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Veziant J, Boudis F, Lenne X, Bruandet A, Eveno C, Nuytens F, Piessen G. Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study. Ann Surg 2023; 278:709-716. [PMID: 37497641 DOI: 10.1097/sla.0000000000006048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
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 Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized.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.
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Affiliation(s)
- Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
| | - Fabio Boudis
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Xavier Lenne
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Az Groeninge Hospital, Kortrijk, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
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Chirica M, Bonavina L. Esophageal emergencies. Minerva Surg 2023; 78:52-67. [PMID: 36511315 DOI: 10.23736/s2724-5691.22.09781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.
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Affiliation(s)
- Mircea Chirica
- Department of Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France -
| | - Luigi Bonavina
- Medical School, Division of General Surgery, IRCCS San Donato Polyclinic, University of Milan, Milan, Italy
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3
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Kanlerd A, Mahawongkajit P, Achavanuntakul C, Boonyasatid P, Auksornchart K. Successful management of 72-h delay-detected blunt esophageal injury with trans-gastric primary repair; a case report and literature review. Trauma Case Rep 2023; 43:100755. [PMID: 36654763 PMCID: PMC9841267 DOI: 10.1016/j.tcr.2023.100755] [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] [Accepted: 01/05/2023] [Indexed: 01/08/2023] Open
Abstract
Diagnosis of blunt esophageal injury is currently a challenging issue. Early surgical interventions still play as the mainstay of treatment. There was no consensus about appropriate treatment options. However, it was potential morbidity if delayed management. We report a 33-year-old man with a history of a motorcycle accident who presented with hematemesis and epigastrium pain. He was initially diagnosed with left pneumohemothorax and low-grade gastric injury. The patient developed a high-grade fever with complex left pneumohemothorax 72-h after admission. The diagnostic studies revealed a lower esophageal rupture. He was treated with trans-gastric primary repair and recovered well with no complications. We propose the trans-gastric intraluminal repair is one of the surgical options in a blunt lower esophageal rupture.
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Affiliation(s)
- Amonpon Kanlerd
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand,Corresponding author at: Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, 95 M.8 Paholyotin Rd., Klongluang, Pathumthani 12120, Thailand.
| | - Prasit Mahawongkajit
- Gastrointestinal Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chompoonut Achavanuntakul
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Piyapong Boonyasatid
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Karikarn Auksornchart
- Trauma and Surgical Critical Care Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Axtell AL, Gaissert HA, Morse CR, Premkumar A, Schumacher L, Muniappan A, Ott H, Allan JS, Lanuti M, Mathisen DJ, Wright CD. Management and outcomes of esophageal perforation. Dis Esophagus 2022; 35:6312958. [PMID: 34212186 DOI: 10.1093/dote/doab039] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Andrea L Axtell
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Akash Premkumar
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Lana Schumacher
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James S Allan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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5
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Moletta L, Pierobon ES, Capovilla G, Valotto G, Gavagna L, Provenzano L, Zanchettin G, Salvador R, Costantini M, Merigliano S, Valmasoni M. Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center. J Trauma Acute Care Surg 2022; 92:108-116. [PMID: 34561399 DOI: 10.1097/ta.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Lucia Moletta
- From the Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
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Tang A, Ahmad U, Raja S, Siddiqui HU, Sinopoli JN, O'Dell A, Pande A, Blackstone EH, Murthy SC. Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus. Ann Surg 2021; 274:e417-e424. [PMID: 33630450 DOI: 10.1097/sla.0000000000003648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to determine differences in esophageal perforation populations undergoing different advanced interventions for perforated esophagus and identify predictors of treatment outcomes. SUMMARY BACKGROUND DATA Contained esophageal perforation can often be managed expectantly, but uncontained perforation is uniformly fatal without invasive intervention. Treatment options for the latter range from simple endoscopic control through advanced intervention. Clinical presentation varies greatly and directs which intervention is most appropriate. METHODS From 1996 to 2017, 335 patients were treated for esophageal perforation, and 166 for advanced interventions: 74 primary repair with tissue flap (repair), 26 esophagectomy and gastric pull-up (resection), and 66 esophagectomy and immediate diversion with planned delayed reconstruction (resection-diversion). Patient characteristics, clinical presentation, operative outcomes, and survival were abstracted. Pittsburgh Severity Scores (PSS) were retrospectively calculated. Random survival forest analysis was performed for 90-day mortality and competing risks for reconstruction after resection-diversion. RESULTS Repair and resection patients had lower PSS than resection-diversion patients (3 vs 3 vs 6, respectively). Ninety-day mortality for repair, resection, and resection-diversion was 11% vs 7.7% vs 23%, and 5-year survival was 71% vs 63% vs 47%. Risk of death after resection-diversion was highest within 1 year, but 52% of patients had reconstruction of the upper alimentary tract within 2 years. CONCLUSIONS Several advanced interventions exist for critically ill patients with uncontained esophageal perforation. Repair and organ preservation are always preferred; however, patients at extremes of illness might best be treated with resection-diversion, with the understanding that the competing risk of death may preclude eventual reconstruction.
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Affiliation(s)
- Andrew Tang
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Usman Ahmad
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Siva Raja
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Hafiz U Siddiqui
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Jillian N Sinopoli
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Alexander O'Dell
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Amol Pande
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
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7
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Brinkmann S, Knepper L, Fuchs H, Hoelscher A, Kuhr K, Dos Santos DP, Plum P, Chon SH, Bruns C, Schroeder W, Leers J. Short- and long-term follow-up of patients with non-neoplastic esophageal perforation. Langenbecks Arch Surg 2021; 407:569-577. [PMID: 34562118 PMCID: PMC8933311 DOI: 10.1007/s00423-021-02327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/04/2021] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Sebastian Brinkmann
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany. .,Department of General, Visceral and Vascular Surgery, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| | - Laura Knepper
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hans Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Arnulf Hoelscher
- Department of General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | | | - Patrick Plum
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Wolfgang Schroeder
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jessica Leers
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:54-59. [PMID: 34516474 DOI: 10.1097/sle.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
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.
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Soliman A. Thoracic esophageal rupture during sleeve gastrectomy: a case report with successful laparoscopic transhiatal repair. Surg Obes Relat Dis 2020; 16:2129-2131. [PMID: 33032914 DOI: 10.1016/j.soard.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/25/2022]
Abstract
While laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures for morbid obesity, the rate of complications is decreasing. These complications include hemorrhage and gastric leak that are considered life threatening. The esophageal complications in the form of perforation or rupture during LSG are rare and mainly because of iatrogenic reasons, such as blind, unguided instrumentation, which include the bougie (commonly used for gastric calibration during LSG). These complications are potential life threatening. The detection and management of these complications can affect the outcome and minimize the morbidity and avoid the incidence of mortality. We report a case of 38-year-old female, with a body mass index of 42 with iatrogenic rupture of distal and thoracic part of esophagus for >10-cm length during LSG and the immediate full laparoscopic transhiatal primary repair.
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Affiliation(s)
- Ayman Soliman
- Ain Shams University Faculty of Medicine, Cairo, Egypt.
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10
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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11
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Yan XL, Jing L, Guo LJ, Huo YK, Zhang YC, Yan XW, Deng YZ. Surgical management of Boerhaave's syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:669-674. [PMID: 32496118 DOI: 10.17235/reed.2020.6746/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND spontaneous esophageal rupture (Boerhaave's syndrome) is a rare and challenging clinical condition. OBJECTIVE to evaluate the outcome of different surgical treatments for patients with Boerhaave's syndrome with an early diagnosis (< 24 h) and delayed diagnosis (> 24 h), using a retrospective cohort study in a tertiary referral center. PATIENTS AND METHODS eighty-eight patients with Boerhaave's syndrome who underwent surgical treatment were identified from March 1994 to March 2019 in the First Hospital of Shanxi Medical University. Subsequently, they were retrospectively divided into two groups according to time from symptom onset to diagnosis (group 1, < 24 h, n = 16; group 2, > 24 h, n = 72). Primary suture repair was used in group 1 and reinforcement with a vascular muscle flap was used in group 2, in order to reduce the incidence of fistula. Patients in group 2 were further divided into two subgroups according to reinforcement using diaphragmatic flaps (subgroup 1) or intercostal muscle flaps (subgroup 2). RESULTS the duration of hospitalization and stay in Intensive Care Unit (ICU) was significantly shorter in group 1 (p = 0.027 and p = 0.001). Group 1 had fewer postoperative esophageal leaks (p = 0.037) compared to group 2. Various aspects were compared in the two subgroups and the differences were not statistically significant (p > 0.05). CONCLUSIONS it is very important to establish an early diagnosis for patients with Boerhaave's syndrome. Early (< 24 h) and primary suture repair is superior to delayed (> 24 h) primary repair, even for those reinforced with vascular muscle flaps. Furthermore, repair reinforcement with different muscle flaps appears to render similar results for patients with delayed diagnosis.
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Affiliation(s)
- Xiao-Liang Yan
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University, china
| | - Li Jing
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Lin-Jing Guo
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Yun-Kui Huo
- Cardiovascular Surgery, The First Hospital of Shanxi Medical University,
| | - Yong-Cai Zhang
- Cardiovascular Surgery, The First Hospital of Shanxi Medical University,
| | - Xiu-Wen Yan
- Cardiothoracic Surgery, The First Hospital of Shanxi Medical University,
| | - Yong-Zhi Deng
- Cardiovascular Surgery, The Affiliated Cardiovascular Hospital of Shanxi Medical University,
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12
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Piyachaturawat P, Mekaroonkamol P, Rerknimitr R. Use of the Over the Scope Clip to Close Perforations and Fistulas. Gastrointest Endosc Clin N Am 2020; 30:25-39. [PMID: 31739966 DOI: 10.1016/j.giec.2019.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In gastrointestinal perforation or fistula, endoscopic closure techniques could be used as alternatives to surgery. Early endoscopic recognition and treatment of gastrointestinal perforation is the most important factor determining procedural success and clinical outcomes. The over-the-scope clip with full-thickness grasping capability provides greater technical and clinical success rates compared with the through-the-scope clips. Although the technical success rate of chronic fistula closure is comparable to perforation closure, it has a significantly lower clinical success owing to its less healthy tissue edge of the fistula. The over-the-scope clip system should be considered before surgery for the closure of perforation and fistula.
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Affiliation(s)
- Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Rama 4 Road, Patumwan, Bangkok 10330, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand
| | - Parit Mekaroonkamol
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Rama 4 Road, Patumwan, Bangkok 10330, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Rama 4 Road, Patumwan, Bangkok 10330, Thailand; Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand.
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13
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Chirica M, Kelly MD, Siboni S, Aiolfi A, Riva CG, Asti E, Ferrari D, Leppäniemi A, Ten Broek RPG, Brichon PY, Kluger Y, Fraga GP, Frey G, Andreollo NA, Coccolini F, Frattini C, Moore EE, Chiara O, Di Saverio S, Sartelli M, Weber D, Ansaloni L, Biffl W, Corte H, Wani I, Baiocchi G, Cattan P, Catena F, Bonavina L. Esophageal emergencies: WSES guidelines. World J Emerg Surg 2019; 14:26. [PMID: 31164915 PMCID: PMC6544956 DOI: 10.1186/s13017-019-0245-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023] Open
Abstract
The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.
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Affiliation(s)
- Mircea Chirica
- 1Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, NSW 2640 Australia
| | - Stefano Siboni
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Alberto Aiolfi
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Carlo Galdino Riva
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Emanuele Asti
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Davide Ferrari
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Ari Leppäniemi
- Department of Emergency Surgery, University Hospital Meilahti Abdominal Center, Helsinki, Finland
| | - Richard P G Ten Broek
- 5Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pierre Yves Brichon
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Yoram Kluger
- 7Department of General Surgery, Rambam Health Campus, Haifa, Israel
| | - Gustavo Pereira Fraga
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Gil Frey
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Nelson Adami Andreollo
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Federico Coccolini
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | | | | | - Osvaldo Chiara
- 12General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy
| | - Salomone Di Saverio
- 13Cambridge Colorectal Unit, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | | | - Dieter Weber
- 15Trauma and General Surgery, Royal Perth Hospital, Perth, Australia
| | - Luca Ansaloni
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | - Walter Biffl
- 16Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA USA
| | - Helene Corte
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Imtaz Wani
- 18Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Pierre Cattan
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Fausto Catena
- 20Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Luigi Bonavina
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
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14
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Aljehani Y, AlQattan AS, Alkuwaiti FA, Alsaif F, Aldossari I, Elbawab H. Thoracic Complications of Bariatric Surgeries: Overlooked Entities. Obes Surg 2019; 29:2485-2491. [PMID: 30972639 DOI: 10.1007/s11695-019-03868-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Bariatric surgeries are increasingly performed to treat obesity worldwide. The currently available literature on these surgeries mainly focuses on their abdominal complications, giving less attention to their thoracic ones. Hence, the present work aimed to highlight the thoracic complications associated with bariatric surgeries. METHODS A retrospective descriptive study was performed and involved the review of the medical charts of 390 patients who underwent different bariatric surgeries between January 2014 and January 2017 in our hospital or who were referred to us from other centers after their specific operations. The data of patients who developed thoracic complications and who required further intervention were identified and categorized by the modality of diagnosis, outcome, duration of hospital and ICU stays, and management. Patients with a history of a preexisting pulmonary disease were excluded. RESULTS Twenty-six patients were observed to have thoracic complications secondary to their bariatric surgeries. Twenty-two patients (84.6%) received post-laparoscopic sleeve gastrectomy (LASG). Nine patients (34.6%) required ICU stays. Twenty patients (76.9) had incidences of pleural effusion in the postoperative period. The mean duration of hospital and ICU stays were 4.4 ± 11.67 days and 15 ± 19.36 days, respectively. Other reported thoracic complications included esophageal perforations, thoracic empyema, septic pericardial effusion, and pancreaticopleural fistula. CONCLUSION Bariatric surgeries are safe procedures in selected patients. There is a significant amount of literature describing abdominal, nutritional, neurological, and even ophthalmic complications after bariatric surgeries. Being that they are relatively rare, thoracic complications are underreported in the literature. The management of thoracic complications after bariatric surgery requires awareness and a high index of suspicion to prevent further morbidities and mortalities.
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Affiliation(s)
- Yasser Aljehani
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Abdullah Saleh AlQattan
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Feras Ahmed Alkuwaiti
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Farah Alsaif
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ibrahim Aldossari
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hatem Elbawab
- Thoracic Surgery Division, Department of Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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15
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Wigley C, Athanasiou A, Bhatti A, Sheikh A, Hodson J, Bedford M, Griffiths EA. Does the Pittsburgh Severity Score predict outcome in esophageal perforation? Dis Esophagus 2019; 32:5212887. [PMID: 30496380 DOI: 10.1093/dote/doy109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforation is an uncommon and challenging surgical emergency associated with high rates of morbidity and mortality. At present, no consensus exists on optimal management of the condition. The Pittsburgh Severity Score (PSS) is a tool intended to stratify perforation severity and guide treatment. However, there is a paucity of literature examining the validity of the score or its application in a UK population. This study aims to validate the PSS and explore its use in stratifying patients with esophageal perforation into distinct subgroups with differential outcomes in an independent UK study population.All patients treated for esophageal perforation at Queen Elizabeth Hospital, Birmingham between September 2003 and October 2017 were included in this study. Cases were identified using a combination of ICD-10 and OPCS informatics search codes and prospective case collection. Data relating to the clinical presentation, diagnosis, management, and outcome of cases were recorded using a preformed data collection form. PSS predictive performance was assessed against five outcomes: rates of post-perforation and post-operative complications, in-hospital mortality, length of intensive care (ICU/HDU) stay, and total length of hospital stay.A total of 87 cases were identified, consisting of 48 (55%) iatrogenic perforations, 24 (28%) cases of spontaneous (Boerhaave's) perforation, and 15 perforations due to other etiologies (17%). Operative management was favored in this series, with 47% of all perforations being treated surgically. Overall in-hospital mortality was 13%, coupled with a median length of hospital stay of 24 days (interquartile range [IQR]: 12-49), of which a median of 2 days was spent in intensive care facilities (IQR: 0-14). A total of 46% of patients developed post-perforation complications, with 59% of the operatively managed cohort developing complications post-operatively.The PSS was not found to be significantly predictive of post-perforation complications (area under the ROC curve [AUROC]: 0.62, p = 0.053) or in-hospital mortality (AUROC: 0.69, p = 0.057) for the cohort as a whole. However, a subgroup analysis found the accuracy of the PSS to vary considerably by etiology, being significantly predictive of post-perforation complications within the subgroup of Boerhaave's perforations (AUROC: 0.86, p = 0.004).In conclusion, we found that the PSS has some utility in stratifying esophageal perforation severity and predicting specific patient outcomes. However, it appears to be of more value when applied to the subgroup of patients with Boerhaave's perforations.
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Affiliation(s)
- C Wigley
- College of Medical and Dental Sciences, University of Birmingham, Birmingham,UK
| | - A Athanasiou
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Bhatti
- College of Medical and Dental Sciences, University of Birmingham, Birmingham,UK
| | - A Sheikh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham,UK
| | - J Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Bedford
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - E A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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16
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Onodera Y, Nakano T, Fukutomi T, Naitoh T, Unno M, Shibata C, Kamei T. Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report. Transplant Proc 2018; 50:3964-3967. [PMID: 30577297 DOI: 10.1016/j.transproceed.2018.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.
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Affiliation(s)
- Y Onodera
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Nakano
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan.
| | - T Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Naitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - M Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - C Shibata
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan
| | - T Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
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17
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Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol 2018; 3:85. [PMID: 30505972 DOI: 10.21037/tgh.2018.10.09] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.
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Affiliation(s)
- Ritu Raj Singh
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy S Nussbaum
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil A Kumta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Isolated Hemorrhagic Pericardial Effusion After Foreign Body Ingestion. Ann Thorac Surg 2018; 106:e141-e143. [PMID: 29596817 DOI: 10.1016/j.athoracsur.2018.02.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/17/2018] [Indexed: 11/21/2022]
Abstract
Foreign body ingestion is one of the many potential causes of esophageal perforation. In this case report we describe a man who presented with chest pain and was found to have an isolated hemorrhagic pericardial effusion secondary to occult ingestion and pericardial migration of a metallic foreign body. Surgical management was successful, and the patient has recovered well.
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19
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Surgical Management of Iatrogenic Perforation of the Gastrointestinal Tract: 15 Years of Experience in a Single Center. World J Surg 2018; 41:1961-1965. [PMID: 28324140 DOI: 10.1007/s00268-017-3986-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal (GI) tract perforation during endoscopy is a rare but severe complication. The aim of this study was to determine predictors of morbidity and mortality after iatrogenic endoscopic perforation. MATERIALS AND METHODS All cases with iatrogenic endoscopic perforation receiving surgery at a tertiary referral center in a 15-year period (2000-2015) were retrospectively analyzed. Demographics, type of endoscopy, site of perforation, operative procedure, morbidity and mortality were analyzed. Multiple logistic regression was used to identify parameters predicting survival. RESULTS A total of 106.492 endoscopies were performed, and 82 (0.08%) patients were diagnosed with GI perforation. Most perforations (63.4%) occurred in the lower GI tract, compared to 36.6% in the upper GI tract. In 21 cases (25%), perforation was noticed during endoscopy, whereas 61 perforations (75%) were diagnosed during the further clinical course. Operative care was applied within 24 h in 61%. Surgery of perforations was almost completely performed maintaining the intestinal continuity (68%), whereas diversion was performed in 32%. Mortality was associated with age above 70 (OR 4.89, p = 0.027), ASA class > 3 (OR 4.08, p = 0.018), delayed surgery later than 24 h after perforation (OR 5.9, p = 0.015), peritonitis/mediastinitis intraoperatively (OR 4.68, p = 0.031) and severe postoperative complications with a Clavien-Dindo grade ≥III (OR 5.12, p = 0.023). CONCLUSION The prevalence of iatrogenic endoscopic perforation is low, although it is associated with a serious impact on morbidity and mortality. Delayed management worsens prognosis. To achieve successful management of endoscopic perforations, early diagnosis is essential in cases of deviation from the normal post-interventional course, especially in elderly.
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20
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Persson S, Rouvelas I, Irino T, Lundell L. Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review. Dis Esophagus 2017; 30:1-10. [PMID: 28881894 DOI: 10.1093/dote/dox108] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 07/28/2017] [Indexed: 12/11/2022]
Abstract
Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.
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Affiliation(s)
- S Persson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Irino
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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21
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Ali JT, Rice RD, David EA, Spicer JD, Dubose JJ, Bonavina L, Siboni S, O'Callaghan TA, Luo-Owen X, Harrison S, Ball CG, Bini J, Vercruysse GA, Skarupa D, Miller CC, Estrera AL, Khalil KG. Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment. Dis Esophagus 2017; 30:1-8. [PMID: 28881905 DOI: 10.1093/dote/dox093] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/29/2017] [Indexed: 12/11/2022]
Abstract
The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.
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Affiliation(s)
- J T Ali
- The University of Texas at Austin, Austin, Texas
| | - R D Rice
- San Antonio Military Medical Center, San Antonio
| | - E A David
- Department of Surgery, University of California at Davis, Sacramento
| | | | | | - L Bonavina
- Department of Surgery, University of Milan, Milan, Italy
| | - S Siboni
- Department of Surgery, University of Southern California, Los Angeles County, Los Angeles
| | - T A O'Callaghan
- Division of Trauma Services, Loma Linda University, Loma Linda, California
| | - X Luo-Owen
- Division of Trauma Services, Loma Linda University, Loma Linda, California
| | - S Harrison
- Department of Cardiothoracic Surgery, University of Mississippi, Jackson, Mississippi
| | - C G Ball
- Department of Surgery, University of Calgary Foothills Medical Center, Calgary, Alberta, Canada
| | - J Bini
- Miami Valley Hospital, Department of Surgery, Dayton, Ohio
| | - G A Vercruysse
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - D Skarupa
- Department of Surgery, University of Florida-Jacksonville, Jacksonville, Florida, USA
| | - C C Miller
- Houston Medical Center, University of Texas, Houston, Texas
| | - A L Estrera
- Houston Medical Center, University of Texas, Houston, Texas
| | - K G Khalil
- Houston Medical Center, University of Texas, Houston, Texas
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22
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Sdralis EIK, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Dis Esophagus 2017; 30:1-6. [PMID: 28575240 DOI: 10.1093/dote/dox013] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 12/11/2022]
Abstract
We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.
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Affiliation(s)
- E Ilias K Sdralis
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK.,Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - S Petousis
- Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - F Rashid
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - B Lorenzi
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - A Charalabopoulos
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
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Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, Sousa-Uva M, Licht PB, Dunning J, Schmid RA, Cardillo G. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017; 51:10-29. [PMID: 28077503 DOI: 10.1093/ejcts/ezw326] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/24/2022] Open
Abstract
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
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Affiliation(s)
- Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital / Inselspital, Switzerland
| | - Paolo Bosco
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, University of Turin-Italy, Città della Salute e della Scienza-San Giovanni Battista Hospital, Torino, Italy
| | - David Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Miguel Sousa-Uva
- Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Ralph A Schmid
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera S. Camillo Forlanini, Lazzaro Spallanzani Hospital, Rome, Italy
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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: 15] [Impact Index Per Article: 2.1] [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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Outcome of stent grafting for esophageal perforations: single-center experience. Surg Endosc 2017; 31:3696-3702. [PMID: 28078464 DOI: 10.1007/s00464-016-5408-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent studies showed that stent grafting is a promising technique for treatment of esophageal perforation. However, the evidence of its benefits is still scarce. METHODS Forty-three consecutive patients underwent stent grafting for esophageal perforation at the Oulu University Hospital, Finland. The main endpoints of this study were early and mid-term mortality. Secondary outcome endpoints were the need of esophagectomy and additional surgical procedures on the esophagus and extraesophageal structures. RESULTS Patients' mean age was 64.6 ± 13.4 years. The mean delay to primary treatment was 23 ± 27 h. The most frequent cause of perforation was Boerhaave's syndrome (46.5%). The thoraco-abdominal segment of the esophagus was affected in 58.1% of cases. Minor primary procedures were performed in 25 patients (58.1%) and repeat surgical procedures in 23 patients (53.5%). Forty-nine repeat stent graftings were performed in 22 patients (50%). Two patients (4.7%) underwent esophagectomy, one for unrelenting preprocedural stricture of the esophagus and another for persistent leakage of a perforated esophageal carcinoma. The mean length of stay in the intensive care unit was 6.0 ± 7.5 days and the in-hospital stay was 24.3 ± 19.6 days. In-hospital mortality was 4.6%. Three-year survival was 67.2%. CONCLUSIONS Stent grafting seems to be an effective less invasive technique for the treatment of esophageal perforation. Repeat stent grafting and procedures on the pleural spaces are often needed to control the site of perforation and for debridement of surrounding infected structures. Stent grafting allows the preservation of the esophagus in most of patients. The mid-term survival of these patients is suboptimal and requires further investigation.
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Marple EJ, Carter XW. Esophageal Perforation Caused by Chicken Bone Ingestion. J Osteopath Med 2017; 117:63. [PMID: 28055095 DOI: 10.7556/jaoa.2017.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lázár G, Paszt A, Mán E. Role of endoscopic clipping in the treatment of oesophageal perforations. World J Gastrointest Endosc 2016; 8:13-22. [PMID: 26788259 PMCID: PMC4707319 DOI: 10.4253/wjge.v8.i1.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/25/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023] Open
Abstract
With advances in endoscopic technologies, endoscopic clips have been used widely and successfully in the treatment of various types of oesophageal perforations, anastomosis leakages and fistulas. Our aim was to summarize the experience with two types of clips: The through-the-scope (TTS) clip and the over-the-scope clip (OTSC). We summarized the results of oesophageal perforation closure with endoscopic clips. We processed the data from 38 articles and 127 patients using PubMed search. Based on evidence thus far, it can be stated that both clips can be used in the treatment of early (< 24 h), iatrogenic, spontaneous oesophageal perforations in the case of limited injury or contamination. TTS clips are efficacious in the treatment of 10 mm lesions, while bigger (< 20 mm) lesions can be treated successfully with OTSC clips, whose effectiveness is similar to that of surgical treatment. However, the clinical success rate is significantly lower in the case of fistulas and in the treatment of anastomosis insufficiency. Tough prospective randomized multicentre trials, which produce the largest amount of evidence, are still missing. Based on experience so far, endoscopic clips represent a possible therapeutic alternative to surgery in the treatment of oesophageal perforations under well-defined conditions.
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Management and Outcomes of Esophageal Perforation: A National Study of 2,564 Patients in England. Am J Gastroenterol 2015; 110:1559-66. [PMID: 26437667 DOI: 10.1038/ajg.2015.304] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 08/04/2015] [Accepted: 08/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Traditionally esophageal perforation is a rare clinical emergency that confers a high rate of mortality and major morbidity. The objective of this study was to establish the annual rate and mortality from esophageal perforation and determine the effect of hospital volume on clinical outcomes. METHODS Hospital Episode Statistics database was used for the identification of patients admitted to hospitals within England with esophageal perforation between 2001 and 2012. The influence of hospital volume and treatment approach upon clinical outcomes was analyzed using multivariable analysis to control for patient age and medical comorbidities that may influence outcome. RESULTS Over the 12-year study period 2,564 patients with esophageal perforation were treated at 158 hospitals. The 30- and 90-day mortality rates were 30.0 and 38.8%, respectively. Esophageal perforation etiology was spontaneous in 81.9% and iatrogenic in 5.9% of cases. There was a significant increase in the percentage of patients managed supportively and a reduction in surgical management over time. Furthermore there were significant reductions in 30-day (36.6% to 24.9%; P<0.001) and 90-day mortality (44.1% to 35.4%; P=0.006) over the 12-year study period. Important patient demographics associated with 30- and 90-day mortality included age ≥70 years, preoperative congestive cardiac failure, ischemic heart, liver, and renal disease. High hospital volume was associated with significant reductions in 30- (odds ratio (OR)=0.68; P=0.001) and 90-day mortality (OR=0.69; P=0.001). In a subset analysis of patients undergoing endoscopic intervention, hospital volume was identified as an important factor associated with mortality. CONCLUSIONS This study provides evidence for the centralization of management of esophageal perforation to high volume centers with appropriate multi-disciplinary infrastructure to treat these complex patients.
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Smallwood NR, Fleshman JW, Leeds SG, Burdick JS. The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations. Surg Endosc 2015; 30:2473-80. [PMID: 26423414 DOI: 10.1007/s00464-015-4501-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Upper intestinal leaks and perforations are associated with high morbidity and mortality rates. Despite the growing experience using endoscopically placed stents, the treatment of these leaks and perforations remain a challenge. Endoluminal vacuum (E-Vac) therapy is a novel treatment that has been successfully used in Germany to treat upper gastrointestinal leaks and perforations. There currently are no reports on its use in the USA. METHODS E-Vac therapy was used to treat 11 patients with upper gastrointestinal leaks and perforations from September 2013 to September 2014. Five patients with leaks following sleeve gastrectomy were excluded from this study. A total of six patients were treated with E-Vac therapy; these included: (n = 2) iatrogenic esophageal perforations, (n = 1) iatrogenic esophageal and gastric perforations, (n = 1) iatrogenic gastric perforation, (n = 1) gastric staple line leak following a surgical repair of a traumatic gastric perforation, and (n = 1) esophageal perforation due to an invasive fungal infection. Four patients had failed an initial surgical repair prior to starting E-Vac therapy. RESULTS All six patients (100 %) had complete closure of their perforation or leak after an average of 35.8 days of E-Vac therapy requiring 7.2 different E-Vac changes. No deaths occurred in the 30 days following E-Vac therapy. One patient died following complete closure of his perforation and transfer to an acute care facility due to an unrelated complication. There were no complications directly related to the use of E-Vac therapy. Only one patient had any symptoms of dysphagia. This patient had severe dysphagia from an esophagogastric anastomotic stricture prior to her iatrogenic perforations. Following E-Vac therapy, her dysphagia had actually improved and she could now tolerate a soft diet. CONCLUSIONS E-Vac therapy is a promising new method in the treatment of upper gastrointestinal leaks and perforations. Current successes need to be validated through future prospective controlled studies.
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Affiliation(s)
- Nathan R Smallwood
- Department of Minimally Invasive Surgery, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, 1st Floor, Roberts Hospital, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Department of Surgery, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, 1st Floor, Roberts Hospital, Dallas, TX, 75246, USA
| | - Steven G Leeds
- Department of Minimally Invasive Surgery, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, 1st Floor, Roberts Hospital, Dallas, TX, 75246, USA
| | - J S Burdick
- Department of Gastroenterology, Baylor University Medical Center at Dallas, 3500 Gaston Ave, Wadley Tower Suite 556, Dallas, TX, 75246, USA
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Abstract
BACKGROUND The high morbidity and mortality of esophageal defects show that the clinical challenge in the treatment of this disease still remains. An innovative method which has been developed in recent years for esophageal leakage is endoscopic vacuum therapy. OBJECTIVES A retrospective analysis of all patients treated for esophageal perforation with endoscopic vacuum therapy in our department was carried out. METHODS From November 2006 to October 2013 a total of 35 patients were treated with this method and of these 21 had anastomotic leakage, 7 had iatrogenic perforation due to flexible or rigid endoscopy and 7 patients had esophageal defects of various other origins. Drainage systems with an open pore polyurethane tip were placed using a standard endoscope. The vacuum drainage may be positioned either in the esophageal lumen onto the defect or through the defect into the extraluminal wound cavity. The intraluminal or intracavitary vacuum drainage is connected to an electronically controlled vacuum device and a continuous negative pressure of 125 mmHg is maintained for several days. The esophageal lumen or wound cavity collapses around the drainage resulting in intraluminal evacuation and closure of the defect. Under endoscopic monitoring the vacuum system is changed regularly until stable secondary healing of the intracorporeal wound or closure of the transmural defect is achieved. RESULTS In 32 out of 35 patients (91.4 %) healing of defects was achieved after median treatment duration of 11 days (range 4-78 days). The postoperative anastomotic leakage healed in 20 out of 21 patients (95.2 %) after a median of 11 days (range 4-46 days) of therapy. The defects in the 7 patients who were treated for iatrogenic perforation all healed (100 %) after a median treatment time of 5 days (range 4-7 days). There was one case of a recurrent fistula 75 days after treatment. The 90-day mortality in this series of 35 patients was 5.7 %. DISCUSSION The results of this retrospective study emphasize the increasing importance of endoscopic vacuum therapy in the current literature as an endoscopic treatment method in the management of esophageal perforation and anastomotic leakage.
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Yılmaz B, Unlu O, Roach EC, Can G, Efe C, Korkmaz U, Kurt M. Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand? Dig Endosc 2015; 27:641-8. [PMID: 25919698 DOI: 10.1111/den.12482] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/06/2015] [Accepted: 04/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non-surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014. METHODS Comprehensive literature screening and a systematic review using PubMed and Medline was done for all reports published between January 2008 and December 2014 using the endoclip technique in the closure of iatrogenic perforations. RESULTS A total of 47 studies published between 2008 and 2014 using endoclips for the closure of iatrogenic perforations of the gut (nine esophagus, 11 stomach, 15 duodenum, 12 colon and rectum) were found. All studies were explained briefly and summarized in a table. CONCLUSIONS There is strong evidence to show the efficacy of endoclips in the management of iatrogenic perforations, especially when recognized early. Limitations of endoclipping such as inefficiency against large perforations may be overcome by improving novel techniques in the future.
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Affiliation(s)
- Bulent Yılmaz
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Ozan Unlu
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Guray Can
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Korkmaz
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Mevlut Kurt
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
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Anderson RE, Wilcox S, Miller ES. A Rare but Lethal Cause of Chest Pain. J Emerg Med 2015; 49:698-702. [PMID: 26281817 DOI: 10.1016/j.jemermed.2015.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022]
Affiliation(s)
- R Eleanor Anderson
- Department of Emergency Medicine, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Susan Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Goenka MK, Goenka U. Endotherapy of leaks and fistula. World J Gastrointest Endosc 2015; 7:702-13. [PMID: 26140097 PMCID: PMC4482829 DOI: 10.4253/wjge.v7.i7.702] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/05/2015] [Accepted: 04/01/2015] [Indexed: 02/05/2023] Open
Abstract
Perforations, leaks and fistula involving gastrointestinal (GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips (through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula. Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.
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Nason KS. Is open surgery for iatrogenic esophageal perforation now a surgical relic, like bloodletting and trepanation? J Thorac Cardiovasc Surg 2015; 149:1556-7. [DOI: 10.1016/j.jtcvs.2015.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 02/12/2015] [Indexed: 11/25/2022]
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van Halsema EE, van Hooft JE. Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature. World J Gastrointest Endosc 2015. [PMID: 25685270 DOI: 10.4253/wjge.v7.i2.135.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIM To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature. METHODS The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics. RESULTS Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications. CONCLUSION The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.
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Affiliation(s)
- Emo E van Halsema
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
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Stavropoulos SN, Modayil R, Friedel D. Closing perforations and postperforation management in endoscopy: esophagus and stomach. Gastrointest Endosc Clin N Am 2015; 25:29-45. [PMID: 25442956 DOI: 10.1016/j.giec.2014.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.
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Affiliation(s)
- Stavros N Stavropoulos
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA.
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
| | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
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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: 0.8] [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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