Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

Surgical versus endoscopic management of esophageal perforation

PURPOSE OF REVIEW

The management of esophageal perforation is a topic of debate, as there now are viable surgical and endoscopic options. Historically, surgical management had been considered the standard of care for these perforations, but such surgical management can be associated with considerable morbidity. In this report, we explore contemporary options for the care of patients with esophageal perforations.

RECENT FINDINGS

Innovations in endoscopic therapies, including self-expanding metal and plastic stents, over-the-scope clips, vacuum therapy, and endoscopic suturing have expanded treatment options for esophageal perforations. These approaches are particularly beneficial for selected patients with early, contained perforations, offering reduced morbidity and shorter hospital stays. However, surgical intervention remains essential in cases of extensive contamination, necrosis, or delayed diagnosis. A growing body of evidence supports a patient-specific approach, integrating both traditional and emerging interventions.

SUMMARY

The management of esophageal perforation is evolving with the increasing use of minimally invasive endoscopic techniques. However, surgical repair remains the definitive treatment in patients with hemodynamic instability or extensive contamination. Timely intervention is critical, as delayed diagnosis significantly increases morbidity and mortality. A tailored approach, incorporating patient-specific factors and nature of the disease, ensures optimal outcomes.

Successful perforation management during esophageal endoscopic submucosal dissection using the stent-anchoring method: A case report

Patients with esophageal endoscopic submucosal dissection-associated adverse events can have a severe clinical course. In this report, we describe the case of a 67-year-old male with a history of endoscopic submucosal dissection who had metachronous superficial esophageal cancer. Although endoscopic submucosal dissection was attempted for challenging lesions adjacent to the scar, perforations occurred during the procedure. We placed an esophageal fully covered self-expandable metallic stent at the perforation site to avoid emergency surgery after lesion removal. However, stent migration and displacement concerns remained, as no stenosis was observed in the esophagus. Therefore, a clip with a thread on the upper edge of the stent was placed, and this anchoring clip was useful in preventing stent migration and closing the perforation. The patient improved with conservative treatment. In conclusion, the stent placement and anchoring method with clip and thread could be a treatment option in such cases.

Endoscopic vacuum therapy for the treatment of Boerhaave syndrome: a multicenter analysis

BACKGROUND AND AIMS

Boerhaave syndrome, an effort rupture of the esophagus, is a rare but serious condition. Endoscopic vacuum therapy (EVT) is a new therapeutic approach for GI perforation. We aimed to evaluate EVT for treatment of Boerhaave syndrome.

METHODS

This retrospective study was conducted at 5 tertiary hospitals in southern Germany. All patients treated for Boerhaave syndrome since 2010 were identified and included. Treatment success and outcomes were assessed and compared between the different modes of primary treatment.

RESULTS

Fifty-seven patients with Boerhaave syndrome were identified (median age, 68 years; n = 16 female). The primary treatment was EVT in 25 cases, surgery in 14, and endoscopic stenting in 15. Primary EVT was successful in 20 (80.0%) of the 25 patients. Two patients were switched to surgical treatment, 1 was switched to esophageal stenting, and 2 patients died. The mortality rate was lower (P = .160) in patients treated primarily with EVT (n = 2 [8.0%]) compared with patients in the non-EVT group (n = 8 [25.0%]). Treatment success was significantly higher (P = .007) for primary EVT (80.0%) than for non-EVT (43.8%). Primary EVT was associated with treatment success in multivariable analysis.

CONCLUSIONS

EVT showed a high success rate for treatment of Boerhaave syndrome and was associated with treatment success.

Navigating the Complexities of Radiation Injuries: Therapeutic Principles and Reconstructive Strategies

Radiation injuries, particularly those resulting from therapeutic or accidental exposure, present complex challenges for medical management. These injuries can manifest localized skin damage or extend to deeper tissues, presenting as various clinical entities that require treatment strategies, ranging from conservative management to complex surgical interventions. Radiation treatment constitutes a fundamental component of neoplastic management, with nearly two out of three oncological instances undergoing it as an element of their therapeutic strategy. The therapeutic approach to radiation injury consists of expanding prophylactic measures while maintaining the efficacy of treatment, such as conservative treatment or local debridement followed by reconstruction. The armamentarium of reconstructive methods available for plastic surgeons, from secondary healing to free tissue transfer, can be successfully applied to radiation injuries. However, the unique pathophysiological changes induced by radiation necessitate a careful and specialized approach for their application, considering the altered tissue characteristics and healing dynamics. The therapeutic strategy is guided by both the severity and progression of the injury, with the primary aim of restoring functionality and aesthetic aspects while simultaneously minimizing the risk of complications. This paper explores the various conditions encompassed by the term "radiation injury," reviews both non-surgical and surgical therapeutic strategies for managing these injuries, and highlights the unique challenges associated with treating irradiated tissues within specific oncological contexts.

What Is New with Cervical Perforations? A Clinical Review Article

Approximately 15% of all esophageal perforations occur within the cervical esophagus. Advances in medical care and surgical technique overtime have led to decreased mortality associated with esophageal perforations. While early recognition, accurate characterization, and adequate drainage, or repair when appropriate, remain the mainstays in the management of cervical perforations, endoscopic innovation has provided a minimally invasive option in the management of this disease and expanded the armamentarium of options available to providers.

Endoscopic Management of Iatrogenic Perforations

The evolution of sophisticated technology has brought about the rise of endoscopic strategies for managing iatrogenic esophageal perforation. This approach is reserved for stable patients with limited contamination. The most commonly performed procedures are reviewed, focusing on procedural steps and outcomes. Esophageal stenting remains the most widely implemented strategy with promising success rates. Clipping, endoluminal vacuum therapy, and suturing are also viable options. Patient selection and further study are paramount to establishing this less invasive strategy as a more standard approach.

Classification of the oesophageal perforation

OBJECTIVES

Esophageal perforations are a complex clinical scenario that have been poorly studied. To date, there is no grading of esophageal perforations, the reason being that the outcome is very heterogeneous, because the perforation is very heterogeneous. A grading of the severity of the perforation may guide treatment, and could ultimately affect morbidity and mortality.

METHODS

The observation period of the study was four years. All patients with a perforation of the esophagus aged 18 to 90 years were included. All anastomotic insufficiencies or fistulas after surgery of the esophagus were excluded. The cause of the injury and the time interval between the event and the start of therapy were analyzed. The severity of each perforation was classified based on the results of a diagnostic CT scan, gastroscopy as well as clinical and laboratory findings. Therapy and signs of infection were evaluated. Endpoints of the study were patient recovery or death. The study was conducted as a retrospective single-center study at a university hospital of Düsseldorf. The study has been approved by the review board. Patients gave their informed consent before data collection. All data were analyzed using SPSS 29 (IBM SPSS Statistics software).

RESULTS

Age, gender and cause of the esophageal perforation did not impact significantly on overall survival. The duration of injury > 24 h (p = 0.01), presence of mediastinitis (p = 0.01) and necrosis of the esophagus (p = 0.02) were associated with an unfavorable outcome. The correlation of the clinical grading of the severity of the perforation based on the endoscopic, radiological and clinical findings with the overall survival of patients was significant. Patients categorized into the four grades of severity (I-IV) had an overall survival of 100%, 100%, 70% and 50%, respectively.

CONCLUSION

The severity of esophageal perforations can be systematically rated grades I to IV based on the radiological, endoscopic and clinical findings at diagnosis. Due to the grading and its correlation to the overall survival, a comparison of patients, their treatment and outcome becomes possible. In future, the grade of a perforation may guide treatment, and therefore affect morbidity and mortality.

Current aspects in the management of esophageal trauma: a systematic review and proportional meta-analysis

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13-25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49-0.89, P = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32-73%), with 68% of patients having associated injuries (95% CI 43-94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1-6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14-8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases.

Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study

BACKGROUND

Traumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP.

METHODS

Retrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome.

RESULTS

Patients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant.

CONCLUSION

E-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.

A rare cause of esophageal stenosis: Compression due to a thoracic osteophyte

Several cases of esophageal stenosis caused by cervical vertebral osteophytes have been reported; however, few reports of esophageal stenosis caused by thoracic osteophytes are available. We describe the case of an 86-year-old man with esophageal stenosis caused by a thoracic osteophyte near the tracheal bifurcation. An endoscopic ultrasonography examination was scheduled to determine the cause of acute pancreatitis; however, lacerations observed at the bifurcation following endoscope removal during prior esophagogastroduodenoscopy led us to cancel the ultrasonography to avoid potential esophageal perforation. A review of the present case and six similar previous cases of thoracic osteophyte-associated esophageal stenosis (identified via a systematic search of the PubMed database) demonstrated the clinical importance of a thoracic osteophyte near physiological esophageal stenosis. Esophagogastroduodenoscopy and computed tomography should be performed to screen for vertebral osteophytes before endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, and transesophageal echocardiography to avoid iatrogenic accidents.

AGA Clinical Practice Update on Endoscopic Full-Thickness Resection for the Management of Gastrointestinal Subepithelial Lesions: Commentary

DESCRIPTION

Subepithelial lesions of the gastrointestinal tract are not encountered uncommonly during routine endoscopy. There has been remarkable progress in the development of endoscopic options for the resection of subepithelial lesions, including full-thickness resection. The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to describe the various techniques for endoscopic full-thickness resection and to facilitate their appropriate application in the management of subepithelial lesions.

METHODS

This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology.

Transgastric drainage of the perforated esophagus: our experiences over 10 years

We first described the technique of transgastric drainage of esophageal injuries in 2008. The method establishes vacuum drainage of the lumen of the esophagus, while maintaining patency, effectively exteriorizing the perforation to allow healing. We summarize this technique and present our experiences from the largest published series of patients. Our unit has treated selected esophageal injuries with transgastric drainage for 10 years. Indications include perforations not amenable to primary repair and treatment failure following prior surgical intervention. A 36 French silastic chest drain is pulled through the abdominal and stomach wall and introduced into the esophagus so that it crosses the perforation. Gastropexy is performed. Mediastinal decontamination and drainage are performed as needed. Continuous suction of -10 cm water is applied. Leak resolution is assessed with weekly water-soluble swallows. For this retrospective observational study, we analyzed data for patients with esophageal perforation, between 2012 and 2022. Inpatient mortality and time to leak resolution were set as primary and secondary outcomes. Esophageal perforations were treated with transgastric drain in 35 patients, of whom 68% (n = 24) were men. Median age was 67 (26-84). Spontaneous perforations accounted for 60% (n = 21), 31% (n = 11) were iatrogenic and 6% (n = 2) were ischemic. Inpatient and 30-day mortality was 14% (n = 5). Among successful treatments, the median length to resolution of leak on imaging was 34.5 days (6-80). Transgastric drainage can successfully treat esophageal perforations, where primary repair is not feasible. The mortality rate of 14% and reduced morbidity compares favorably with other traditional methods of management for esophageal perforation.

Outcome after stent and endoscopic vacuum therapy-based treatment for postemetic esophageal rupture

OBJECTIVES

Extent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment.

MATERIALS AND METHODS

17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie's score).

RESULTS

Seventeen patients aged median 67 years (range 34-88), had a primary hospital stay of 38 days (7-68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2-62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population.

CONCLUSION

Mortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.

Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study

OBJECTIVE

To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4).

BACKGROUND

EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized.

METHODS

Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM.

RESULTS

Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM.

CONCLUSIONS

We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.

Endoscopic iatrogenic esophageal perforation and management: a retrospective outcome analysis in the modern era

INTRODUCTION

Iatrogenic esophageal perforation (IEP) is a severe adverse event (AE) of upper endoscopy procedures (UEPs) associated with morbidity. Management has shifted from surgery to endotherapy with clip closure (CC), self-expanding metal stent (SEMS), and vacuum therapy (VT). Limited analyses measure outcomes during contemporary interventional endoscopy periods.

METHODS

IEPs associated with EGD, upper EUS, small bowel enteroscopy (SBE), and ERCP at a 3-hospital academic center from January 2011 to December 2023 were identified retrospectively from a centralized AE database. Additional information was obtained from medical records. Statistical analysis was performed using Microsoft Excel and STATA.

RESULTS

Thirty-two IEPs from 26 EGDs, 4 EUS, 1 SBE, and 1 ERCP were identified. IEPs occurred mostly after dilation (bougie N = 7; balloon, N = 5) or foreign body removal (N = 6). Most IEPs occurred in the lower esophagus (N = 10) or gastroesophageal junction (N = 8). Diagnosis was made at a median 2 h after the injury by endoscopy (N = 14), CT scan (N = 12), esophagram (N = 5), or x-ray (N = 1). Initial treatment included conservative therapy alone (N = 7), CC (N = 3), SEMS (N = 14), SEMS plus CC (N = 3), or surgery (N = 3). Eleven patients required additional treatment including repeat SEMS or adjustment (N = 4) or VT (N = 1). No surgical interventions were required after 2013. The median hospital stay was 3 days. Disposition included discharge to home (N = 25), long-term care facility (N = 2), 4 deaths (12.5% of IEPs), and 1 unknown.

CONCLUSIONS

IEPs are rare and occur throughout the esophagus after any UEP. The majority are recognized immediately and managed with endotherapy, or rarely, surgery today. These characteristics likely explain the low mortality in this study.

Successful Endoscopic Vacuum Therapy for Extensive Gastric Tubing Necrosis after Ivor-Lewis Esophagectomy: A Case Report

The stomach has become the most commonly used site for grafts to replace the esophagus in esophageal cancer surgery because of its good blood supply and ability to enable single-reconstruction anastomosis. However, anastomotic failure is a serious complication after esophageal cancer surgery. Unlike anastomotic leakage due to local ischemia, gastric tube necrosis is a life-threatening condition with a high mortality rate. Gastric tube necrosis involves extensive ischemia due to a decreased blood supply, and an urgent operation is mandatory in most cases. Endoscopic vacuum therapy (EVT) has been used for anastomotic leakage after esophageal surgery. In recent years, it has been successfully used for more extensive disease, including large esophageal perforation as an indication for reoperation. Hence, we report a case of extensive gastric tube necrosis treated by EVT after an Ivor Lewis operation.

Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study

BACKGROUND : Endoscopic vacuum therapy (EVT) is a novel treatment for esophageal perforations. This study aimed to describe initial experience with EVT of esophageal perforations due to iatrogenic cause, Boerhaave syndrome, or other perforations not related to prior upper gastrointestinal surgery. METHODS : Data from patients treated with EVT for esophageal perforation at five hospitals in three European countries, between January 2018 and October 2021, were retrospectively collected. The primary end point was successful defect closure by EVT, with or without the use of other endoscopic treatment modalities. Secondary end points included mortality and adverse events. RESULTS : 27 patients were included (median age 71 years). The success rate was 89 % (24/27, 95 %CI 77-100). EVT failed in three patients: two deceased during EVT (septic embolic stroke, pulmonary embolism) and one underwent esophagectomy due to a persisting defect. Two adverse events occurred: one iatrogenic defect expansion during sponge exchange and one hemorrhage during sponge removal. Median treatment duration was 12 days (interquartile range [IQR] 6-16) with 1 sponge exchange (IQR 1-3). CONCLUSION : EVT is a promising organ-preserving treatment for esophageal perforations, with a success rate of 89 %. More experience with the technique and indications will likely improve success rates.

Routine nasogastric tube placement in patients with small esophageal perforation after endoscopic foreign body removal may be unnecessary: a propensity score matching analysis

BACKGROUND

Nasogastric tube (NGT) placement is part of the post-operative management of upper gastrointestinal perforation, but its routine use in esophageal perforation (EP) caused by foreign bodies remains unclear. The purpose of this research was to investigate the necessity for routine NGT placement in patients with EP after endoscopic foreign body removal.

METHODS

A total of 323 patients diagnosed with EP caused by foreign bodies at the First Affiliated Hospital of Nanchang University between January 2012 and December 2021 were included in this retrospective study. Patients were divided into the NGT group and the non-NGT group according to whether or not NGT placement was performed. The perforation healing rate, post-operative adverse events, hospital stay, and death rate were analysed using a 1:1 propensity score matching model.

RESULTS

Before matching, there were 263 patients in the NGT group and 60 patients in the non-NGT group. There were significant differences in the time to treatment, infection, albumin, and types of endoscopy between the two groups, while the length of hospital stay in the NGT group was significantly longer than that in the non-NGT group. After 1:1 propensity score matching, 48 pairs of patients were matched between the two groups. The perforation healing rate, post-operative adverse events, length of hospital stay, and death rate did not show significant differences between the two groups.

CONCLUSIONS

For patients with small EP caused by foreign bodies, routine NGT placement after endoscopic foreign body removal may be unnecessary.

Pneumomediastinum complicating diabetic ketoacidosis

Pneumomediastinum is an uncommon finding in patients with diabetic ketoacidosis (DKA) and may occur spontaneously or secondary to an effort rupture of the oesophagus. Excluding oesophageal rupture is important, as delaying treatment increases the risk of mortality. We discuss a case of DKA complicated by vomiting, pneumomediastinum, pneumopericardium and air in the epidural space. Instead of fluoroscopic oesophagography, chest CT was used to investigate oesophageal rupture. We present an overview of case reports and retrospective studies illustrating the utility of chest CT in the investigation of oesophageal rupture over fluoroscopic oesophagography.

A Rare Etiology of Esophageal Obstruction: Esophageal Clot Formation After Teeth Extraction

Esophageal obstruction represents an endoscopic emergency owing to the high mortality rate associated with complications, including perforation and airway compromise. While typically caused by food or foreign body ingestion, esophageal clot represents a rare etiology of obstruction. We present a case of esophageal obstruction in the context of an anastomotic stricture and chronic anticoagulation for atrial fibrillation caused by clot formation due to oral hemorrhage after dental extractions. Clot retrieval was accomplished via endoscopic suction, and balloon dilation of the anastomotic stricture was performed to prevent recurrence. Our case illustrates the importance of considering oral hemorrhage, therapeutic anticoagulation, and esophageal strictures as risk factors for esophageal obstruction due to clot formation in order to make a timely diagnosis and treatment of this potential endoscopic emergency.

Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects

Introduction

Endoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent.

Patients and methods

This prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events.

Results

In total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed.

Conclusion

The vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.

Treatment mode and prognosis of esophageal perforation after radiotherapy in patients with esophageal carcinoma

Objective

Retrospectively analyzed the esophageal carcinoma (EC) patients with esophageal perforation (EP) after radiotherapy to discuss the treatment and prognosis.

Methods

Data of patients with EC who had EP after radiotherapy in Hebei Cancer Hospital were collected from 2001 to 2020 and retrospectively analyzed. All analyses were performed using SPSS Statistics for Windows, version 18. 0 (SPSS Inc., Chicago, Ill., USA). P values less than 0.05 were considered statistically significant.

Results

A total of 94 patients with EC were enrolled, among which 72 were males and 22 were females, with a median age of 62 (38-82) years. The tumor was located in the upper thoracic in 45 patients, middle thoracic in 45 patients, and lower thoracic in 4 patients. There were 30 cases of tracheoesophageal fistula (TEF) and 64 cases of esophagomediastinal fistula (EMF). All patients died within 11 months (median: two months) after EP. After EP, 48 patients were treated by tube feeding (include nasal feeding and gastrostomy), 26 patients by esophageal stenting, and 20 patients by fluid infusion therapy, and their one, three, and six months survival rates after EP were 81.3%, 31.3%, and 12.5% (P = 0.000). In the TEF group, the one, three, and six month survival rates after EP of tube feeding, esophageal stenting and fluid infusion groups were 88.2%, 17.6%, 11.8%; 45.5%, 27.3%, 0%; and 50.0%, 50.0%, 0% (P = 0.345). In the EMF group, the one, three, and six months survival rates after EP of this three groups were 77.4%, 38.7%, 12.9%; 26.7%, 20.0%, 6.7%; and 22.2%, 11.1%, 0% (P=0.002), respectively.

Conclusion

Most patients with EP after radiotherapy died within six months, with low survival and poor prognosis. Tube feeding therapy can achieve relatively good survival, especially for patients with EMF. The survival of patients treated by tube feeding therapy is significantly better than the survival of those treated by other methods.

A Case Report of Esophageal Perforation: Complications of Orogastric Tube Placement

Orogastric tube (OGT) insertion is a routine procedure in medical care. It is often inserted in patients after endotracheal intubation. OGT insertion is often a blind procedure. Misplacement of the tube can cause a variety of complications and can sometimes be life-threatening. We present the case of a 71-year-old male patient who experienced a rare proximal esophageal perforation as a complication of blind insertion of the OGT; he required OGT insertion after receiving endotracheal intubation for hypoxic respiratory failure secondary to COVID-19 infection. The esophageal perforation was revealed on a post-procedural roentgenogram and confirmed by a subsequent computed tomography of the chest. Given the small size of the perforation and the absence of clinical instability, conservative management was pursued leading to improvement of the mediastinitis. Although the complications of OGT insertion are uncommon, their consequences can be potentially serious and require a high degree of suspicion.

Thyroid abscess due to ingested fish bone, endoscopic, and surgical approach: a case presentation

Introduction

Thyroid abscesses are a rare septic complication as the thyroid is innately resistant to infection.

Case presentation

Here, we present a case of a 49-year-old female with history of accidental ingestion of a fish bone, subsequent perforation of the esophagus, and thyroid abscess formation.

Management approach consisted of imaging of the gland followed by upper gastrointestinal endoscopy and surgical thyroidotomy with fish bone extraction.

Conclusion

In this case presentation, we highlight the pathophysiology behind thyroid abscess along with review of offered lines of management of this disease from imaging and procedures of diagnosis to treatment approach of source control by both surgical and conservative approach.

The Etiology, Diagnosis, and Management of Esophageal Perforation

BACKGROUND

Esophageal perforation is a serious and potentially life-threatening medical emergency. Given multiple etiologies and varying clinical presentations of the perforated esophagus, the diagnosis is commonly delayed, complicating expeditious and optimal intervention.

METHODS

We thoroughly reviewed the latest literature on the subject and herein describe the various treatment strategies in varying settings.

RESULTS

Treatment depends on multiple factors including the cause and location of the perforation, the time interval between the inciting event and presentation to the managing clinician, the overall medical stability of the patient, comorbidities including pre-existent esophageal pathology or prior foregut operations, and both the location and extent of extra-esophageal fluid collections. Because of these various considerations, determining the best diagnostic and therapeutic approach requires considerable clinical experience and judgment on the part of the physician. Management principles include (1) adequate fluid resuscitation; (2) expeditious administration of appropriate broad-spectrum antibiotics; (3) repair, occlusion, exclusion, diversion, or exteriorization of the perforation site; (4) drainage of extraluminal fluid collections; (5) relief of distal obstruction; and (6) nutritional support.

CONCLUSIONS

For decades, operative intervention has been the mainstay of therapy for esophageal perforation. More recently, endoscopic therapies, including stenting, clipping, suturing, or endoscopic vacuum therapy, have been introduced, expanding the clinician's therapeutic armamentarium while supplanting surgical approaches in many cases. With further experience and introduction of novel therapies, the management of esophageal perforation undoubtedly will continue to evolve.

Epidemiological, Clinical and Radiological Profile of Patients with Foreign Body Oesophagus: A Prospective Study

To analyse the patients with foreign body oesophagus in relation to the clinico-radiological and socio-economic profile. The present prospective study was conducted on 100 consecutive patients of all age groups who underwent oesophagoscopy for suspected foreign body ingestion in a tertiary care hospital. The most common age group affected was 0-5 years. The median age was 5 ± 14.37 years. There was preponderance in males as compared to females, male to female ratio was 2.23:1. Majority (70%) of the patients, both males and females, belonged to rural areas. Lower socio-economic group was more commonly affected (54%). The most commonly reported symptom was foreign body sensation (55%) followed by vomiting (54%) and difficulty in swallowing (51%). Foreign body ingestion was witnessed in only 19% cases by the family members. The mean time between ingestion of the foreign body and admission to the hospital was found to be 4.5 h. The majority (97%) of foreign bodies were radio-opaque. The most common site of lodgement was just below the cricopharynx (89%). The most common foreign body retrieved in our series were coins (65%). The majority of foreign bodies (68%) were retrieved in 20-40 min after induction of general anaesthesia. In 99% of the patients we did not encounter any complications. The majority (93%) of the patient's parents/relatives had curiosity to have a glimpse of the foreign body till they actually saw the retrieved foreign body. Foreign body lodgement is more common among children of lower socio-economic strata more so in rural areas. Rigid oesophagoscopy is a safe and effective procedure for removal of the foreign body. Early intervention makes it easier to extract the foreign body without complications.

Quantitative CT analysis to predict esophageal fistula in patients with advanced esophageal cancer treated by chemotherapy or chemoradiotherapy

Background

Esophageal fistula is one of the most serious complications of chemotherapy or chemoradiotherapy (CRT) for advanced esophageal cancer. This study aimed to evaluate the performance of quantitative computed tomography (CT) analysis and to establish a practical imaging model for predicting esophageal fistula in esophageal cancer patients treated with chemotherapy or chemoradiotherapy.

Methods

This study retrospectively enrolled 204 esophageal cancer patients (54 patients with fistula, 150 patients without fistula) and all patients were allocated to the primary and validation cohorts according to the time of inclusion in a 1:1 ratio. Ulcer depth, tumor thickness and length, and minimum and maximum enhanced CT values of esophageal cancer were measured in pretreatment CT imaging. Logistic regression analysis was used to evaluate the associations of CT quantitative measurements with esophageal fistula. Receiver operating characteristic curve (ROC) analysis was also used.

Results

Logistic regression analysis showed that independent predictors of esophageal fistula included tumor thickness [odds ratio (OR) = 1.167; p = 0.037], the ratio of ulcer depth to adjacent tumor thickness (OR = 164.947; p < 0.001), and the ratio of minimum to maximum enhanced CT value (OR = 0.006; p = 0.039) in the primary cohort at baseline CT imaging. These predictors were used to establish a predictive model for predicting esophageal fistula, with areas under the receiver operating characteristic curves (AUCs) of 0.946 and 0.841 in the primary and validation cohorts, respectively. The quantitative analysis combined with T stage for predicting esophageal fistula had AUCs of 0.953 and 0.917 in primary and validation cohorts, respectively.

Conclusion

Quantitative pretreatment CT analysis has excellent performance for predicting fistula formation in esophageal cancer patients who treated by chemotherapy or chemoradiotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40644-022-00490-2.

Esophageal perforations - a population-based nationwide study in Sweden with survival analysis

BACKGROUND

Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality.

METHOD

All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality.

RESULTS

879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide.

CONCLUSIONS

90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.

Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis

BACKGROUND

Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different.

METHODS

The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities.

RESULTS

There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001).

CONCLUSIONS

In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.

Short- and long-term follow-up of patients with non-neoplastic esophageal perforation

PURPOSE

Esophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. Although health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention, not much is known about HRQoL, particularly in the long-term follow-up of patients treated for non-neoplastic esophageal perforation with different treatment strategies. The aim of this study was to evaluate patients' outcome after non-neoplastic esophageal perforation with focus on HRQoL in the long-term follow-up.

METHODS

Patients treated for non-neoplastic esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were included. Primary outcome and management of esophageal perforation were documented. Long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD), and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal specific QoL (QLQ-C30 and QLQ-OES18).

RESULTS

Fifty-eight patients were included in the study. Based on primary treatment, patients were divided into an endoscopic (n = 27; 46.6%), surgical (n = 20; 34.5%), and a conservative group (n = 11; 19%). Short- and long-term outcome and quality of life were compared. HRQoL was measured after a median follow-up of 49 months. HRQoL was generally reduced in patients with non-neoplastic esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group.

CONCLUSION

HRQoL in patients with non-neoplastic esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery, not only in the short-term but also in the long-term follow-up.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Neck and mediastinal hematoma caused by a foreign body in the esophagus with diagnostic difficulties: A case report

BACKGROUND

Esophageal foreign body (FB) is a common clinical emergency. Clinically, computed tomography (CT) scans are important in the diagnosis of FBs in the esophagus. Here, we report a case of esophageal perforation and cervical hematoma, caused by a FB, whose uniqueness made rapid diagnosis difficult.

CASE SUMMARY

A 42-year-old man was transferred to our hospital with esophageal perforation, which was accompanied by cervical and mediastinal hematoma. CT scans only revealed a black shadow, approximately 2.5 cm in diameter, in the upper esophagus. After multidisciplinary discussion, he was quickly subjected to mediastinal hematoma resection, peripheral nerve compression release, esophageal FB removal and esophagectomy. Eventually, we removed a small crab with a pointed tip from his esophagus.

CONCLUSION

This was an unusual case of occurrence of sharp polygonal esophageal FBs caused by a small crab. Rapid diagnosis of this FB was difficult, mainly due to its translucent nature. Occurrence of sharp FBs, with cavities that sometimes only appear as black shadows on CT scans, can easily be mistaken for esophageal lumens. More attention should be paid to such sharp polygonal FBs.

Postoperative Leckagen im Gastrointestinaltrakt – Diagnostik und Therapie

Postoperative Leckagen nach Ösophagus‑, Magen- oder Kolon- bzw. Rektumchirurgie stellen schwerwiegende chirurgische Komplikationen mit einer hohen Morbidität und Mortalität dar. Leckagen werden zumeist durch eine Kombination aus klinischer Beobachtung, Infektionsparametern sowie endoskopischen und schnittbildgebenden Verfahren diagnostiziert. Die Therapie ist bei intraperitonealen Leckagen chirurgisch, bei retroperitonealen bzw. mediastinalen Leckagen in einem interdisziplinären Setting überwiegend interventionell endoskopisch. Hier stehen der Defektverschluss durch die Abdichtung mittels selbstexpandierender gecoverter Stents mit gleichzeitiger externer extraluminaler Drainage sowie der Defektverschluss mit simultaner innerer Drainage und endoskopischer Unterdrucktherapie als vorrangige Methoden zur Verfügung.

Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video)

BACKGROUND AND AIMS

The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates.

METHODS

Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract.

RESULTS

Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself.

CONCLUSIONS

EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.

Safety and Efficacy of Nonoperative Treatment in Esophageal Perforation Caused by Foreign Bodies

INTRODUCTION

Esophageal foreign bodies are often treated by endoscopy, but the treatment of esophageal perforation caused by foreign bodies remains controversial. The purpose of this study was to investigate the safety and efficacy of nonoperative treatment of esophageal perforation caused by foreign bodies.

METHODS

We retrospectively analyzed 270 patients admitted to our hospital for esophageal perforation caused by foreign bodies from January 2012 to December 2020, all of whom received nonoperative treatment.

RESULTS

The mean age of the patients was 56 ± 17 years, and fish bones were the most common type of foreign body. A total of 61.2% of the perforations were in the cervical esophagus. All patients received nonoperative treatment initially, and the foreign body removal rate using endoscopy reached 97%. The perforation healing rate reached 94.8%, whereas 3 patients (1.1%) died during hospitalization. The median (range) duration of hospitalization was 4 days (3-6). Multivariable analysis showed age ≥ 66 years (odds ratio [OR]: 2.196; 95% confidence interval [CI]: 1.232-3.916; P = 0.008), men (OR: 1.934; 95% CI: 1.152-3.246; P = 0.013), and time to treatment (OR: 1.126; 95% CI: 1.027-1.233; P = 0.011) were independent risk factors for infection, whereas the risk of infection was lower when the foreign body type was fish bone (OR: 0.557; 95% CI: 0.330-0.940; P = 0.028).

DISCUSSION

Nonoperative treatment is safe and effective for esophageal perforation caused by foreign bodies. Even if perforation is combined with infection, active nonoperative treatment can still achieve a good effect. Early intervention can effectively reduce the risk of infection and improve patient outcomes.

Esophageal Perforation Successfully Treated With EVT

Esophageal perforation is rare and carries high morbidity and mortality. A high degree of suspicion is needed for timely diagnosis and treatment. A 54-year-old man presented with fever and confusion. Imaging revealed air in the hepatic inferior vena cava and concern for a fistula between the distal esophagus and the inferior vena cava. An upper endoscopic evaluation revealed a dental floss pick penetrating the distal esophagus. The foreign body was removed, and endoluminal vacuum therapy was used to close the perforation. Endoluminal vacuum therapy is an emerging therapy to treat full-thickness gastrointestinal injuries.

Management and outcomes of esophageal perforation

BACKGROUND

Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality.

METHODS

A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity.

RESULTS

Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02-3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31-17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39-4.43], P = 0.046) and sepsis (OR 3.26 [1.44-7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning.

CONCLUSIONS

Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.

Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center

BACKGROUND

Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions.

METHODS

All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and >5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention.

RESULTS

Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p < 0.01), in-hospital mortality (p = 0.01), ICU admission (p < 0.01), need for surgical treatment (p < 0.01), and need for reintervention (p = 0.02).

CONCLUSION

Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation.

LEVEL OF EVIDENCE

Management, Therapeutic/Care; level IV.

High risk and low prevalence diseases: Esophageal perforation

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.

Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation

An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.

Emergency management of jujube pit esophageal impactions using rigid esophagoscopy in the aged

OBJECTIVE

To study the emergency management of esophageal jujube pit ingestion.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective study of 114 consecutive cases of jujube pits esophageal impaction during 3 months was performed.

RESULTS

One hundred and fourteen cases were confirmed as jujube pit esophageal impaction using contrast-enhanced radiography. All jujube pits were retrieved using rigid esophagoscopy under general anesthesia as outpatients, except one case where a direct laryngoscope was used. In four cases, esophageal perforation was found, the patients were treated with conservative measures, and none died.

CONCLUSION

Jujube pit esophageal impaction is characterized by a high incidence of perforation. The conservative management of cervical perforation is effective in this study. Rigid esophagoscopy under general anesthesia is safe for jujube pit esophageal impaction.

LEVEL OF EVIDENCE

4.

Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study

Background

Esophageal perforation and rupture (EPR) is a serious, potentially life-threatening condition. However, no treatment methods have been established, and data concerning factors affecting mortality are limited. This report presents the prognostic factors of mortality in EPR based on experience in the management of such patients.

Methods

For this retrospective analysis, 79 patients diagnosed as having EPR between 2006 and 2016 and managed at Gyeongsang National University Hospital were examined. The management method was determined in accordance with the location and size of the EPR, laboratory findings, and radiological findings. Thirty-nine patients were treated with surgery; and 40, with nonsurgical management.

Results

The most common cause of EPR was foreign body (fish bone or meat bone), followed by vomiting, iatrogenic causes, and trauma. Thirty-nine patients underwent primary repair of EPR, of whom 4 patients died. Forty patients underwent nonsurgical management, of whom 3 patients died. The remaining patients were discharged. Mortality correlated with the size of the EPR (> 25 mm) and the segmented neutrophil count percentage (> 86.5%) in the white blood cell test and differential.

Conclusions

The mortality risk was increased when the EPR size and the segmented neutrophil count percentage in the white blood cell test and differential was high. Delayed diagnosis, which was considered an important predictive factor in previous investigations, was not statistically significant in this study.

Trial registration: Not applicable.

Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort

BACKGROUND

Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence.

PATIENTS AND METHODS

A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality.

RESULTS

Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drain insertion for those treated with TGD alone was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality.

CONCLUSION

These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.