Low mortality after treatment for esophageal perforation: a single-center experience

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Classification of the oesophageal perforation

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: a case report and literature review

Treatment of esophageal perforation or rupture is complicated and controversial, especially in advanced cases. In fact, it is generally accepted that this disease must be treated individually according to the location, causes and clinical features of rupture or perforation. A very rare case was admitted to our department, who was injured 5 days ago by high-pressure gas of a running air compressor and resulted in a long-term longitudinal rupture of the thoracic esophagus. Although the patient suffered from empyema and mediastinitis at the same time, and his condition was very serious, the debridement and desquamation of empyema were still implemented, followed by left thoracic esophagectomy and left neck approach esophagogastrostomy in the same period successfully. The patient got a good result finally.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management and outcomes of esophageal perforation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Management, Therapeutic/Care; level IV.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

[Minimally invasive treatment of post-burn esophageal perforation]

Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.

Surgical management and prognostic factors in esophageal perforation caused by foreign body

OBJECTIVES

Esophageal perforation is associated with multiple serious complications and high mortality. Herein, we identify some predictors for postoperative outcomes, compare the outcomes of various surgical approaches, and summarize our experience with esophageal perforation over the past 13 years.

METHODS

We retrospectively analyzed 38 patients diagnosed with esophageal perforation caused by foreign body between November 2004 and May 2018. Univariate analysis and multivariate logistic regression analysis were performed to identify potential risk factors related to prognosis. Effects of different surgery were compared based on postoperative outcomes.

RESULTS

Of the 38 patients, the number of females was equal to males with a mean age of 55.6 ± 14.9 (range 23-93) years; 22 had thoracic perforations and 16 had cervical perforations. The overall mortality rate was 5.3%. Univariate analysis revealed that sex (p = 0.049), type of foreign body (p = 0.042), abscess (p = 0.049), and site of perforation (p = 0.031) were associated with prognosis. The interval between perforation and surgery did not significantly influence prognosis (p = 0.929). No significant difference was found in postoperative outcomes among various surgeries.

CONCLUSIONS

The interval between perforation and treatment was not as important as previously reported. Surgical management should be performed early when feasible, even if the interval between perforation and surgery is 24 h or longer.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Endoluminal Therapies for Esophageal Perforations and Leaks

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Multimodal Treatment Strategies for Esophageal Perforation

PURPOSE

Esophageal perforation constitutes a potentially life-threatening condition, and this study aimed to evaluate the indications and outcome for the different treatment modalities.

PATIENTS AND METHODS

In total, 43 patients with esophageal perforation were considered for this retrospective analysis. Age, sex, length of hospital stay and intensive care treatment, in-hospital mortality, localization of perforation and etiology, treatment modality, and 90-day morbidity were analyzed.

RESULTS

Most patients suffered from Boerhaave syndrome and from iatrogenic esophageal perforation. In total, 63% of patients (26/41) received successful nonoperative treatment, whereas 36% required additional surgery. Two patients (5%) underwent primary surgery. In all cases no esophagectomy was necessary. In-hospital mortality was 7%. During the 90-day follow-up 1 patient with stenosis required repetitive dilatations.

CONCLUSIONS

Initial endoscopic treatment, either by stent or by endosponge, alone or combined with an additional operative treatment, seems feasible in patients suffering from esophageal perforation. In all patients, there was no need for esophagectomy.

Surgical management of early and late esophageal perforation

Introduction

Esophageal perforation is a rare and life-threating problem with a 10%–40% mortality rate. Early diagnosis and treatment are important for prevention of complications. Strategies for treatment of esophageal perforation have been controversial for many years, especially in cases of late presentation.

Methods

We prospectively studied 27 patients (12 male, 17 female, mean age 42.7 ± 17.8 years) who presented with esophageal perforation from 1996 to 2015, and evaluated the results of surgical treatment. The patients were divided into 3 groups according to time of presentation: early (<24 h), intermediate (24–72 h), and late (>72 h). We also considered the etiology and site of esophageal perforation, complications, and mortality.

Results

Surgery was performed in 5 patients in the early group, 7 in the moderate group, and 15 in the late group. Primary repair was carried out in 5 cases, primary repair and reinforcement with a flap in 10, esophageal resection and reconstruction in 8, and a T-tube stent was used in 4. Four patients developed a fistula postoperatively, and there was one death due to respiratory failure. No relationship was found between complications and the cause of perforation, time of presentation, or type of treatment.

Conclusion

In patients without sepsis, primary repair can be an option even in those presenting late after esophageal perforation, with an acceptable result.

Minimally invasive management of esophageal perforation

Esophageal perforation is a medical emergency associated with high morbidity and mortality. There is no consensus on the optimal treatment of this life-threatening condition. Conventional treatment of esophageal perforation is surgical. However, more recently, endoscopic treatment has become the treatment of choice given its less invasive nature compared to surgical treatment. This includes endoscopic clip administration, endoscopic stent placement, endoscopic suturing, endoscopic vacuum therapy and tissue sealants which are all administered via the endoluminal route. Whilst small defects (<2 cm) may be closed with endoscopic clips, larger defects require stent placement or suturing. Removable esophageal stent is an effective method of treatment in cases with esophageal perforation as they allow minimal invasive repair of perforation and rapid nutrition. Endoscopic suturing can be used both to fix the stent to prevent migration and to primarily close the perforation. If perforation is associated with a mediastinal collection, drainage is mandatory and this procedure can be performed by computed tomography guided percutaneous drainage, thoracoscopy or endoscopic vacuum therapy. In some cases, a combination of these minimally invasive methods is required. Since endoscopic methods provide better quality of life and outcomes and shorten length of hospitalization, such methods have become the treatment of choice for esophageal perforation.

Patient Outcomes After Stent Failure for the Treatment of Acute Esophageal Perforation

BACKGROUND

Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients.

METHODS

Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed.

RESULTS

Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement.

CONCLUSIONS

Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.

Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases

Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.

Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment

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.

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.

Endoscopic management of esophageal leaks

Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents. Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse complications. This review summarizes the modern history of esophageal stent use in the treatment of esophageal perforation as well as the evidenced based recommendations for the use of esophageal stent placement in the treatment of acute esophageal perforation.

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.

Open surgery versus stent placement in failed primary surgical treatment of esophageal perforation - a single institutional experience

BACKGROUND

Surgical treatment is an accepted method to manage esophageal perforation, but in many cases it may result in failure. This paper compares the efficacy of surgical treatment and stenting in patients after previous surgical intervention for esophageal perforation.

METHODS

A single-institution retrospective study was performed in a group of patients treated for esophageal perforation admitted to our centre from 2010 to 2015. Seventy eight patients (76.5%) with esophageal perforation received surgical treatment. In this group of patients, the mean time between perforation and treatment was 80.6 h (24-240 h). Spontaneous and iatrogenic perforation was observed in 33 (42.3%) and 45 (57.7%) patients, respectively. Partial esophageal resection was performed in 11 cases (14.1%). The perforation site was sutured in the remaining 67 patients (85.9%). Surgical treatment failed in 29 cases (37.2%).

RESULTS

In patients with failed previous surgical treatment, revision surgery was performed in 14 patients (48.3%) (group A), and a large-diameter self-expandable stent was implanted in 15 cases (51.7%) (group B). Perforation in the thoracic and distal esophagus was observed in 5 (35.7%) and 9 (64.3%) patients from group A, and in 7 (46.7%) and 8 (53.3%) patients from group B, respectively. The mean intubation time in both groups was 30.3 and 12.5 days (p < 0.001), respectively. The mean daily drainage within five days after the intervention was 350 mL in group A, and 500 mL in group B (p < 0.02). In both groups hospitalisation time was 41.5 and 19.4 days, respectively (p < 0.001). Six patients died (42.8%) following revision surgery, and 2 (13.3%) patients died after stent implantation (p < 0.001).

CONCLUSIONS

Intubation time, hospitalization, and the rate of fatal complications in patients who underwent stent implantations were significantly lower compared to reoperated patients; however, the rate of prolonged drainage was lower in patients who underwent revision surgery. In conclusion, stent implantation is a significantly superior method to treat persistent leakage following failure of previous surgical treatment.

Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients

Background and Aims:

Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation.

Patients and Methods:

This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig–Holstein, Luebeck Campus, from January 1986 through December 2011.

Results:

Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance.

Conclusion:

Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.

Conservative Management of an Iatrogenic Esophageal Tear in Kenya

Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis.

A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation

OBJECTIVES

Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities.

METHODS

The Premiere database for a single health system's hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs.

RESULTS

Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost ($91,000 vs $142,000; P < .0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Operative mortality did not differ significantly.

CONCLUSIONS

Esophageal stent placement for the treatment of an acute esophageal perforation seems to be as effective as surgical repair when compared between propensity-matched patients. However, stent placement resulted in a shorter length of stay, lower rates of morbidity, and lower costs when compared with traditional surgical repair.

Repair of complete longitudinal esophageal rupture with preservation of esophageal motility

There is no consensus on the ideal treatment for esophageal perforation and on the maximal extent of esophageal disruption amenable to primary repair. The effect of extensive esophageal injury on postoperative esophageal motility is also unknown. We report the case of a longitudinal iatrogenic esophageal laceration extending from the hypopharynx to the cardia in a morbidly obese patient treated with primary repair. The patient exhibited no postoperative esophageal leak or stricture and maintained a preserved esophageal peristalsis on manometry at 3 months. An extensively lacerated esophagus can be repaired primarily while maintaining a normal postoperative function.

An analysis of esophageal stent placement for persistent leak after the operative repair of intrathoracic esophageal perforations

BACKGROUND

Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement.

METHODS

Patients undergoing esophageal stent placement for the treatment of a leak after the operative repair of an intrathoracic esophageal perforation were identified from a single institution's database, which included patients initially treated at other facilities. Patient outcomes were recorded and analyzed.

RESULTS

During a 7-year period, 32 esophageal stents were placed in 29 patients who experienced an esophageal leak after operative repair. Associated surgical procedures were simultaneously performed in 7 (24%) patients. Leak occlusion occurred in 27 patients (93%). Two patients required a reoperative repair. Twenty-five patients (86%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration in 5 patients (19%) required repositioning (n=2) or replacement (n=3). Stents were removed at a mean of 22±16 days after placement. Mean hospital length of stay was 8±11 days.

CONCLUSIONS

Endoluminal esophageal stent placement is a safe and effective treatment for the majority of leaks after the operative repair of an intrathoracic esophageal perforation. Stent placement resulted in rapid leak occlusion and provided the opportunity for early oral nutrition while eliminating the need for reoperative repair or esophageal exclusion in the majority of patients.

Oesophageal injuries: Position paper, WSES, 2013

The oesophagus is a difficult challenge for the surgeon because of its lack of serosal covering, the tenuous, segmental blood supply and the common delay in the diagnosis of injury. Early diagnosis is the key to successful management. Recent introduction of newer, minimally invasive techniques have provided management alternatives for both the normal and the diseased organ that is injured with both early and delayed diagnosis.

Spectrum of oesophageal perforations and their influence on management

Background

Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.

Methods

All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.

Results

There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days.

Conclusion

The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.

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

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Management of esophageal perforation in 120 consecutive patients: clinical impact of a structured treatment algorithm

INTRODUCTION

The therapy of esophageal perforation is still challenging. The aim of this study was to assess the etiology, specific treatment, and outcome of esophageal disruption in order to generate an optimal therapeutic approach to improve patient's outcome.

METHODS

We reviewed the cases of 120 consecutive patients with esophageal perforation treated within 10 years.

RESULTS

Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave's syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave's syndrome (p = 0.005), initial sepsis (p = 0.002), pleural effusion/empyema (p = 0.001), mediastinitis (p = 0.003), peritonitis (p = 0.001), and redo-surgery (p = 0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave's syndrome 33.3 %.

CONCLUSIONS

An approach considering etiology and extent of perforation, diagnostic delay, and septic status is required to improve patient's outcome. Primary repair is feasible in patients without intrinsic esophageal disease and evidence of sepsis. The greater the diagnostic delay, the more the destruction of the esophageal wall especially in the case of septic esophageal disease, thus the stronger the argument for esophagectomy if anatomically and/or oncologically possible.

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

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Esophageal perforation: clinical patterns and outcomes from a patient cohort of Western Norway

BACKGROUND

Esophageal perforation is a rare, often life-threatening condition, and management remains challenging.

METHODS

Retrospective review of consecutive patients with esophageal perforation treated at two university hospitals between 2000 and 2010. Pertinent data from hospital records were retrieved for statistical calculations and evaluation of perforation score.

RESULTS

Forty-seven patients [47% female, median age 62 years (range 15-88)] were included. The annual incidence was 4.7/1,000,000. Perforations were spontaneous in 14 patients (30%), iatrogenic in 25 (53%), and caused by trauma and foreign body impaction in 8 patients (17%). ASA score (p = 0.004), perforation localization (p = 0.001), diagnostic delay (p = 0.002), and perforation score (p < 0.001) differed significantly between patient groups with different etiology, but not between groups with different outcomes. Early diagnosis (≤24 h) was significantly associated with a low perforation score (p = 0.033). A non-operative approach was employed in 26 patients (55%) - more commonly for proximally localized perforations (p = 0.045). The non-operative group showed lower severe complication rates (p = 0.033), shorter ICU stays (p < 0.001) and durations of mechanical ventilation (p = 0.022). The overall 30-day mortality was 23.4%.

CONCLUSION

Careful clinical evaluation and appropriate, individualized treatment are important. The high mortality may be partly explained by the underlying disease and the complexity of the clinical condition in many patients.

Esophageal stenting for spontaneous esophageal perforation

BACKGROUND

Stenting has proven to be a promising treatment of spontaneous esophageal perforation, but currently, the scientific background to treatment of this condition is limited.

METHODS

Fourteen consecutive patients with spontaneous esophageal perforation were treated with coated self-expandable stent and a debridement procedure (three patients by thoracotomy, four by thoracoscopy, three by tube drainage, and two patients with no drainage). Eight patients had one stent, while six patients needed one or more additional stents to achieve source control.

RESULTS

Patients were treated for a mean period of 9 days in the intensive care unit. Patients who had definitive source control with primary stent were treated for a mean of 3 days in the intensive care unit, while those who needed more stents were treated for a mean of 15 days (p = 0.009). Two patients (14%) died during the in-hospital stay, both of them having received more than one stent. Eight patients had one stent, while six patients needed one or more additional stents to achieve source control. The mean estimated time from rupture to stenting was 58 hours (median, 27 hours). Fourteen percent of patients who underwent stenting within 24 hours to stent placement were in septic shock compared with 86% of patients with a delay of more than 24 hours.

CONCLUSION

Stent placement with thoracic debridement seems to be effective as a primary treatment of spontaneous esophageal perforation. According to our findings, it is of utmost importance to achieve source control with the first stent. Additional debridement procedures are still invariably needed.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Esophageal perforation caused by a fish bone treated with surgically indwelling drainage and fibrin glue injection for fistula formation

We herein report a case of thoracic esophageal perforation caused by a fish bone. The patient was a 68-year-old female who presented with a persistent sore throat after eating sea bream four days previously. She was diagnosed with an esophageal perforation and posterior mediastinal abscess formation by chest computed tomography and inflammatory findings in her blood test. Surgically indwelling drainage was able to effectively control the leakage of contaminants and infection. Endoscopic injection of fibrin glue into the long-standing thoracic-esophageal fistula promoted closure of the esophageal wall defect and enabled her to restart oral intake. This case report suggests that effective drainage and the use of fibrin glue sealant may be one of the treatment options for esophageal perforation.

Advances in the management of esophageal perforation

Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.

Evolving management strategies in esophageal perforation: surgeons using nonoperative techniques to improve outcomes

BACKGROUND

Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes.

STUDY DESIGN

Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality.

RESULTS

Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative.

CONCLUSIONS

Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.