Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience

Current treatment and outcome of esophageal perforation: A single-center experience and a pooled analysis

BACKGROUND

Esophageal perforation has been one of the serious clinical emergencies, because of the high mortality and complication rates. However, the current prognosis of esophageal perforation and the outcomes of available treatment methods are not well defined. This study attempted to pool the immediate outcomes of esophageal perforation in the past 2 decades.

METHODS

The clinical data of 22 consecutive adult patients with esophageal perforation in our center were analyzed. A pooled analysis was also conducted to summarize results from the literatures published between 1999 and 2020. Studies that met the inclusion criteria were assessed, and their methodological quality was examined.

RESULTS

The mortality and complication rates in our center were 4.55% and 31.82%, separately. The pooled analysis included 45 studies published between 1999 and 2019, which highlighted an overall immediate mortality rate of 9.86%. Surgical treatments were associated with a pooled immediate mortality of 10.01%, and for conservative treatments of 6.49%. Besides, in the past decade, the mortality and complication rates decreased by 27.12% and 46.75%, respectively.

CONCLUSIONS

In the past 2 decades, the overall immediate mortality rate of esophageal perforation was about 10% in the worldwide, and the outcomes of esophageal perforation treatment are getting better in the last 10 years.

ETHICS REGISTRATION INFORMATION

LW2020011.

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

INTRODUCTION

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.

METHODS

A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

RESULTS

A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001).

CONCLUSIONS

Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

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.

Oesophageal perforation – therapeutic and diagnostics challenge. Retrospective, single-center case report analysis (2009–2015)

Background: Esophageal perforation is a life-threatening condition of a complex etiology. No clear guidelines are available regarding the management of this condition. In this study, we review publications related to esophageal perforation, and analyze patients treated for this condition at our Department of Thoracic, General and Oncological Surgery. Objective: The objective of the study was to retrospectively assess and analyze management methods for esophageal perforations of different etiologies. All patients were treated in the Department of Thoracic, General and Oncological Surgery in years 2009-2015. Patients with perforations resulting from post-operational leaks within surgical anastomoses were excluded from the study. Material, methods, results: The analysis involved a total of 16 cases of esophageal ruptures. All cases were treated in years 2009-2015. Patients with perforations resulting from postoperative leaks within surgical anastomoses following elective surgeries for either oncological or non-oncological causes were excluded. The most common reason for esophageal rupture was iatrogenic injury (7 cases, 44%). Other causes included Boerhaave syndrome (5 cases, 31.2%), blunt trauma (2 cases, 12.5%), abscess perforation (1 case, 6.2%), and ulcer perforation (1 case, 6.2%). Ten patients underwent surgery, and the rest underwent esophageal prosthesis placement, of whom 2 cases required drainage of the mediastinum and pleural cavity. The mortality rate in the study group was 9/16 cases (56.2%). Conclusions: Esophageal perforation poses a significant interdisciplinary challenge regarding diagnostic workup, selection of treatment methods, and management of potential postoperative complications. This retrospective study was conducted in a single center. Although the analyzed period was long, we found only 16 cases. In spite of a variety of etiologies present, we found several statistically significant results of potential clinical value. 1. Most perforations that are not diagnosed within 48 hours affected the lower part of the esophagus and presented with unclear symptoms and imaging findings 2. Delaying diagnosis and treatment beyond 24 hours was associated with a higher mortality rate.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review

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.

Are single or dual luminal covered expandable metallic stents suitable for esophageal squamous cell carcinoma with esophago-airway fistula?

BACKGROUND

To analyze the outcomes of single or dual luminal self-expandable covered metallic stents (SECMS) for palliative treatment for esophageal cancer with esophago-airway fistula (EAF).

METHODS

We retrospectively assessed 50 patients who underwent SECMS placement for malignant EAF at our institution between June 2005 and December 2014 to define clinical results of stenting. Treatment provided was classified into initial single airway, single esophageal, or double stent placement. Independent associations between size, location of the EAF, patient's condition, and the risk of migration or reopening with the different types of stenting were examined using logistic regression analysis.

RESULTS

The final management of malignant EAF was esophageal stent in 21 patients, airway stent in 13, and dual stents in 16. No patients failed stenting. During a median follow-up of 178 days (range 1-893 days), the fistula reopened in 33 (66 %) of 50 patients. No factors, including fistula size, location, or initial selection of single or dual stenting, were correlated with reopening. Nineteen (57.6 %) of 33 patients needed restenting, and the reopened EAF was sealed off successfully in 52.6 % of new stent placements. The clinical failure of EAF closure was correlated only with proximal dilated esophagus (p = 0.013). Mean survival in patients with clinical success of EAF closure was also significantly longer than that in patients with clinical failure (242.0 vs. 80.1 days, p < 0.001). KPS (p = 0.026), cough ability (p = 0.004), successful closure of EAF (p = 0.001), and reopening (p = 0.007) all had significant effects on survival.

CONCLUSIONS

We conclude that SECMS is safe and effective in the palliation of esophageal cancer with malignant EAF, especially in patients with an otherwise excellent general condition. Other modalities of management are recommended for malignant EAF with proximal dilation of the esophagus.

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.

Outcome of stent grafting for esophageal perforations: single-center experience

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.