[Mortality from iatrogenic esophageal perforations is high: experience of 54 treated cases]

Stem-cell therapy via gastroscopy improves the outcome of esophageal anastomotic leakage

Background

Esophageal anastomotic leakage (EAL) is a severe complication usually occurring after esophagectomy. Although there are various therapeutic methods for EAL treatment, they have not achieved satisfactory results. A previous study showed that the combination of mesenchymal stem cells (MSCs) and fibrin scaffold (FS) can treat EAL. This study aimed to evaluate the efficacy of the injection of MSCs and FS through a new engraftment gastroscope for EAL treatment.

Methods

Twelve adult pigs were randomly divided into the MSCs group (n = 6) and control group (n = 6). A stomach tube was then inserted through the leakage to construct the EAL model, which was removed after one week. The combination of MSCs and FS was autografted at the EAL site for pigs in the MSCs group using the tailor-made gastroscope while only FS was autografted for the pigs in the control group. Local status of EAL was evaluated using gastroscopy. Histological analyses and western blot (WB) were used to assess the gross specimens of esophagi around EALs.

Results

Gastroscopy showed a higher closure rate and a lower infection rate in the MSCs group than in the control group. However, the mortality was not significantly different between the two groups. HE staining showed a severe inflammatory response with dispersive infiltration of inflammatory cells and unhealed leakage in the control group. However, the infiltration of inflammatory cells was not altered in the MSCs group, and the leakage was completely healed. WB analyses showed that Myogenin and α-SMA expressions were significantly higher in the MSCs group than in the control group.

Conclusion

A porcine model of EAL was successfully developed by accessing the transplantation site through the esophagus. Further data revealed that the implantation of MSCs in FS via the novel engraftment gastroscope can promote the repair and occlusion of EAL. Therefore, the proposed method is a promising strategy for EAL treatment.

Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract

AIM

To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract.

PATIENTS AND METHODS

This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany).

RESULTS

11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak.

CONCLUSION

EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.

Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula

Upper gastrointestinal perforations, fistula, and anastomotic leaks are severe conditions with high mortality. Temporary endoscopic placement of fully covered self-expanding metal stent (fSEMS) has emerged as treatment option. Stent migration is a major drawback of currently used stents. Migration is often attributed to a relatively too small stent diameter as esophageal stents were initially intended for the treatment of strictures. This study aimed to investigate the safety and efficacy of a large-diameter fSEMS for treatment of these conditions. Data were retrospectively collected from patients who received this stent in the Netherlands between March 2011 and August 2013. Clinical success was defined as sufficient leak closure after stent removal as confirmed by endoscopy or X-ray with oral contrast without surgical intervention or placement of another type of stent. Adverse events were graded according a standardized grading system. Stent placement was performed in 34 patients for the following indications: perforation (n = 6), anastomotic leak (n = 26), and fistula (n = 2). Technical success rate was 97% (33/34). Clinical success rate was 44% (15/34) after one stent and 50% (17/34) after an additional stent. There were no severe adverse events and stent-related mortality. The overall adverse event rate was 50% (all graded 'moderate'). There were 14 (41%) stent migrations (complete n = 8, partial n = 6). Other adverse events were bleeding (n = 2) and aspiration pneumonia (n = 1). Reinterventions for failure of the large-diameter fSEMS were placement of another type of fSEMS (n = 4), surgical repair (n = 3), or esophagectomy (n = 1). Eleven patients (32%) died in-hospital because of persisting intrathoracic sepsis (n = 10) or preexistent bowel ischemia (n = 1). This study suggests that temporary placement of a large-diameter fSEMS for the treatment of upper gastrointestinal perforations, fistula, and anastomotic leaks is safe in terms of severe adverse events and stent-related mortality. The larger diameter does not seem to prevent stent migration.

Comparison of Endoscopic Vacuum Therapy and Endoscopic Stent Implantation With Self-Expandable Metal Stent in Treating Postsurgical Gastroesophageal Leakage

The aim of the present study was to evaluate the more effective therapy for the postsurgical gastroesophageal leakage by a head-to-head comparison of endoscopic vacuum therapy (EVT) and endoscopic stent implantation with self-expandable metal stent (E-SEMS). In this hospital-based, retrospective, observative study, the patients were classified into 2 groups. Those treated with EVT were assigned to the EVT group (n = 7), and those treated with E-SMS were assigned to the E-SEMS group (n = 11). We evaluated the clinical characteristics and treatment outcomes between the 2 groups. All 7 patients (100%) were treated with EVT, but only 7 of 11 patients (63.6%) in the stenting group were treated successfully. The median time to clinical success was 19.5 (5-21) days in the EVT group and 27.0 (3-84) days in the E-SEMS group. The median hospital stay was 37.1 (13-128) days in the EVT group and 87.3 (17-366) days in the E-SEMS group. The complicaion rate was lower in the EVT group (0/7, 0.0%) than that in the E-SEMS group (6/11, 54.5%) with statistically significant difference (P = 0.042). EVT is more effective and has fewer adverse effects than E-SMS therapy as a treatment for postsurgical gastroesophageal leakage.

Endoscopic vacuum-assisted closure system (E-VAC): case report and review of the literature

Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach - from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.

Combined Placement of Covered Self-Expanding Metallic Stents and Nasojejunal Tube for Managing Large Lower Esophageal Perforations

Covered self-expanding metallic stents (cSEMSs) have emerged as effective treatment option for esophageal perforations. However, the large lower esophageal perforations where the cSEMS is placed across gastroesophageal junction have lower healing rates because refluxed gastric contents constantly irritate perforation and also there is increased risk of stent migration. Moreover, gastric mucosa tends to prolapse into lumen of lower end of stent causing its obstruction, leading to seepage of saliva and fluids from upper end of stent even in the patients who are on parenteral nutrition. We present our experience of a novel technique of combined cSEMS and nasojejunal tube (NJT) placement in four patients (two males) with benign large lower esophageal perforations. The NJT was placed through the stent into the jejunum through which patients were given enteral feeding. The stents were placed 5 - 21 days after esophageal perforation with the size of perforation ranging from 4 to 6 cm. As the NJT formed a loop in stomach, it prevented migration of stent. And also its presence in lumen of stent prevented its obstruction by prolapsing gastric mucosa, thereby preventing seepage of saliva and fluids from side of stent. Both stents and NJT were removed after 6 weeks and leak closed in all patients. Combined cSEMS and NJT placement seems to be safe and effective for treating large lower esophageal perforations. NJT placement seems to decrease risk of migration, prevents seepage of fluids and permits early enteral nutrition, thereby improving the healing rates.

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

Background

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

Methods

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

Results

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause.

Conclusions

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

BACKGROUND

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

METHODS

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

RESULTS

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause.

CONCLUSIONS

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus

BACKGROUND

Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred.

AIM

To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs.

METHODS

A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival.

RESULTS

Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68].

CONCLUSIONS

Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).

[Foreign body perforation of the thoracic esophagus]

BACKGROUND

Esophageal perforation due to foreign body (FB) ingestion is an unusual occurrence. This study aims to define diagnostic difficulties of esophageal perforation by FB.

PATIENTS AND METHODS

A chart review of patients on our service with FB esophageal perforation was carried out. Diagnosis of perforation was made by CT scan and/or esophagoscopy. Surgery was indicated when a FB could not be removed endoscopically or on a case-by-case basis according to clinical/laboratory, radiologic, and/or endoscopic findings.

RESULTS

Seven patients (age range: 27 to 80 years) were admitted for esophageal FB perforation. All patients presented with dysphagia. Two patients presented with signs of sepsis more than 24 hours after FB ingestion. Perforation was diagnosed at initial evaluation in five cases (three by endoscopy, two by CT) and after FB extraction in two cases. Six patients underwent surgery (suture repair: n=4; esophageal exclusion: n=1; mediastinal drainage: n=1). Five surgeries were performed at the initial diagnosis and one after failure of medical management. Mortality was zero; one patient developed esophageal fistula.

CONCLUSION

Diagnosis of FB esophageal perforation is difficult and is delayed in up to a quarter of patients. The perforation can be due to the FB itself or may be incurred during endoscopic extraction. Both CT and endoscopy are necessary for diagnosis and treatment. Most patients require surgical intervention.

Esophageal perforation: principles of diagnosis and surgical management

PURPOSE

Esophageal perforation (EP) is still associated with a high mortality rate, even after surgical repair. We reviewed 17 cases of EP to evaluate the management of this major surgical problem.

METHODS

We reviewed the medical records of all patients treated for EP in our department between November 2001 and November 2004. Therapy was based on various patient-related factors.

RESULTS

Seventeen patients, with a mean age of 63 years, presented with EP mostly caused by iatrogenic incidents (11/17). In nine patients, the perforation was located in the thoracic segment, with a mean size of 2.5 +/- 0.6 cm. Thoracic computed tomography (CT) was performed in all patients to assess the periesophageal inflammation precisely. More than 50% showed signs of systemic inflammation indicative of sepsis, reflected by a dramatic increase in serum C-reactive protein and leukocytosis. Treatment consisted of debridement and drainage (n = 3), primary repair (n = 3), reinforced repair (n = 4), esophageal resection (n = 5), and conservative measures (n = 2). All patients, except for three with pre-existing liver dysfunction and other comorbidities, survived, representing a mortality rate of 17.6% (14/17). An analysis of the literature (2000-2005) revealed an overall mortality rate of 19.7% (101/521), ranging from 3% to 67%.

CONCLUSION

Our data support the individualized surgical management of EP, based on careful evaluation of various patient-related factors, including CT findings.

Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents

BACKGROUND

Spontaneous or iatrogenic esophageal perforations after endoscopic procedures are potentially life-threatening events with a considerable mortality rate. The aim of this study was to demonstrate that a nonoperative endoscopic treatment with self-expanding metal stents may have a lower morbidity and mortality rate compared with surgical treatment.

METHODS

A nonrandomized observational study was conducted with 15 consecutive patients between January 1997 and June 2004. Benign spontaneous and iatrogenic esophageal perforations after endoscopic procedures were treated with self-expandable metal stents.

RESULTS

Seven patients (group 1) underwent stent insertion with an average time delay of 45 minutes. In 8 patients (group 2), the median delay was 123 hours. All patients in group 1 had an uneventful recovery and left hospital 5 days (range, 3 to 9) after stent insertion. One patient in group 2 (1 of 8) died of pneumonia after 6 days. In any other cases, perforations healed successfully after stent placement, but the clinical course was generally complicated with sepsis and multiple organ failure. The average hospital stay was 44 days (range, 15 to 70).

CONCLUSIONS

Immediate insertion of a self-expandable metal stent enables an excellent outcome with minimal mortality and morbidity without the need for operation. Even in cases of old esophageal perforations, sealing with self-expandable metal stents is still a good option although the clinical course is much less impressive than in early treated perforations.

Assessment of spontaneous pneumomediastinum: experience with 12 patients

BACKGROUND

The aim of this study is to report a series of spontaneous pneumomediastinum in a population of young, tall, and thin patients with a history of thoracic hyper pressure, and to analyze the assessment required in such patients.

METHODS

A retrospective study of an unicentric series and a review of the literature from 1980 to 2002 were performed.

RESULTS

Between December 1996 and January 2002, 12 patients (mean age, 25 years old; mean height, 172 cm; and mean weight, 63 kg) were admitted with spontaneous pneumomediastinum. In all patients, high intrathoracic pressure by cough or acute effort was the precipitating factor. Most frequent complaints were acute chest pain, asthenia, and subcutaneous emphysema. The following assessment was performed: chest roentgenogram in 12 of 12 patients (12/12); computer tomography (CT) scan in 8/12; bronchoscopy in 7/12; esophagoscopy in 6/12; esophagography in 2/12. Outcome was always uneventful without any recurrence. Hospital stay ranged from 0 to 6 days. The Medline research revealed that articles consist mainly of case reports. Two articles only report a multicentric series of 25 and 36 cases, respectively. No organ perforation was found either in our series or in our review of the literature.

CONCLUSIONS

Spontaneous pneumomediastinum follows alveolar rupture in the pulmonary interstitium. The dissection of gas towards the hilum and mediastinum is produced by an episode of acute high intrathoracic pressure. It affects mostly young people, and this is the case in our series. Endoscopic thoracic assessment may be risky and is not always necessary. Chest CT or esophageal contrast study should be performed in case of diagnostic doubt of esophageal perforation.

[Perforation and rupture of the oesophagus: treatment and prognosis]

AIM OF THE STUDY

To analyze treatment and prognosis of perforations and ruptures of the oesophagus.

MATERIAL AND METHODS

This retrospective study included 40 patients (26 men and 14 women; mean age = 59 +/- 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic (n = 6) or following ingestion of a foreign body (n = 1). Thirty-three perforations were thoracic: iatrogenic (n = 15), spontaneous rupture (n = 14), following ingestion of foreign body (n = 3) or traumatic (n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture (n = 13), oesophagectomy (n = 11) or double exclusion (n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body).

RESULTS

The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion.

CONCLUSION

Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.