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

Spontaneous esophageal rupture resulting in formation of multiple pulmonary artery pseudoaneurysms: A case report

Esophageal rupture and pulmonary artery pseudoaneurysm are 2 rare but life-threatening conditions that are challenging to detect but require prompt intervention once diagnosed. The present case describes a patient with spontaneous esophageal rupture resulting in necrotizing pneumonia and multiple PAP that were ultimately managed via endovascular embolization combined with surgical resection. Although atypical, it emphasizes the need for a high degree of clinical suspicion when either of these diagnoses are on the differential and additionally illustrates another scenario in which interventional radiology and surgery can collaborate to optimize patient care.

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.

Optimizing CT Esophagography: Ex Vivo Study on Contrast Ratios, Image Quality, and Dual-Energy Benefits

This study aimed to optimize CT esophagography by identifying effective oral contrast dilution ratios and exploring the advantages of dual-energy CT (DECT) over conventional CT for improving image quality. Ex vivo experiments using iodine contrast agents (320-400 mgI/mL) at 21 dilution ratios were scanned at three voltages, with additional dual-energy scans generating various reconstruction images. Image quality was assessed both objectively and subjectively. The study found significant variability in image quality across different dilution ratios. Specific dilution ratios that produced image quality comparable to the control group (a commercial oral contrast agent) and those meeting the standards for clinical diagnosis and high-quality images were identified based on image quality assessments. Recommendations for preparing 100 mL of oral contrast solution were provided, such as for achieving high-quality images at a scanning voltage of 100 kVp: the optimal dilution ratios are 1:6 to 1:19 for 320 mgI/mL, and 1:8 to 1:19 for 350 to 400 mgI/mL. Additionally, beam-hardening artifacts were significantly reduced in DECT images. These findings provide valuable guidance for improving CT esophagography protocols.

What Is New with Cervical Perforations? A Clinical Review Article

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

Perforated Esophageal Cancer

Esophageal perforation in the setting of malignancy is a surgical emergency for which there is little direct evidence in the literature to guide treatment. Instead, treatment is based on a combination of our understanding of managing benign esophageal perforations and a contemporary understanding of the treatment and prognosis of esophageal cancer. Due to the numerous challenges of managing perforated esophageal cancer, incorporating clinicians with expertise in esophageal cancer, advanced endoscopy, and esophageal surgery into shared decision-making discussions with patients and their families is essential.

Endoscopic Management of Iatrogenic Perforations

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

Live Fish in the Throat Causing Upper Airway Obstruction and Esophageal Perforation

Having a large live fish stuck in the throat is rare and prompts the urgent need to secure a definitive airway. Such sizeable foreign body (FB) in the aerodigestive tract also poses a constant threat of hollow viscus perforation, and the removal process can be complex. This report describes a fishing mishap causing the impaction of a large live fish in the laryngopharynx and esophagus, leading to respiratory distress and upper esophageal perforation. The paper highlights the mechanism of injury, emergent airway management, anatomical consideration of the location of the FB, and technical challenges in FB removal. After endotracheal intubation, the depth and location of the live fish were confirmed with a plain radiograph. The removal of the live fish was eventually successful after dislodging its fins from the laryngopharynx and rotating its head out from the upper esophagus endoscopically. The upper esophageal perforation healed with non-operative management, and the patient was discharged well.

Management and prognosis of iatrogenic perforations of the cervical oesophagus and hypopharynx

Objective

The study aimed to identify factors affecting the management and prognosis of iatrogenic cervical oesophageal and hypopharyngeal perforations (iCEHPs).

Methods

We retrospectively analysed 24 patients treated for iCEHP between 2004 and 2021 at a tertiary university medical centre. Data on demographics, clinical features, imaging, management and outcomes were collected. Factors associated with primary management and patient outcome were assessed.

Results

The most common management approach was surgical neck exploration (15 patients, 62.5%). Surgical management was used in 93% of uncontained perforations compared to 11% of contained perforations (p < 0.001). Surgically-treated patients had higher levels of C-reactive protein (CRP) than conservatively-treated patients (median, 18.3 vs 4.8 mg/dL; p = 0.001). Delayed diagnosis (≥ 24 hours) was associated with increased mortality (100 vs 5%; p = 0.011). The mortality rate was significantly higher in patients who had a history of neck irradiation than in patients who did not (67 vs 5%; p = 0.032).

Conclusions

Early diagnosis of iCEHP improves outcomes. The appropriate management should be carefully selected on the basis of CRP level and imaging findings. Prior neck radiation is a poor prognostic factor.

Early Presentation of Boerhaave Syndrome in the Emergency Department: A Case Report and Review of the Literature

We present the case of a 46-year-old patient who arrived at the emergency department with chest pain following an episode of vomiting. The diagnosis was Boerhaave syndrome and acute mediastinitis. Due to the prompt presentation and the location of the rupture in the lower esophagus, emergency surgical intervention was performed, including esophageal suturing, mediastinal drainage, and jejunostomy for feeding. Postoperatively, the patient was transferred to the intensive care unit for advanced monitoring and support. The patient's condition improved favorably in the intensive care unit, allowing for extubation. Progress continued positively, and the patient was discharged 12 days postoperatively with a functional jejunostomy. At regular follow-ups, the patient's recovery remained favorable, and the jejunostomy was removed 30 days after the surgery. This case highlights the importance of rapid diagnosis and early surgical intervention in Boerhaave syndrome, demonstrating the successful management of a severe condition through a multidisciplinary effort.

Endoscopic full-thickness resection of a large gastric schwannoma and iatrogenic cervical esophageal perforations: A case report

INTRODUCTION

Gastrointestinal schwannomas are most commonly found in the stomach. Owing to their nonspecific clinical and endoscopic presentations, distinguishing gastric schwannomas (GS) from other gastric submucosal tumors based on typical symptoms and endoscopic features is challenging. Endoscopic full-thickness resection (EFTR) is safe and effective for GS management; however, no standard method exists for the extraction of large gastric specimens after endoscopic treatment.

CASE PRESENTATION

We report the case of a 72-year-old Chinese woman who presented with abdominal distension.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

Gastroscopy revealed a submucosal bulge on the anterior wall of the lower stomach near the greater curvature. Endoscopic ultrasonography and computed tomography suggested a stromal tumor. The patient underwent EFTR of the stomach, and the tumor was successfully removed. The surgical specimen, with a long-axis diameter of approximately 5.5 cm in vitro, was extracted using a snare. Subsequent endoscopic examination revealed longitudinal, full-thickness perforations > 2 cm at the esophageal entrance. Over 10 metal clips were used to seal the mucosa, and a gastrointestinal decompression tube was placed. Follow-up radiography performed at 1 week postoperatively revealed an esophageal mediastinal fistula, which required subsequent endoscopic intervention to close the fistula using metal clips. The patient showed improvement and was discharged at 3 weeks postoperatively. Follow-up esophageal radiography revealed no abnormalities. Postoperative immunohistochemical analysis indicated CD34 (-), CD117 (-), DOG-1 (-), Ki67 (1%), S-100 (+), SDHB (+), SOX-10 (+), and Desmin (-), confirming the diagnosis of GS. Three months postoperatively, gastroscopy showed that the esophageal perforation healed well, a white ulcer scar had formed locally, metal clips were found in the stomach body, and no recurrence was found.

CONCLUSION

EFTR is effective for removing giant schwannomas, although the extraction of large specimens may result in iatrogenic cervical esophageal perforations. Perforations > 2 cm can be managed using endoscopic metal clip closure.

The role of radiology in diagnosing gastrointestinal tract perforation

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series

Background

Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation.

Methods

All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized.

Results

Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery.

Conclusion

Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

CT esophagogram in the emergency setting: typical findings and suggested workflow

PURPOSE

Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide.

METHODS

Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance.

RESULTS

EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP.

CONCLUSION

CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.

Multicenter, Prospective Cohort Study of Oesophageal Injuries and Related Clinical Outcomes (MUSOIC study)

OBJECTIVE

To identify prognostic factors associated with 90-day mortality in patients with oesophageal perforation (OP), and characterize the specific timeline from presentation to intervention, and its relation to mortality.

BACKGROUND

OP is a rare gastro-intestinal surgical emergency with a high mortality rate. However, there is no updated evidence on its outcomes in the context of centralized esophago-gastric services; updated consensus guidelines; and novel non-surgical treatment strategies.

METHODS

A multi-center, prospective cohort study involving eight high-volume esophago-gastric centers (January 2016 to December 2020) was undertaken. The primary outcome measure was 90-day mortality. Secondary measures included length of hospital and ICU stay, and complications requiring re-intervention or re-admission. Mortality model training was performed using random forest, support-vector machines, and logistic regression with and without elastic net regularisation. Chronological analysis was performed by examining each patient's journey timepoint with reference to symptom onset.

RESULTS

The mortality rate for 369 patients included was 18.9%. Patients treated conservatively, endoscopically, surgically, or combined approaches had mortality rates of 24.1%, 23.7%, 8.7%, and 18.2%, respectively. The predictive variables for mortality were Charlson comorbidity index, haemoglobin count, leucocyte count, creatinine levels, cause of perforation, presence of cancer, hospital transfer, CT findings, whether a contrast swallow was performed, and intervention type. Stepwise interval model showed that time to diagnosis was the most significant contributor to mortality.

CONCLUSIONS

Non-surgical strategies have better outcomes and may be preferred in selected cohorts to manage perforations. Outcomes can be significantly improved through better risk-stratification based on afore-mentioned modifiable risk factors.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early Diagnosis and Surgical Management of Boerhaave Syndrome: A Case Report

Boerhaave syndrome is a rare condition of spontaneous esophageal perforation after multiple episodes of forceful emesis. Due to its high morbidity and mortality rates, early diagnosis and treatment are key prognostic factors. Herein, we present a case of Boerhaave syndrome, which was initially misinterpreted as a coronary event due to similar confusing symptoms. However, a diagnosis was made without delay and confirmed with a chest computed tomography (CT) scan, which revealed pneumomediastinum. The patient was treated surgically by primarily repairing the rupture with an omentum patch reinforcement, draining the mediastinum and both pleural cavities, and creating a feeding jejunostomy. After a long stay in the ICU and the Surgical Department, the patient was discharged in good clinical condition with normal oral feeding.

Successful retrosternal esophageal bypass with gastric transposition in the management of esophago-pleural fistula as a complication of Boerhaave syndrome

INTRODUCTION AND IMPORTANCE

Boerhaave syndrome is a rare life-threatening condition that represents about 15 % of esophageal perforation and is associated with significant mortality. A subset of patients with effort rupture of the esophagus can present with esophago-pleural fistula. Management of esophago-pleural fistula remains a challenge due to the lack of high-quality evidence studies and the rarity of reported cases. Esophageal bypass with gastric transposition could have a role in management by using the same principles used in chronic esophago-pleural fistula in esophageal malignancy.

CASE PRESENTATION

We report a unique case of a 33-year-old male with effort rupture of esophagus who developed esophago-pleural fistula successfully managed with an esophageal bypass with gastric transposition after multiple attempts of CSES placement have failed.

CLINICAL DISCUSSION

Boerhaave syndrome is a rare clinical presentation with mortality ranging from 20 to 50 %. A case of Boerhaave syndrome present with esophageal pleural fistula is uncommon despite the anatomical proximity of these structures. For delayed presentation deployment of CSES to control the fistula was not effective as retrosternal esophageal bypass in this case study.

CONCLUSIONS

Esophageal bypass with gastric transposition might be an effective strategy for esophago-pleural fistula compared to CSES placement following delayed presentation of Boerhaave syndrome but further appropriately designed studies are required to make recommendations.

Identification of Iatrogenic Perforation in Pediatric Gastrointestinal Endoscopy

OBJECTIVES

Iatrogenic viscus perforation in pediatric gastrointestinal endoscopy (GIE) is a very rare, yet potentially life-threatening event. There are no evidence-based recommendations relating to immediate post-procedure follow-up to identify perforations and allow for timely management. This study aims to characterize the presentation of children with post-GIE perforation to better rationalize post-procedure recommendations.

METHODS

Retrospective study based on unrestricted pooled data from centers throughout Europe, North America, and the Middle East affiliated with the Endoscopy Special Interest Groups of European Society for Paediatric Gastroenterology Hepatology and Nutrition and North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Procedural and patient data relating to clinical presentation of the perforation were recorded on standardized REDCap case-report forms.

RESULTS

Fifty-nine cases of viscus perforation were recorded [median age 6 years (interquartile range 3-13)]; 29 of 59 (49%) occurred following esophagogastroduodenoscopy, 26 of 59 (44%) following ileocolonoscopy, with 2 of 59 (3%) cases each following balloon enteroscopy and endoscopic retrograde cholangiopancreatography; 28 of 59 (48%) of perforations were identified during the procedure [26/28 (93%) endoscopically, 2/28 (7%) by fluoroscopy], and a further 5 of 59 (9%) identified within 4 hours. Overall 80% of perforations were identified within 12 hours. Among perforations identified subsequent to the procedure 19 of 31 (61%) presented with pain, 16 of 31 (52%) presented with fever, and 10 of 31 (32%) presented with abdominal rigidity or dyspnea; 30 of 59 (51%) were managed surgically, 17 of 59 (29%) managed conservatively, and 9 of 59 (15%) endoscopically; 4 of 59 (7%) patients died, all following esophageal perforation.

CONCLUSIONS

Iatrogenic perforation was identified immediately in over half of cases and in 80% of cases within 12 hours. This novel data can be utilized to generate guiding principles of post-procedural follow-up and monitoring.

PLAIN LANGUAGE SUMMARY

Bowel perforation following pediatric gastrointestinal endoscopy is very rare with no evidence to base post-procedure follow-up for high-risk procedures. We found that half were identified immediately with the large majority identified within 12 hours, mostly due to pain and fever.

Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort

BACKGROUND

Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.

METHODS

Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.

RESULTS

Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).

CONCLUSIONS

Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Boerhaave's Syndrome: An Unusual Geriatric Presentation

Boerhaave's syndrome (BS) is a non-iatrogenic spontaneous esophageal perforation that, if not appropriately recognized and managed, can cause localized infections such as mediastinitis, pneumonia, and empyema, as well as systemic infections with significant morbidity and mortality rates. An autonomous 83-year-old male presented to the emergency department with a three-day history of behavioral changes. Three days earlier, the patient had a self-limited episode of cough, nonspecific thoracalgia, palpitations, prostration, and pallor. On physical examination, he was alert but had temporal disorientation, hypoxemia, and pulmonary auscultation with abolished breath sounds in the middle third of the left chest. Laboratory tests showed hypoxemia, elevated C-reactive protein (28.2 mg/dL), and D-dimer (3.28 µg/mL). A chest X-ray revealed periaortic small bubbles, left atelectasis, and left pleural effusion. Computed tomographic angiography of the chest showed infra-carinal esophageal rupture, small bubbles of the anterior pneumomediastinum, and a loculated left pleural empyema. Mediastinitis and empyema due to BS were assumed. He underwent left thoracic drainage, broad-spectrum antibiotics, and the placement of a surgical esophageal prosthesis. He was discharged after 48 days. The condition known as BS is frequently misdiagnosed, mostly as a result of the lack of a preexisting pathological background and the wide array of potential symptoms that may manifest. The diagnosis in this particular case was rendered particularly complex due to the combination of an unusual presentation and a delayed seeking of medical attention. Against all expectations, our patient was successfully treated.

Role of shrinkage in esophageal-gastric junction cancer

The esophagus undergoes shrinkage after resection and fixation. The surgical in situ margin is greater than the specimen margin, measured by the pathologist. The length of disease-free margins is critical to therapeutic planning. We propose specimen fixing to avoid discrepancies between the operative finding and the pathological result.

Esophageal Perforation

Esophageal perforation is a rare but fatal disease process that requires prompt diagnosis and treatment. Surgery has historically been required for treatment; however, there is currently a shift toward endoscopic management. Although no randomized controlled trials exist to compare patient outcomes, many case series and systematic analyses describe their indications, efficacy, and safety profile. Endoscopic stenting and endoscopic vacuum therapy are the 2 therapies most widely described across a diverse patient population and appear to be safe and effective when treating esophageal perforation, in the proper clinical setting. Guidelines and scoring systems exist to help direct management and stratify patient risk.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience

BACKGROUND

Esophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP.

METHODS

We retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients.

RESULTS

There were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776-6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418-23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674-17.233, P = 0.018) were independent risk factors for poor prognosis.

CONCLUSION

Foreign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.

The Etiology, Diagnosis, and Management of Esophageal Perforation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endoscopic vacuum therapy (EVT) for acute esophageal perforation: Could it replace surgery?

Background and study aims  Acute esophageal perforation is a potentially life-threating condition that demands a multidisciplinary approach. Based on recently published data indicating that EVT may be effective in managing esophageal perforation, we report our institution's experience with EVT in this clinical setting. Patients and methods  We retrospectively analyzed all 10 patients with acute esophageal perforation from May 2018 to January 2021, using descriptive statistics. The primary outcome was successful closure of the perforation. Secondary outcomes included the length of treatment, number of endoscopic procedures required, and complication rate. Results  All patients (site of perforation: 4 upper, 2 middle, 4 lower esophagus; etiology: 8 iatrogenic, 2 foreign body ingestion) were treated with EVT successfully. In eight cases, EVT was started immediately after the perforation, in the other two cases 1 and 2 days later. The median (interquartile range) number of endoscopic procedures was 2.5 (range, 2-3) and the median duration of treatment was 7.5 days (range, 7-11.5). The sponge was placed in eight cases intraluminally, in the other two cases initially intracavitary. No complication occurred. Conclusions  EVT is highly effective for managing acute esophageal perforation within 1 to 3 weeks. Immediate start of EVT to prevent abscess formation and induce defect closure is crucial.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

BACKGROUND

Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation.

CASE PRESENTATION

We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis.

CONCLUSION

Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

High risk and low prevalence diseases: Esophageal perforation

INTRODUCTION

Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality.

OBJECTIVE

This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence.

DISCUSSION

Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting.

CONCLUSIONS

An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.

Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

Human Adipose Derived Stem Cells Enhance Healing in a Rat Model of Esophageal Injury with Stent

BACKGROUND

Mesenchymal stem cells have been proven to promote cellular recruitment and remodeling during healing. Considering challenges encountered in the healing process of esophageal injury, we sought to evaluate the effect of human adipose derived stem cells (hASC) on esophageal injury with stent and to assess the feasibility of submucosal hASC injection as a mechanism of delivery.

METHODS

An intrabdominal esophagotomy was created in rodents with placement of an expandable fully covered metal esophageal stent. A submucosal injection of 2 × 10⁶ hASC was delivered in experimental animals. Animals were sacrificed on postoperative day 3 (POD3) or 7 (POD7). Macroscopic, immunohistochemical and immunofluorescence analyses were conducted to assess for markers of healing and viability of transplanted cells.

RESULTS

hASC were identified within submucosal and muscular layers with proliferation demonstrated in respective areas on anti-Ki67 stained sections. Lower adhesion and abscess scores were observed in hASC specimens without significant statistical difference. Prevalence of submucosal collagen was increased in samples treated with hASC compared to control, with abundant collagen deposition demonstrated within the POD7 group. Granulation tissue at the site of esophageal injury was more prominent in tissue sections treated with hASC compared to control, with significantly higher density at POD3 (control 1.94 versus hASC 2.83, P < 0.01).

CONCLUSIONS

Presence of hASC at the site of an esophageal injury may enhance wound healing predominantly through increased granulation and decreased inflammation in conjunction with esophageal stent placement. Targeted submucosal injection at the time of esophageal stent placement is an effective delivery method of hASC therapy.

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.

Endoscopic negative pressure therapy (ENPT) in head and neck surgery: first experiences in treatment of postoperative salivary fistulas and cervical esophageal perforations

INTRODUCTION

Iatrogenic cervical esophageal perforations (CEP) and postoperative salivary fistulas (PSF) are some of the complications requiring treatment in head and neck surgery. Conservative, surgical and endoscopic therapeutic techniques are used. Both CEP and PSF are potentially life-threatening complications and require intensive treatment. Endoscopic negative pressure therapy (ENPT) is an innovative endoscopic surgical procedure for the treatment of transmural intestinal defects throughout the gastrointestinal tract (GIT). In this retrospective study, we demonstrate its application in head and neck surgery.

MATERIALS AND METHODS

In ENPT, open-pore drains are placed endoscopically in the wound area. The drains can be inserted in an intraluminal position spanning the length of the defect (intraluminal ENPT), or through the defect into the extraluminal wound cavity (intracavitary ENPT). An electronic suction pump applies and maintains a continuous negative pressure of - 125 mmHg over a period of several days. The endoscopic drains are changed at regular intervals every few days until stable intracorporeal wound healing by secondary intention or defect closure is achieved. Between 06/2008 and 05/2019 ten patients (f = 3, m = 7; 46-78 years old) were treated with ENPT for CEP or PSF. Five patients had postoperative wound defects with consecutive PSF after total laryngectomy or floor of mouth resection. In five patients iatrogenic CEP was found following endoscopic procedures.

RESULTS

In all patients treated with ENPT, healing of the perforation defect or fistula was achieved (cure rate 100%). The median treatment duration was 13.7 days (range 4-42 days). No relevant treatment-associated complications were observed.

CONCLUSION

ENPT is a new, minimally invasive method for treating PSF and CEP.

Caustic ingestion: CT findings of esophageal injuries and thoracic complications

Ingestion of caustic substances, whether accidental or for the purpose of suicide, can cause severe lesions of the lips, oral cavity, pharynx, upper gastrointestinal system, and upper airways. In particular, caustic agents could be responsible for severe esophageal injuries resulting in short- and long-term complications. Because of these important clinical implications, timely diagnosis and appropriate management are crucial. In the evaluation of esophageal injuries, thoraco-abdominal computed tomography (CT) is preferable to endoscopy as it avoids the risk of esophageal perforation and allows the evaluation of esophageal injuries as well as of the surrounding tissue. In this review, we report CT findings of esophageal injuries and possible related thoracic complications caused by caustic ingestion.

Endoluminal vacuum-assisted closure (E-Vac) therapy for postoperative esophageal fistula: successful case series and literature review

Background

Treatment of esophageal perforations and postoperative anastomotic leaks of the upper gastrointestinal tract remains a challenge. Endoluminal vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years, to the management of upper gastrointestinal tract perforations by using the same principle of vacuum-assisted closure therapy of external wounds. The aim is to provide continuous wound drainage and to promote tissue granulation, decreasing the needed time to heal with a high rate of leakage closure.

Cases presentation

A series of two different cases with clinical and radiological diagnosis of esophageal fistulas, recorded from 2018 to 2019 period at our institution, is presented. The first one is a case of anastomotic leak after esophagectomy for cancer complicated by pleuro-mediastinal abscess, while the second one is a leak of an esophageal suture, few days after resection of a bronchogenic cyst perforated into the esophageal lumen. Both cases were successfully treated with E-Vac therapy.

Conclusion

Our experience shows the usefulness of E-Vac therapy in the management of anastomotic and non-anastomotic esophageal fistulas. Further research is needed to better define its indications, to compare it to traditional treatments and to evaluate its long-term efficacy.

Development of a Bioinspired, Self-Adhering, and Drug-Eluting Laryngotracheal Patch

OBJECTIVES/HYPOTHESIS

Novel laryngotracheal wound coverage devices are limited by complex anatomy, smooth surfaces, and dynamic pressure changes and airflow during breathing. We hypothesize that a bioinspired mucoadhesive patch mimicking how geckos climb smooth surfaces will permit sutureless wound coverage and also allow drug delivery.

STUDY DESIGN

ex-vivo.

METHODS

Polycaprolactone (PCL) fibers were electrospun onto a substrate and polyethylene glycol (PEG) - acrylate flocks in varying densities were deposited to create a composite patch. Sample topography was assessed with laser profilometry, material stiffness with biaxial mechanical testing, and mucoadhesive testing determined cohesive material failure on porcine tracheal tissue. Degradation rate was measured over 21 days in vitro along with dexamethasone drug release profiles. Material handleability was evaluated via suture retention and in cadaveric larynges.

RESULTS

Increased flocking density was inversely related to cohesive failure in mucoadhesive testing, with a flocking density of PCL-PEG-2XFLK increasing failure strength to 6880 ± 1810 Pa compared to 3028 ± 791 in PCL-PEG-4XFLK density and 1182 ± 262 in PCL-PEG-6XFLK density. The PCL-PEG-2XFLK specimens had a higher failure strength than PCL alone (1404 ± 545 Pa) or PCL-PEG (2732 ± 840). Flocking progressively reduced composite stiffness from 1347 ± 15 to 763 ± 21 N/m. Degradation increased from 12% at 7 days to 16% after 10 days and 20% after 21 days. Cumulative dexamethasone release at 0.4 mg/cm² concentration was maintained over 21 days. Optimized PCL-PEG-2XFLK density flocked patches were easy to maneuver endoscopically in laryngeal evaluation.

CONCLUSIONS

This novel, sutureless, patch is a mucoadhesive platform suitable to laryngeal and tracheal anatomy with drug delivery capability.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1958-1966, 2021.

Patient-Reported Long-Term Outcome is Superior After Treatment with Self-Expanding Metallic Stents in Esophageal Perforations

BACKGROUND AND AIMS

Esophageal perforations are life threatening. Since the 1990s, placing of covered esophageal stents has become an alternative to surgery. Theoretically, this minimally invasive approach has several benefits; however, little data are available on long-term outcome in these patients. We aimed to evaluate how patient-reported outcome differed between full surgery and placement of self-expanding metallic stents when treating primary benign esophageal perforations.

MATERIAL AND METHODS

Of 48 patients treated at our hospital in 2000-2015, 23 were alive and asked to answer three questionnaires. We used a short clinical questionnaire, the QLQ-OG25 from the European Organization for Research and Treatment of Cancer and a simplified quality-of-life instrument, the Check Your Health. Non-parametric statistics were used to evaluate differences between the two groups.

RESULTS

In all, 20 (87%) individuals (13 men, 64 years of age) responded. At survey, surgical patients had lost 13 kg of initial weight, compared to no weight loss in the self-expanding metallic stents group (p = 0.01). This involuntary weight loss worried patients according to the QLQ-OG25; otherwise patient-experience measures did not differ between groups. For quality of life, surgical patients scored significantly lower physical health, emotional well-being, social functioning, and overall quality of life after treatment, but after stenting no differences were seen.

CONCLUSIONS

In contrast to stenting, surgical treatment was associated with involuntary, and worrisome, weight loss as well as reduced quality of life. We therefore believe that self-expanding metallic stents should be used when possible in treating benign esophageal perforations.

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.

Thoracoscopic subtotal esophagectomy via a right thoracic cavity approach to treat an intractable fistula after 20 months from onset of an idiopathic esophageal rupture: A case report

An intractable fistula caused by idiopathic esophageal rupture is a rare but severe condition. In the present case, a 69-year-old man had been treated conservatively at another hospital for esophageal rupture but had developed an abscess in the left thoracic cavity due to an intractable fistula at the rupture site. He was referred to our hospital for treatment 19 months after the esophageal rupture. On admission, the intractable fistula was found to be continuous with an abscess in the left thoracic cavity. Preoperative continuous enteral nutrition was administered to improve the patient's nutritional status, and drainage was performed to reduce the size of the abscess. Then, to minimize the invasion of the intractable fistula, thoracoscopic subtotal esophagectomy was performed via a right thoracic cavity approach 20 months after the esophageal rupture. Preoperative management and thoracoscopic surgery via an opposite chest cavity approach was found to be safe and feasible for the intractable fistula caused by idiopathic esophageal rupture.

Surgical management of Boerhaave's syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients

BACKGROUND

spontaneous esophageal rupture (Boerhaave's syndrome) is a rare and challenging clinical condition.

OBJECTIVE

to evaluate the outcome of different surgical treatments for patients with Boerhaave's syndrome with an early diagnosis (< 24 h) and delayed diagnosis (> 24 h), using a retrospective cohort study in a tertiary referral center.

PATIENTS AND METHODS

eighty-eight patients with Boerhaave's syndrome who underwent surgical treatment were identified from March 1994 to March 2019 in the First Hospital of Shanxi Medical University. Subsequently, they were retrospectively divided into two groups according to time from symptom onset to diagnosis (group 1, < 24 h, n = 16; group 2, > 24 h, n = 72). Primary suture repair was used in group 1 and reinforcement with a vascular muscle flap was used in group 2, in order to reduce the incidence of fistula. Patients in group 2 were further divided into two subgroups according to reinforcement using diaphragmatic flaps (subgroup 1) or intercostal muscle flaps (subgroup 2).

RESULTS

the duration of hospitalization and stay in Intensive Care Unit (ICU) was significantly shorter in group 1 (p = 0.027 and p = 0.001). Group 1 had fewer postoperative esophageal leaks (p = 0.037) compared to group 2. Various aspects were compared in the two subgroups and the differences were not statistically significant (p > 0.05).

CONCLUSIONS

it is very important to establish an early diagnosis for patients with Boerhaave's syndrome. Early (< 24 h) and primary suture repair is superior to delayed (> 24 h) primary repair, even for those reinforced with vascular muscle flaps. Furthermore, repair reinforcement with different muscle flaps appears to render similar results for patients with delayed diagnosis.

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.