosenberg GM, Udelsman BV, Kim AW. Initial management and outcomes of nonmalignant esophageal perforations: A Nationwide Inpatient Sample analysis. Surgery 2024; 176:1115-1122. [PMID: 39025691 DOI: 10.1016/j.surg.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/11/2024] [Accepted: 06/02/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Management of esophageal perforation includes open surgery, minimally invasive surgery, and endoscopic stent placement. This study analyzed initial treatment and the associated short-term outcomes. METHODS A retrospective study using the National Inpatient Sample between October 2015 and December 2019 identified adults >18 years with esophageal perforation undergoing an initial nonelective esophageal procedure categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement. Patients with esophageal cancer were excluded. Baseline characteristics and the van Walraven-weighted Elixhauser Comorbidity Index were identified. Outcomes included in-hospital mortality and postintervention complications. Univariable and multivariable Cox regression was used to compare in-hospital survival. RESULTS In total, 3,345 patients met inclusion criteria: the median age was 62 years (interquartile range 50-72 years), and 1,310 (39%) were female. Open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%) with no differences in van Walraven-weighted Elixhauser Comorbidity Index or mortality. Patients who underwent minimally invasive surgery had a greater proportion of gastrointestinal complications (P = .006); otherwise, there were no differences in postintervention complications. In total, 380 (11%) patients died and were significantly older, with greater van Walraven-weighted Elixhauser Comorbidity Index, and had more postintervention complications. Univariable Cox regression identified age (hazard ratio 1.95, P < .001), van Walraven-weighted Elixhauser Comorbidity Index (hazard ratio 1.06, P < .001), stent placement (hazard ratio 1.93, P = .045), and transfer from a health facility (HR 2.40, P = .049) as associated with decreased in-hospital survival. Multivariable Cox regression revealed age (hazard ratio 1.041, P < .001) and van Walraven-weighted Elixhauser comorbidity index (hazard ratio 1.055, P < .001) were associated with decreased in-hospital survival. CONCLUSION Patients with esophageal perforation had an 11% in-hospital mortality rate and significant associated complications regardless of intervention. Increasing age and comorbidities are associated with poorer in-hospital survival.
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Affiliation(s)
- Matthew J Ashbrook
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Hailey A Theeuwen
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Vincent Cheng
- Division of Bariatric Surgery, Kaiser Permanente - Ontario Medical Center, Ontario, CA
| | - Takashi Harano
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Sean C Wightman
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Scott M Atay
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Graeme M Rosenberg
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Brooks V Udelsman
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Anthony W Kim
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA.
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Wong LY, Leipzig M, Liou DZ, Backhus LM, Lui NS, Shrager JB, Berry MF. Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort. J Gastrointest Surg 2023; 27:1757-1765. [PMID: 37165161 DOI: 10.1007/s11605-023-05700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/15/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort. METHODS Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined. RESULTS Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009). CONCLUSIONS Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA.
| | - Matthew Leipzig
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Leah M Backhus
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California, USA
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Kim MJ, Ryu DG, Park SB, Choi CW, Kim HW, Kim SJ. Esophageal Stricture after Endoscopic Drainage of Esophageal Abscess as a Complication of Acute Phlegmonous Esophagitis: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 80:262-266. [PMID: 36567439 DOI: 10.4166/kjg.2022.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 12/27/2022]
Abstract
Esophageal abscess caused by acute phlegmonous esophagitis is rare but life-threatening. Rapid abscess drainage is an important part of the treatment, and endoscope-assisted intra-luminal abscess drainage is frequently performed. Although endoscopic drainage is less invasive than surgery, it has the potential to cause esophageal stricture as a complication. We present a rare case of esophageal stricture as a complication of intra-luminal drainage and evaluate a method to minimize the incidence of esophageal stricture complications.
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Affiliation(s)
- Min Ji Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Gon Ryu
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med 2021; 53:29-36. [PMID: 34971919 DOI: 10.1016/j.ajem.2021.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality. OBJECTIVE This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence. DISCUSSION Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting. CONCLUSIONS An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.
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Scutaru TT, Kupcsulik P, Sahin P, Szücs Á. From eosinophilic esophagitis to esophagus perforation: clinical management strategies. Arch Clin Cases 2021; 6:37-47. [PMID: 34754907 PMCID: PMC8565702 DOI: 10.22551/2019.23.0602.10152] [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] [Indexed: 11/25/2022] Open
Abstract
Introduction: Eosinophilic esophagitis is a chronic, antigen-mediated inflammation of the esophagus. The disease is most common at young ages, with a male to female ratio of 3:1. Eosinophilic granulocyte infiltration induced by oral/aeroantigens in the esophagus, mucosal hyperplasia, and fibrosis of the subepithelial layers can lead to constriction, dysphagia, blockage and esophageal perforation. Case report: A 36-year-old male patient presented in June 2016 with dysphagia as the main complaint. Workup with plain chest radiography with a water soluble contrast swallow did not reveal any pathological lesions. The patient's swallowing difficulties persisted and one year later he was treated by esophageal food bolus impaction (EFBI) in another institution. A new plain chest radiography with a water soluble contrast swallow confirmed a 9 cm long stricture in the middle third with an EFBI. During gastroscopy, a clinical picture of eosinophilic esophagitis was noted, with partially destroyed foreign body at 25cm and iatrogenic perforation at the upper half of the esophagus. After preoperative intensive care unit valuation and preparation, transhiatal esophagectomy without thoracotomy and cervical esophagostomy was performed with pyloromyotomy and feeding jejunostomy. The postoperative period was uneventful. Histological examination confirmed the presence of strictures and perforation on the background of eosinophilic esophagitis. Elective esophageal reconstruction with cervical esophagogastric anastomosis was performed on January 2018. Control blood tests revealed persistent eosinophilia, while the plain chest radiography with a water soluble contrast swallow showed no contrast leakage. Per os nutrition was resumed and the patient was discharged in good general condition. Conclusions: Eosinophilic esophagitis is a rare and difficult to diagnose entity due to its non-specific clinical presentation. In order to avoid complications and undesired delay in diagnosis, one should take into consideration this entity in every clinical situation of a young male patient with swallowing complaints.
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Affiliation(s)
| | - Péter Kupcsulik
- Semmelweis University's First Department of Surgery, Budapest, Hungary
| | - Péter Sahin
- Jahn Ferenc South-Pest Hospital and Clinic, Budapest, Hungary
| | - Ákos Szücs
- Semmelweis University's First Department of Surgery, Budapest, Hungary
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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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Saffo S, Farrell J, Nagar A. Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock. Acute Crit Care 2021; 36:264-268. [PMID: 33691378 PMCID: PMC8435440 DOI: 10.4266/acc.2020.01067] [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: 12/01/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.
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Affiliation(s)
- Saad Saffo
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - James Farrell
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Anil Nagar
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.,West Haven Veteran Affairs Medical Center, West Haven, CT, USA
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Schweigert M, Beattie R, Solymosi N, Booth K, Dubecz A, Muir A, Moskorz K, Stadlhuber RJ, Ofner D, McGuigan J, Stein HJ. Endoscopic Stent Insertion versus Primary Operative Management for Spontaneous Rupture of the Esophagus (Boerhaave Syndrome): An International Study Comparing the Outcome. Am Surg 2020; 79:634-40. [DOI: 10.1177/000313481307900627] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spontaneous rupture of the esophagus (Boerhaave syndrome) is an extremely rare, life-threatening condition. Traditionally surgery was the treatment of choice. Endoscopic stent insertion offers a promising alternative. The aim of this study was to compare the results of primary surgical therapy with endoscopic stenting. A British and a German high-volume center for esophageal surgery participated in this retrospective study. At the British center, operative therapy (primary repair or surgical drainage) was routinely carried out. Endoscopic stent insertion was the primary treatment option at the German center. Only patients with nonmalignant, spontaneous rupture of the esophagus (Boerhaave syndrome) were included. Demographic characteristics, comorbidity, clinical course, and outcome were analyzed. The study comprises 38 patients with a median age of 60 years. Time between rupture and treatment was less than 24 hours in 22 patients. Overall mortality was four of 38. Diagnosis greater than 24 hours was associated with higher risk for fatal outcome (odds ratio [OR], 4.64; 95% confidence interval [CI], 0.33 to 265.79). The surgery (S) and the endoscopic stent group (E) included 20 and 13 cases, respectively. Esophagectomy was unavoidable in three cases and two were managed conservatively. There were no significant differences in age, time to diagnosis less than 24 hours, intensive care unit days, hospital stay, sepsis, renal failure, slow respiratory weaning, or presence of comorbidity between the two groups. In 11 of 13 in the stent group, operative intervention (video-assisted thoracic surgery, thoracotomy, mediastinotomy) was eventually mandatory and three of 13 even required repeated surgery. The rate of reoperation in the surgery group was six of 20. Mortality was two of 13 (E) versus one of 20 (S). The odds for fatal outcome were 3.3 times higher in the stent group than in the surgery group (OR, 3.32; 95% CI, 0.15 to 213.98). Management of Boerhaave syndrome by means of endoscopic stent insertion offers no advantage regarding morbidity, intensive care unit or hospital stay, and is associated with frequent treatment failure eventually requiring surgical intervention. Furthermore, endoscopic stenting shows a higher risk for fatal outcome than primary surgical therapy.
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Affiliation(s)
- Michael Schweigert
- Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; the
| | - Rory Beattie
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK
| | | | - Karen Booth
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK
| | - Attila Dubecz
- Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; the
| | - Andrew Muir
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK
| | - Kerstin Moskorz
- Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; the
| | - Rudolf J. Stadlhuber
- Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; the
| | - Dietmar Ofner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Jim McGuigan
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK
| | - Hubert J. Stein
- Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany; the
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10
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Abila AW, Nditika ME, Kipkemoi RD, Ondigo S, Khwa-Otsyula BO. Primary repair of esophageal perforation: Case report. Int J Surg Case Rep 2020; 71:159-162. [PMID: 32454452 PMCID: PMC7248577 DOI: 10.1016/j.ijscr.2020.04.026] [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: 02/18/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mortality after esophageal perforation is high irrespective of the treatment modality. The rarity of traumatic esophageal perforations has made it difficult to conduct comprehensive studies that can answer pertinent questions with regard to management. PRESENTATION OF CASE We report a case of through and through thoracic esophageal injury caused by an assailant's arrow in a young physically active male adult. Diagnosis was made on-table. He successfully underwent primary repair of the esophageal injury 16 h post injury via a left thoracotomy. Recurrent lung collapse and pleural effusion was managed with tube thoracostomy and chest physiotherapy. DISCUSSION Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion. CONCLUSION Primary repair of traumatic injury to a healthy esophagus is feasible for cases diagnosed early and without significant mediastinal contamination as in our case. Associated injuries are more likely in such cases to lead to increased morbidity and prolonged hospital stay and must be handled carefully.
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Affiliation(s)
- Akello W Abila
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Faculty of Health Sciences, Egerton University, Nakuru, Kenya.
| | - Mburu E Nditika
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya
| | - Rono D Kipkemoi
- Faculty of Health Sciences, Egerton University, Nakuru, Kenya
| | - Stephen Ondigo
- Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barasa O Khwa-Otsyula
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
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11
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Chen S, Shapira-Galitz Y, Garber D, Amin MR. Management of Iatrogenic Cervical Esophageal Perforations. JAMA Otolaryngol Head Neck Surg 2020; 146:488-494. [DOI: 10.1001/jamaoto.2020.0088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Sophia Chen
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Yael Shapira-Galitz
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - David Garber
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Milan R. Amin
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
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12
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Gisasola P, Iriarte A, Larez MR, Casanova L, Bujanda L. Mediastinal abscess, an unusual way of presentation of eosinophilic esophagitis. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2019; 15:12. [PMID: 30858868 PMCID: PMC6396444 DOI: 10.1186/s13223-018-0313-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/20/2018] [Indexed: 11/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. EoE represents a chronic, local immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Mediastinal abscess is an uncommon condition that typically appears after esophageal perforations or thoracic surgeries, usually requiring treatment for surgical intervention due to its high morbidity-mortality. Mediastinal abscess, outside these two contexts, is extremely rare. We present the case of a mediastinal abscess secondary to EoE. It is important to think about this entity when there is a mediastinal abscess without trauma or previous surgery.
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Affiliation(s)
- Paul Gisasola
- Zumarraga Ospitalea, OSI Goierri-Urola Garaia, Department of Gastroenterology, Hospital Zumarraga, Argixao Auzoa, 20700 Zumarraga, Gipuzkoa, Basque Country Spain
| | - Ainara Iriarte
- Zumarraga Ospitalea, OSI Goierri-Urola Garaia, Department of Gastroenterology, Hospital Zumarraga, Argixao Auzoa, 20700 Zumarraga, Gipuzkoa, Basque Country Spain
| | - Martha Rosa Larez
- Zumarraga Ospitalea, OSI Goierri-Urola Garaia, Department of Gastroenterology, Hospital Zumarraga, Argixao Auzoa, 20700 Zumarraga, Gipuzkoa, Basque Country Spain
| | - Laura Casanova
- Zumarraga Ospitalea, OSI Goierri-Urola Garaia, Department of Gastroenterology, Hospital Zumarraga, Argixao Auzoa, 20700 Zumarraga, Gipuzkoa, Basque Country Spain
| | - Luis Bujanda
- Department of Gastroenterology, Instituto Biodonostia, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas Y Digestivas (CIBERehd), Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
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13
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Abstract
PURPOSE Esophageal perforation constitutes a potentially life-threatening condition, and this study aimed to evaluate the indications and outcome for the different treatment modalities. PATIENTS AND METHODS In total, 43 patients with esophageal perforation were considered for this retrospective analysis. Age, sex, length of hospital stay and intensive care treatment, in-hospital mortality, localization of perforation and etiology, treatment modality, and 90-day morbidity were analyzed. RESULTS Most patients suffered from Boerhaave syndrome and from iatrogenic esophageal perforation. In total, 63% of patients (26/41) received successful nonoperative treatment, whereas 36% required additional surgery. Two patients (5%) underwent primary surgery. In all cases no esophagectomy was necessary. In-hospital mortality was 7%. During the 90-day follow-up 1 patient with stenosis required repetitive dilatations. CONCLUSIONS Initial endoscopic treatment, either by stent or by endosponge, alone or combined with an additional operative treatment, seems feasible in patients suffering from esophageal perforation. In all patients, there was no need for esophagectomy.
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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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15
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Aiolfi A, Inaba K, Recinos G, Khor D, Benjamin ER, Lam L, Strumwasser A, Asti E, Bonavina L, Demetriades D. Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank. World J Emerg Surg 2017; 12:19. [PMID: 28465715 PMCID: PMC5408440 DOI: 10.1186/s13017-017-0131-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 04/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality. METHODS This National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications. RESULTS A total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p = 0.008), 30-day mortality (4.2 vs. 9.3%, p = 0.005), and overall mortality (7.9 vs. 13.5%, p = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV-V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148-0.546; p < 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06-2.53; p = 0.026). CONCLUSIONS Despite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival. TRIAL REGISTRATION iStar, HS-16-00883.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Piazza Edmondo Malan, 1, 20097 Milan, Italy
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Gustavo Recinos
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Desmond Khor
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Elizabeth R. Benjamin
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Aaron Strumwasser
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Piazza Edmondo Malan, 1, 20097 Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Piazza Edmondo Malan, 1, 20097 Milan, Italy
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Los Angeles, CA 90033 USA
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16
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Saxena P, Khashab MA. Endoscopic Management of Esophageal Perforations: Who, When, and How? ACTA ACUST UNITED AC 2017; 15:35-45. [PMID: 28116696 DOI: 10.1007/s11938-017-0117-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.
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Affiliation(s)
- Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA
| | - Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA.
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17
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Shehab H, Baron TH. Enteral stents in the management of gastrointestinal leaks, perforations and fistulae. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160006] [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: 11/22/2022] Open
Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy Unit, Kasralainy University Hospital, Cairo University, Cairo, Egypt
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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18
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Zimmermann M, Hoffmann M, Jungbluth T, Bruch HP, Keck T, Schloericke E. Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients. Scand J Surg 2016; 106:126-132. [DOI: 10.1177/1457496916654097] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation. Patients and Methods: This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig–Holstein, Luebeck Campus, from January 1986 through December 2011. Results: Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance. Conclusion: Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.
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Affiliation(s)
- M. Zimmermann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - M. Hoffmann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Jungbluth
- Department of Surgery, Klinikum Wolfsburg, Wolfsburg, Germany
| | - H. P. Bruch
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Keck
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - E. Schloericke
- Department of Surgery, Westküstenklinikum Heide, Heide, Germany
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19
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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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20
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Liu HC, Chen CH, Chan ML, Chen CH, Huang WC. Management of Esophageal Perforations in Elderly Patients. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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21
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Bayram AS, Erol MM, Melek H, Colak MA, Kermenli T, Gebitekin C. The success of surgery in the first 24 hours in patients with esophageal perforation. Eurasian J Med 2014; 47:41-7. [PMID: 25745344 DOI: 10.5152/eajm.2014.55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/27/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Esophageal perforation (EP) is a critical and potentially life-threatening condition with considerable rates of morbidity and mortality. Despite many advances in thoracic surgery, the management of patients with EP is still controversial. MATERIALS AND METHODS We retrospectively reviewed 34 patients treated for EP, 62% male, mean age 53.9 years. Sixty-two percent of the EPs were iatrogenic. Spontaneous and traumatic EP rates were 26% and 6%, respectively. Three patients had EP in the cervical esophagus and 31 in the thoracic esophagus. RESULTS Mean time to initial treatment was 34.2 hours. Twenty patients comprised the early group <24 h) and 14 patients the late group (>24 h). Management of the EP included primary closure in 30 patients, non-surgical treatment in two, stent in one and resection in one. Mortality occurred in nine of the 34 patients (26%). Mortality was EP-related in four patients. Three of the nine patients that died were in the early group (p<0.05). Mean hospital stay was 13.4 days. CONCLUSION EP remains a potentially fatal condition and requires early diagnosis and accurate treatment to prevent the morbidity and mortality.
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Affiliation(s)
- Ahmet Sami Bayram
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Mehmet Muharrem Erol
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Huseyin Melek
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Mehmet Ali Colak
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Tayfun Kermenli
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Cengiz Gebitekin
- Department of Thoracic Surgery, Uludag University Faculty of Medicine, Bursa, Turkey
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22
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Abstract
Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross-sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98-3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65-5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50-4.71]) and male gender (OR = 1.52 [1.46-1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07-1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39-1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (∼46%) and mortality (∼20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.
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Affiliation(s)
- Marc Makhani
- Section of Gastroenterology, Temple University School of Medicine, Philadelphia, PA
| | - Deena Midani
- Division of Internal Medicine, Temple University School of Medicine, Philadelphia, PA
| | - Amy Goldberg
- Department of Trauma Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Frank K Friedenberg
- Section of Gastroenterology, Temple University School of Medicine, Philadelphia, PA
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23
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Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience. Surg Endosc 2014; 29:700-7. [PMID: 25034382 DOI: 10.1007/s00464-014-3724-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/30/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic treatment for esophageal perforation with stenting is an alternative to surgery. There is no data on the impact of timing of esophageal stent placement and outcomes in patients with esophageal perforation. OBJECTIVE To determine the significance of timing of esophageal stent placement on short-term (30-day complications) and long-term clinical outcomes of patients with esophageal perforation. METHODS Patients with esophageal perforations who underwent endoscopic treatment with stenting from 2007 to 2012 at the Cleveland Clinic were included for the study. Main outcomes measurements were impact of time to esophageal stent placement on 30-day complications and long-term outcomes. RESULTS A total of 20 patients (males 40 % and females 60 %) were included. Mean age was 72.5 ± 10 years. The most common etiology for perforation was iatrogenic after endoscopy procedure in 10 (50 %) patients. The stent was in place for a median of 24.6 days in our cohort. Eight patients (40 %) had stent placement within 24 h, while the remaining 12 patients (60 %) had stent placement after 24 h. The mortality rate due to perforation related causes was 10 % (2/20) in our study. The 30-day complication rate was 10 %; 1 with stent migration and the other with chest pain. The 30-day readmission rates excluding patients who died during the initial hospitalization were 10 %. On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain. The timing of stent placement (within 24 h or later) did not impact the risk of complications (Odds Ratio [OR] 1.13, 95 % confidence interval 0.1-8.9, P = 0.91). CONCLUSIONS Endoscopic stent placement is safe and effective for treating esophageal perforations. However, the timing of stent placement on outcomes remains unclear.
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24
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Cervical esophageal perforation: a 10-year clinical experience in north of iran. Indian J Otolaryngol Head Neck Surg 2014; 67:34-9. [PMID: 25621251 DOI: 10.1007/s12070-014-0737-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022] Open
Abstract
Perforations of the cervical esophagus are infrequent severe conditions associated with a high rate of morbidity and mortality if misdiagnosed. The diagnosis and management of cervical esophageal perforation remains a challenging clinical problem. We aimed to present our experience of the etiology, presentation, management and outcome of cervical esophageal perforation in a 10 years period. In this cross-sectional study, we reviewed the records of all patients with a diagnosis of cervical esophageal perforation admitted at the teaching Razi Hospital of Rasht, north of Iran, between 2001 and 2011. 26 patients (15 male) were studied with mean age of 47.6 ± 13.78 years, a range from 10 to 68 years. Only 16 (61.5 %) of patients were referred within 24 h of injury. The etiology was iatrogenic in 15 cases (57.69 %), foreign body ingestion in 7 cases (26.9 %), and penetrating traumatic injury in 4 cases (15.4 %). The common clinical manifestations of perforation were neck pain in 22 cases (84.6 %), fever in 19 cases (73.1 %), and subcutaneous emphysema in 12 cases (46.2 %). Barium and gastrografin swallow were performed in 57.7 and 23.1 % of patients, respectively and flexible esophagoscopy was used in 23.06 %. Most of patients (65.4 %) were managed by primary repair. Overall, mortality rate was 7.7 %. Our study demonstrates that the most common cause of cervical esophageal perforation is iatrogenic injury. Clinical suspicion is most important problem. Furthermore, Diagnosis is mainly made by Barium and gastrografin swallow. For a successful outcome, primary repair is a preferred treatment for most perforation patients.
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25
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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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26
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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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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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Hamid UI, Jones JM. Combined tracheoesophageal transection after blunt neck trauma. J Emerg Trauma Shock 2013; 6:117-22. [PMID: 23723621 PMCID: PMC3665059 DOI: 10.4103/0974-2700.110774] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 08/25/2012] [Indexed: 11/04/2022] Open
Abstract
Survival following tracheoesophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Understanding the mechanism of the incident can be a useful adjunct in predicting the likelihood and severity of specific anatomical patterns of injuries. We discuss published literature on combined tracheoesophageal injuries after blunt neck trauma and their outcome. A search of MEDLINE for papers published regarding tracheoesophageal injury was made. The literature search identified 14 such articles referring to a total of 27 patients. Age ranged from 3-73 years. The mechanism of injury was secondary to a rope/wire in 33%, metal bar in 4% of cases and unspecified in 63%. All of the patients were managed surgically. A number of tissues were used to protect the anastomosis including pleural and sternocleidomastoid muscle flaps. There were no reported mortalities. Patients with combined tracheoesophageal injury after blunt neck trauma require acute management of airway along with concomitant occult injuries.
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Affiliation(s)
- Umar Imran Hamid
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Grosvenor road, Belfast, UK BT12 6BA
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29
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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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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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31
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Jabłoński S, Brocki M, Kordiak J, Misiak P, Terlecki A, Kozakiewicz M. Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients. ANZ J Surg 2012; 83:657-63. [DOI: 10.1111/j.1445-2197.2012.06252.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marian Brocki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Jacek Kordiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Piotr Misiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Artur Terlecki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marcin Kozakiewicz
- Department of Faciomaxillary Surgery; Medical University of Lodz; Łódź; Poland
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Jabłoński S, Kozakiewicz M. Proposal for a recovery prediction method for patients affected by acute mediastinitis. World J Emerg Surg 2012; 7:11. [PMID: 22574625 PMCID: PMC3518827 DOI: 10.1186/1749-7922-7-11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 05/10/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An attempt to find a prediction method of death risk in patients affected by acute mediastinitis. There is not such a tool described in available literature for that serious disease. METHODS The study comprised 44 consecutive cases of acute mediastinitis. General anamnesis and biochemical data were included. Factor analysis was used to extract the risk characteristic for the patients. The most valuable results were obtained for 8 parameters which were selected for further statistical analysis (all collected during few hours after admission). Three factors reached Eigenvalue >1. Clinical explanations of these combined statistical factors are: Factor1 - proteinic status (serum total protein, albumin, and hemoglobin level), Factor2 - inflammatory status (white blood cells, CRP, procalcitonin), and Factor3 - general risk (age, number of coexisting diseases). Threshold values of prediction factors were estimated by means of statistical analysis (factor analysis, Statgraphics Centurion XVI). RESULTS The final prediction result for the patients is constructed as simultaneous evaluation of all factor scores. High probability of death should be predicted if factor 1 value decreases with simultaneous increase of factors 2 and 3. The diagnostic power of the proposed method was revealed to be high [sensitivity =90%, specificity =64%], for Factor1 [SNC = 87%, SPC = 79%]; for Factor2 [SNC = 87%, SPC = 50%] and for Factor3 [SNC = 73%, SPC = 71%]. CONCLUSION The proposed prediction method seems a useful emergency signal during acute mediastinitis control in affected patients.
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Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, 113 Żeromskiego St,, 90-547, Łódź, Poland.
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Abstract
Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.
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Affiliation(s)
- Philip W Carrott
- Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, C6-GS, Seattle, WA 98111, USA
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Liu J, Zhang X, Xie D, Peng A, Yang X, Yu F, Liu D. Acute mediastinitis associated with foreign body erosion from the hypopharynx and esophagus. Otolaryngol Head Neck Surg 2012; 146:58-62. [PMID: 21987647 DOI: 10.1177/0194599811425140] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 09/09/2011] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Mediastinitis secondary to hypopharyngeal and esophageal foreign bodies is a rare but lethal complication. So far, no literature on a large scale has been reported. This investigation reviewed cases of mediastinitis associated with foreign body ingestion during the past 40 years. STUDY DESIGN Case series with chart review. SETTING Second Xiangya Hospital, Central South University. SUBJECTS AND METHODS Of 2981 patients with hypopharyngeal and esophageal foreign body impaction included between 1969 and 2010, 93 had complications of acute mediastinitis. Four patients were dead within 4 hours after admission. The rest of the 89 patients underwent surgical drainage. Thirteen underwent primary repair (7 cases with suture, 6 cases with omentum onlay graft), and 9 patients underwent endoscopic stent placement at the same time. RESULTS The mean (SD) time between ingestion and initial treatment of patients who developed mediastinitis was 7.72 (1.93) days, compared with 1.92 (1.41) days for those who did not (P < .05). Morbidity was 3.1% and mortality was 30.1% (28/93), but the mortality of every decade has decreased from 38.7% in the 1970s to 8.3% today. Nine cases with local stent were all recovered. CONCLUSIONS Delay in initiating treatment and intrathoracic esophageal foreign bodies are the main risk factors of mediastinitis secondary to foreign body ingestion. Computed tomography plays an important role in diagnosis and guiding treatments. In conjunction with aggressive surgical debridement and drainage, endoscopic stent placement could be the optimal management for most patients.
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Affiliation(s)
- Jiajia Liu
- Department of Otolaryngology-Head and Neck Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan, PR China
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Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg 2011; 92:209-15. [PMID: 21718846 DOI: 10.1016/j.athoracsur.2011.03.131] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 03/26/2011] [Accepted: 03/29/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND Perforation of the esophagus remains a challenging clinical problem. METHODS A retrospective review was performed of patients diagnosed with an esophageal perforation admitted to the London Health Sciences Centre from 1981 to 2007. Univariate and multivariate logistic regression was used to determine which factors had a statistically significant effect on mortality. RESULTS There were 119 patients; 15 with cervical, 95 with thoracic, and 9 with abdominal perforations. Fifty-one percent of all the perforations were iatrogenic and 33% were spontaneous. Multivariate logistic regression analysis revealed that patients with preoperative respiratory failure requiring mechanical ventilation had a mortality odds ratio of 32.4 (95% confidence interval [CI] 3.1 to 272.0), followed by malignant perforations with 20.2 (95% CI 5.4 to 115.6), a Charlson comorbidity index of 7.1 or greater with 19.6 (95% CI 4.8 to 84.9), the presence of a pulmonary comorbidity with 13.9 (95% CI 2.9 to 97.4), and sepsis with 3.1 (95% CI 1.0 to 10.1). A wait time of greater than 24 hours was not associated with an increased risk of mortality (p=0.52). CONCLUSIONS Malignant perforations, sepsis, mechanical ventilation at presentation, a higher overall burden of comorbidity, and a pulmonary comorbidity have a significant impact on the overall survival. Time to treatment is not as important. Restoration of intestinal continuity, either by primary repair or by excision and reanastomosis can be attempted even in patients with a greater time from perforation to treatment with respectable morbidity and mortality rates.
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Affiliation(s)
- Pankaj Bhatia
- Division of Thoracic Surgery, The University of Western Ontario, London, Ontario, Canada
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D'Cunha J, Rueth NM, Groth SS, Maddaus MA, Andrade RS. Esophageal stents for anastomotic leaks and perforations. J Thorac Cardiovasc Surg 2011; 142:39-46.e1. [PMID: 21683837 DOI: 10.1016/j.jtcvs.2011.04.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 04/09/2011] [Accepted: 04/26/2011] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Intrathoracic esophageal anastomotic leaks and perforations are very morbid and challenging problems. Esophageal stents are increasingly playing an integral role in the management of these patients. Our objective was to report our experience with esophageal stent placement for anastomotic leaks and perforations and to provide a treatment algorithm. METHODS We performed a review of patients with stent placement for esophagogastric anastomotic leaks or esophageal perforation from March 2005 to August 2009. A prospective database was used to collect data. Success was defined as endoscopic defect closure, negative esophagram, and resumption of oral intake. Failure was defined as no change in leak size or clinical signs of ongoing infection. We collected and analyzed patient demographics, diagnosis, clinical history, and poststent outcomes using descriptive statistics. RESULTS Thirty-seven patients underwent esophageal stent placement for anastomotic leaks (n = 22) and perforations (n = 15). The median time from original procedure to diagnosis of leak or perforation was 6 days (0-420 days). Nineteen patients (51%) had 21 associated procedures for source control. We placed 94 stents (mean = 2.7 stents/patient); 16 patients (43%) required more than 1 stenting procedure (mean = 1.8 procedures/patient). The median time to restoration of esophageal integrity was 33 days (7-120 days). There were 22 successes (59%); 2 failures were secondary to undrained abscess. Only 2 failures occurred in the last 15 patients (88% success). Strictures did not develop in any patients. Serious complications occurred in 3 patients (stent erosion, leak enlargement, fatal gastroaortic fistula). CONCLUSIONS Esophageal stents can potentially play an integral role in the management of anastomotic leaks and perforations. Success depends on appropriate procedures for source control and surgeon experience.
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Affiliation(s)
- Jonathan D'Cunha
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn 55455, USA.
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Mahmodlou R, Abdirad I, Ghasemi-rad M. Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases. ISRN SURGERY 2011; 2011:868356. [PMID: 22084783 PMCID: PMC3200272 DOI: 10.5402/2011/868356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 04/29/2011] [Indexed: 11/27/2022]
Abstract
Introduction. Esophageal perforation is a relatively uncommon and lethal disease usually resulting from endoscopic procedures. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40% to 60%, but this rate decreases is 10%-25% if treatment is carried out within 24 hours of perforation. Case Presentation. To analyze the characteristics, etiology, site of perforation, presentation, time interval till diagnosis, treatment and outcome of patients with esophageal perforation. Over a five-year period, from October 2004 through March 2009, 11 patients with esophageal perforation were referred to the division of thoracic surgery of a tertiary referral hospital. In eight patients, perforations were thoracic with delayed diagnosis for at least 48 hours. Two patients had cervical esophageal perforation, and one patient had early-diagnosed Boerhaave's syndrome. Eight patients are alive after followup for a period ranging from eight months to five years. In the remaining three patients, cancer was the underlying disease and the reason of death. Conclusion. No patient with esophageal perforation should be deprived from surgical repair due to delayed diagnosis. All, except preterminal patients, should undergo exploration after resuscitation, and appropriate treatment should be carried out depending on the findings during operation. Aggressive treatment is necessary in the case of established mediastinitis.
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Affiliation(s)
- Rahim Mahmodlou
- Department of General and Thoracic Surgery, Emam Hospital, Urmia University of Medical Sciences, Urmia 57/35, Iran
| | - Isa Abdirad
- Department of Genetics, Motahhari Hospital, Urmia University of Medical Sciences, Urmia 57/35, Iran
| | - Mohammad Ghasemi-rad
- Genius and Talented Student Organization, Student Research Committee (SRC), Urmia University of Medical Sciences, Urmia 57/35, Iran
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Kuppusamy MK, Hubka M, Felisky CD, Carrott P, Kline EM, Koehler RP, Low DE. Evolving management strategies in esophageal perforation: surgeons using nonoperative techniques to improve outcomes. J Am Coll Surg 2011; 213:164-71; discussion 171-2. [PMID: 21429768 DOI: 10.1016/j.jamcollsurg.2011.01.059] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 01/15/2011] [Accepted: 01/21/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes. STUDY DESIGN Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality. RESULTS Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative. CONCLUSIONS Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.
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Affiliation(s)
- Madhan Kumar Kuppusamy
- Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA
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39
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Keeling WB, Miller DL, Lam GT, Kilgo P, Miller JI, Mansour KA, Force SD. Low mortality after treatment for esophageal perforation: a single-center experience. Ann Thorac Surg 2010; 90:1669-73; discussion 1673. [PMID: 20971287 DOI: 10.1016/j.athoracsur.2010.06.129] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 06/21/2010] [Accepted: 06/23/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically, esophageal perforation has been associated with significant mortality. Improvements in diagnosis, critical care, and surgical and endoscopic techniques may lead to lower mortality rates in the modern era. We reviewed our experience with the management of esophageal perforation to determine whether outcomes have improved. METHODS We retrospectively reviewed all cases of esophageal perforation from 1997 through 2008 at our institution. Univariate and propensity-matching analysis were performed. RESULTS We reviewed the charts of 147 patients, and 97 met eligibility criteria. There were 45 women, (46.4%); mean age was 60.7 ± 15.6 years. Etiologies included iatrogenic in 50 (51.6%), spontaneous in 23 (23.7%), and idiopathic in 22 (22.7%). Treatment within 24 hours of presentation occurred in 55.2% of patients; 22.7% of patients were septic on presentation. Treatment included surgery in 72 patients (74.2%) and nonoperative management in 25 (25.8%). Forty-one patients (42.3%) underwent primary repair, 5 (6.9%) underwent esophageal resection, 4 (5.6%) underwent exclusion, and 22 (22.7%) underwent drainage or stent placement. Thirty-day mortality rate for the entire cohort was only 8.3% (8 patients). The mortality rate for the primary repair patients was 7.7%, and none of the resection patients died. There was similar in-hospital mortality rate between operative and nonoperative treatment groups (p = 0.96). Propensity-matching analysis showed equal morbidity (p = 0.74) and 30-day mortality (p = 0.35) between operative and nonoperative treatment groups. CONCLUSIONS Our study represents a large series of patients treated for esophageal perforation. The results demonstrate that the overall mortality from esophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Nonoperative management, in appropriate patients, can also lead to good success rates and low mortality.
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Dalal S, Dalal N, Goyal P. Isolated Esophageal Injury Following Blunt Thoracic Trauma: A Rarity. Gastroenterology Res 2009; 2:307-308. [PMID: 27956976 PMCID: PMC5139779 DOI: 10.4021/gr2009.10.1317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2009] [Indexed: 11/24/2022] Open
Abstract
Esophageal injury following blunt trauma to chest is an extremely rare event, with only a limited number of cases being reported in the world literature. We report a case of perforation of the lower thoracic esophagus following a crush injury to the chest in a 14 year old child. An appropriately placed chest drain and decompression gastrostomy resulted in complete resolution of the esophageal leak within four weeks. This case report demonstrates that a conservative approach to lower thoracic esophageal perforations can be carried out successfully without the added morbidity of thoracotomy and risks of direct repair.
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Affiliation(s)
- Satish Dalal
- Department of General Surgery, Pt.B.D.Sharma Postgraduate Institute of Medical Sciences (P.G.I.M.S.), Rohtak-124001, Haryana, India
| | - Nityasha Dalal
- Department of General Surgery, Pt.B.D.Sharma Postgraduate Institute of Medical Sciences (P.G.I.M.S.), Rohtak-124001, Haryana, India
| | - Pawan Goyal
- Department of General Surgery, Pt.B.D.Sharma Postgraduate Institute of Medical Sciences (P.G.I.M.S.), Rohtak-124001, Haryana, India
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41
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Esophageal stent placement for the treatment of spontaneous esophageal perforations. Ann Thorac Surg 2009; 88:194-8. [PMID: 19559223 DOI: 10.1016/j.athoracsur.2009.04.004] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/31/2009] [Accepted: 04/02/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent. METHODS During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram. RESULTS Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 +/- 15 days after placement. Hospital length of stay was 9 +/- 12 days. CONCLUSIONS Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.
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Salminen P, Gullichsen R, Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks. Surg Endosc 2009; 23:1526-30. [PMID: 19301070 DOI: 10.1007/s00464-009-0432-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Revised: 02/04/2009] [Accepted: 02/26/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. METHODS All esophageal stent placement procedures (174 procedures for 157 patients) at the authors' unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave's syndrome (n = 4), or an anastomotic leakage (n = 2). RESULTS The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. CONCLUSIONS Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.
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Affiliation(s)
- P Salminen
- Department of Surgery, Turku University Central Hospital, Turku, Finland.
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Griffiths EA, Yap N, Poulter J, Hendrickse MT, Khurshid M. Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK. Dis Esophagus 2009; 22:616-25. [PMID: 19302220 DOI: 10.1111/j.1442-2050.2009.00959.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23-86) years. The etiology of the perforations were Boerhaave's syndrome (n= 19), therapeutic endoscopy (n= 9), diagnostic endoscopy (n= 2), gastric lavage injury (n= 1), foreign body (n= 1), blunt chest trauma (n= 1), and spontaneous tumor perforation (n= 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair (n= 9), T-tube drainage (n= 7), emergency esophagectomy (n= 1), or intra-operative stent insertion (n= 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.
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Affiliation(s)
- E A Griffiths
- Department of General Surgery, Furness General Hospital, Barrow in Furness, Cumbria, UK.
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Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent. Surg Endosc 2009; 23:2258-62. [PMID: 19184216 DOI: 10.1007/s00464-008-0302-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 12/01/2008] [Accepted: 12/09/2008] [Indexed: 01/19/2023]
Abstract
BACKGROUND Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS). METHODS Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal. RESULTS SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing. CONCLUSIONS Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.
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Zhou JH, Gong TQ, Jiang YG, Wang RW, Zhao YP, Tan QY, Ma Z, Lin YD, Deng B. Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent. Dis Esophagus 2009; 22:434-8. [PMID: 19191858 DOI: 10.1111/j.1442-2050.2008.00927.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this article, we reviewed our experience of treatment of the delayed intrathoracic nonmalignant esophageal perforation employing modified intraluminal esophageal stent. Between February 1990 and August 2006, eight patients were included in this study. Five patients experienced sepsis. The interval time between perforation and stent placement ranged from 36 h to 27 days (average, 8.6 days). Esophageal stenting and throracotomy for foreign body removal were performed in four patients. The remaining four patients underwent stent placement and thoracostomy. Nutrition was initiated through gastrostomy after 7 to 10 days after the stenting. The stent was removed after the patients resumed oral intake of food and the esophagogram showed that perforation was closed. There was no death in this group. Signs of sepsis remitted 1 week after stent placement. Complications included stress ulcer, stimulative cough, and pneumonia each. Stent removal ranged 32 to 120 days (average 66.7) after its placement. The stent was kept in place for 4 months to prevent formation of esophageal stricture in one patient with caustic esophageal burns. The follow-up was completed in all the patients. The mean follow-up period was 59 months (range 12-180). One patient with caustic esophageal burn underwent cicatricial esophagectomy and gastric transposition 3 years later due to the esophageal stricture. Barium swallow demonstrated that there was a diverticulum-like outpouching in one patient and slight esophageal stricture at T2 and T3 level in another. One patient developed reflux esophagitis 5 years after stent removal. All the patients finally had a normal intake of food. Modified esophageal stenting is an effective method to manage the delayed intrathoracic esophageal perforation. Prevention of stent migration and its convenient adjustment might be the major advantages of this method.
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Affiliation(s)
- J-H Zhou
- Department of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
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21st ESICM Annual Congress. Intensive Care Med 2008. [PMCID: PMC2799007 DOI: 10.1007/s00134-008-1240-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tuebergen D, Rijcken E, Mennigen R, Hopkins AM, Senninger N, Bruewer M. Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations. J Gastrointest Surg 2008; 12:1168-76. [PMID: 18317849 DOI: 10.1007/s11605-008-0500-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/05/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center. METHODS Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured. RESULTS Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%). CONCLUSIONS Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.
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Affiliation(s)
- Dirk Tuebergen
- Department of General Surgery, Unit of Surgical Endoscopy, University of Muenster, Muenster, Germany
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Abstract
We present a case of blunt traumatic rupture of the distal oesophagus successfully managed following early diagnosis and treatment. This is a rare cause of oesophageal perforation. We present the evidence that early diagnosis of ruptured oesophagus leads to reduced mortality and fewer complications. Our report reminds colleagues to consider this unusual and potentially fatal condition in cases of blunt chest trauma.
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Breigeiron R, de Souza HP, Sidou JPP. Risk factors for surgical site infection after surgery for esophageal perforation. Dis Esophagus 2008; 21:266-71. [PMID: 18430110 DOI: 10.1111/j.1442-2050.2007.00779.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforations carry a high potential for morbidity and mortality. The prognosis depends on rapid and precise diagnosis and management. Surgical site infections (SSIs) are very common following the surgical treatment of esophageal lesions. We aimed identify significant risk factors for SSI after surgery for esophageal perforation via an historical cohort study including patients who underwent surgical management of esophageal perforation. The predictive variables were analyzed by bivariate analysis and multiple logistic regression. Eighty-one patients were studied during a 10-year period ending in 2004. The mean age was 42.6 years. In 44% of the patients the time interval between the perforation and surgery was up to 6 h and in 30% it was > 24 h. Associated lesions occurred in other cavities; 17% in the chest, 5% in the abdomen, 5% in the extremities, 4% in the spinal column and bone marrow and 2% in the face. There were grade I lesions in eight cases (10%), grade II in 64 cases (79%) and grade III in nine cases (11%). The mean time of surgery procedure was 117.2 min. The mean SSI was 7.99. SSIs occurred in 33 patients (41%). The risk factors for SSI following surgical management of esophageal perforation were: age > or = 50 years, time delay to treatment > 24 h, associated lesion in another cavity and Injury Severity Score > or = 15.
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Affiliation(s)
- R Breigeiron
- General Surgery Service and Digestive Surgery, Hospital São Lucas-Pontifícia Universidade Católica do Rio Grande do Sul, and General and Trauma Surgery, Pronto Socorro de Porto Alegre, Porto Alegre, Brazil.
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