1
|
Hauge T, Abu Hejleh A, Nilsson M, Schröder W. Boerhaave syndrome. Br J Surg 2024; 111:znae216. [PMID: 39225330 DOI: 10.1093/bjs/znae216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/17/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Tobias Hauge
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Aram Abu Hejleh
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| | - Magnus Nilsson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| |
Collapse
|
2
|
Lunt AJ, Ariyarathenam A, Chan D, Humphreys L, Sanders G, Wheatley T, Berrisford RG. Transgastric drainage of the perforated esophagus: our experiences over 10 years. Dis Esophagus 2024; 37:doad049. [PMID: 37501521 DOI: 10.1093/dote/doad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/09/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
We first described the technique of transgastric drainage of esophageal injuries in 2008. The method establishes vacuum drainage of the lumen of the esophagus, while maintaining patency, effectively exteriorizing the perforation to allow healing. We summarize this technique and present our experiences from the largest published series of patients. Our unit has treated selected esophageal injuries with transgastric drainage for 10 years. Indications include perforations not amenable to primary repair and treatment failure following prior surgical intervention. A 36 French silastic chest drain is pulled through the abdominal and stomach wall and introduced into the esophagus so that it crosses the perforation. Gastropexy is performed. Mediastinal decontamination and drainage are performed as needed. Continuous suction of -10 cm water is applied. Leak resolution is assessed with weekly water-soluble swallows. For this retrospective observational study, we analyzed data for patients with esophageal perforation, between 2012 and 2022. Inpatient mortality and time to leak resolution were set as primary and secondary outcomes. Esophageal perforations were treated with transgastric drain in 35 patients, of whom 68% (n = 24) were men. Median age was 67 (26-84). Spontaneous perforations accounted for 60% (n = 21), 31% (n = 11) were iatrogenic and 6% (n = 2) were ischemic. Inpatient and 30-day mortality was 14% (n = 5). Among successful treatments, the median length to resolution of leak on imaging was 34.5 days (6-80). Transgastric drainage can successfully treat esophageal perforations, where primary repair is not feasible. The mortality rate of 14% and reduced morbidity compares favorably with other traditional methods of management for esophageal perforation.
Collapse
Affiliation(s)
- Adam J Lunt
- Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth, UK
| | | | - David Chan
- Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth, UK
| | - Lee Humphreys
- Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth, UK
| | - Grant Sanders
- Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth, UK
| | - Tim Wheatley
- Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth, UK
| | | |
Collapse
|
3
|
Gasanov MA, Danielyan SN, Chernousov FA, Gasanov AM, Rabadanov KM, Tatarinova EV, Barmina TG, Titova GP, Nevdah SK. [Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]. Khirurgiia (Mosk) 2024:21-28. [PMID: 38258684 DOI: 10.17116/hirurgia202401121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations. MATERIAL AND METHODS The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions. RESULTS Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery. CONCLUSION EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.
Collapse
Affiliation(s)
- M A Gasanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - Sh N Danielyan
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- National Institute of Health, Yerevan, Armenia
| | - F A Chernousov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A M Gasanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - K M Rabadanov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - E V Tatarinova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - T G Barmina
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - G P Titova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - S K Nevdah
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| |
Collapse
|
4
|
Fairbairn K, Worrell SG. Esophageal Perforation. Thorac Surg Clin 2023; 33:117-123. [PMID: 37045480 DOI: 10.1016/j.thorsurg.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
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.
Collapse
|
5
|
Chirica M, Bonavina L. Esophageal emergencies. Minerva Surg 2023; 78:52-67. [PMID: 36511315 DOI: 10.23736/s2724-5691.22.09781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.
Collapse
Affiliation(s)
- Mircea Chirica
- Department of Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France -
| | - Luigi Bonavina
- Medical School, Division of General Surgery, IRCCS San Donato Polyclinic, University of Milan, Milan, Italy
| |
Collapse
|
6
|
Delayed Esophageal Perforation Diagnosed 12 Years After Anterior Cervical Diskectomy and Fusion: A Case Report and Review of Current Literature. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202210000-00003. [PMID: 36227832 PMCID: PMC9575766 DOI: 10.5435/jaaosglobal-d-22-00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/25/2022] [Indexed: 11/05/2022]
Abstract
Esophageal perforation associated with anterior cervical diskectomy and fusion (ACDF) is a rare but serious complication. ACDF-related esophageal perforations can be acute or delayed. Delayed perforations more than 10 years after ACDF are exceedingly rare. Here, a delayed esophageal perforation discovered 12 years after a three-level ACDF is presented. This case highlights two main points. First, all diverticula after an ACDF warrant close clinical monitoring. Second, routine follow-up should be performed for patients with screw pullout to assist in early diagnosis of delayed esophageal perforation.
Collapse
|
7
|
Maher TR, Rech JVT, Pereira Ternes CM, dal Forno A, D’Avila A. Esophageal Perforation Following Radiofrequency Catheter Ablation for Atrial Fibrillation: A Conservative Approach. J Innov Card Rhythm Manag 2022; 13:5154-5158. [PMID: 36196233 PMCID: PMC9521727 DOI: 10.19102/icrm.2022.130904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/23/2022] [Indexed: 11/06/2022] Open
Abstract
Esophageal perforation following radiofrequency catheter ablation of atrial fibrillation (AF) is a rare and potentially deadly complication. Here, we report a case with successful conservative management of esophageal perforation following AF ablation demonstrating how surgery is not always required in properly selected patients.
Collapse
Affiliation(s)
- Timothy Richard Maher
- Harvard-Thorndike Arrhythmia Institute and Division of Cardiovascular Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA,Address correspondence to: Timothy Richard Maher, MD, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA.
| | | | | | - Alexander dal Forno
- Cardiac Arrhythmia Service—Hospital SOS Cardio, Florianópolis, Santa Catarina, Brazil
| | - André D’Avila
- Harvard-Thorndike Arrhythmia Institute and Division of Cardiovascular Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA,Cardiac Arrhythmia Service—Hospital SOS Cardio, Florianópolis, Santa Catarina, Brazil
| |
Collapse
|
8
|
Edholm D, Andersson RE, Frankel A. Esophageal perforations - a population-based nationwide study in Sweden with survival analysis. Scand J Gastroenterol 2022; 57:1018-1023. [PMID: 35400263 DOI: 10.1080/00365521.2022.2060051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality. METHOD All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality. RESULTS 879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide. CONCLUSIONS 90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.
Collapse
Affiliation(s)
- David Edholm
- Department of Surgery, Linköping University, Linköping, Sweden.,Department Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Roland E Andersson
- Futurum, Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
| | - Adam Frankel
- Discipline of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| |
Collapse
|
9
|
Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy. Ann Med Surg (Lond) 2022; 77:103623. [PMID: 35637995 PMCID: PMC9142553 DOI: 10.1016/j.amsu.2022.103623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/10/2022] [Accepted: 04/10/2022] [Indexed: 11/20/2022] Open
|
10
|
Modi HN, Shreshtha U, Patel U, Kotecha H, Patel MD, Dileep P. Esophageal Perforation After Anterior Cervical Surgery: A Case Report and Literature Review. Clin Spine Surg 2022; 35:49-58. [PMID: 34232154 DOI: 10.1097/bsd.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
SUMMARY AND BACKGROUND Esophageal perforation (EP) after anterior cervical surgery is a rare but potentially life-threatening condition. EP caused by malpositioned implants in cervical spine injury with multiple comorbidities is challenging to treat simultaneously. STUDY This was a case report study. PURPOSE OF STUDY The aim of this study was to present successful treatment of EP in a subluxated C5-C6 level with implant failure, infection, septicemia, and comorbidities. The aim was to emphasize the need for a multispecialty approach while treating serious complications. CASE A 72-year-old woman presented to the ER with a history of operated cervical spine a week ago and having breathlessness, fever, wound infection, and tracheostomy in situ. After primary investigations, the patient was initially treated in the intensive care unit, where bleeding from the tracheostomy site was noticed. Upon endoscopy, EP was diagnosed due to implant failure. She was operated for revision cervical spine surgery (drainage of pus with anterior and posterior cervical fixation) and percutaneous endoscopic gastrostomy tube insertion (esophageal diversion). On exploration of EP, a decision was made to perform conservative treatment as initial tag sutures did not hold due to infection. Postoperatively, the patient developed rectal bleed 3 times, which was ultimately treated with cecal bleed embolization. The infected cervical wound was managed with an open dressing. The patient was managed with intermittent assisted ventilation through tracheostomy postoperatively. Barium swallow at 10 weeks confirmed healing of EP and oral feed was started. Tracheostomy closure was performed once the wound had healed, and the patient was discharged with improved neurology at 12 weeks. CONCLUSIONS Perioperative problems after cervical surgery such as breathing difficulty, wound discharge, and worsening of neurology may lead to suspicion of underlying EP due to implant failure. Upper gastrointestinal endoscopy needs to be considered for a prompt diagnosis. Revision spine surgery with treatment of perforation simultaneously and maintenance of enteral nutrition through a percutaneous endoscopic gastrostomy tube with a multispecialty approach is recommended for this potentially life-threatening condition.
Collapse
Affiliation(s)
- Hitesh N Modi
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | - Utsab Shreshtha
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | - Udit Patel
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | | | | | - Pratibha Dileep
- Critical Care Medicine and Pulmonology, Zydus Hospital, Ahmedabad, Gujarat, India
| |
Collapse
|
11
|
Jung DH, Huh CW, Min YW, Park JC. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022; 95:281-290. [PMID: 34555386 DOI: 10.1016/j.gie.2021.09.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates. METHODS Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract. RESULTS Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself. CONCLUSIONS EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.
Collapse
Affiliation(s)
- Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Cheal Wung Huh
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med 2021; 53:29-36. [PMID: 34971919 DOI: 10.1016/j.ajem.2021.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
|
13
|
Kim Y, Kang S, Ahn JY. Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.
Collapse
|
14
|
García-Moreno V, Maiocchi K, Gómez-Quiles L, Villarin-Rodríguez A, Aliaga-Hilario E, Martínez-Hernández A, Abdelkader N, López E, Escrig-Sos J, Laguna-Sastre JM. Treatment of esophageal perforation: A review of our experience at a tertiary referral hospital spanning the past 19 years. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021; 87:405-410. [PMID: 34887217 DOI: 10.1016/j.rgmxen.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 02/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION AND AIMS Esophageal perforation is an uncommon event that is a medical/surgical emergency, with a 15-30% mortality rate. The aim of the present study was to communicate our experience in the management of esophageal perforation, evaluating the different strategies utilized, in an effort to establish measures to guide decision-making in selecting treatment. MATERIALS AND METHODS A retrospective descriptive study was conducted on patients diagnosed with esophageal perforation at our hospital center, within the time frame of 2000 and 2019. RESULTS Over the past 19 years, 15 patients were diagnosed with esophageal perforation. Surgical treatment was carried out in 80% of the cases. Primary closure, reinforced with plasty, was performed in 67% of the patients, of whom 62.5% had early diagnosis and a 100% survival rate. Diagnosis was late in 37.5% of the cases, with a 33.3% survival rate. Esophagectomy and gastric pull-up were performed on 25% of the patients, 66.6% of whom had early diagnosis and a 100% survival rate. In the 33.3% that had late diagnosis, the mortality rate was 100%. Esophagectomy, with cervical esophagostomy and feeding jejunostomy, was performed on one of the patients (8.3%) that had early diagnosis and a 100% survival rate. CONCLUSIONS The main survival predictor in esophageal perforation is the interval of time between the injury and its diagnosis, and in turn, the resulting treatment. Each patient with esophageal perforation should have individualized treatment to adequately manage the condition.
Collapse
Affiliation(s)
- V García-Moreno
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain.
| | - K Maiocchi
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - L Gómez-Quiles
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - A Villarin-Rodríguez
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - E Aliaga-Hilario
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - A Martínez-Hernández
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - N Abdelkader
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - E López
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - J Escrig-Sos
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - J M Laguna-Sastre
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| |
Collapse
|
15
|
Kim JD. Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study. J Cardiothorac Surg 2021; 16:291. [PMID: 34627308 PMCID: PMC8502388 DOI: 10.1186/s13019-021-01680-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/29/2021] [Indexed: 12/05/2022] Open
Abstract
Background Esophageal perforation and rupture (EPR) is a serious, potentially life-threatening condition. However, no treatment methods have been established, and data concerning factors affecting mortality are limited. This report presents the prognostic factors of mortality in EPR based on experience in the management of such patients. Methods For this retrospective analysis, 79 patients diagnosed as having EPR between 2006 and 2016 and managed at Gyeongsang National University Hospital were examined. The management method was determined in accordance with the location and size of the EPR, laboratory findings, and radiological findings. Thirty-nine patients were treated with surgery; and 40, with nonsurgical management. Results The most common cause of EPR was foreign body (fish bone or meat bone), followed by vomiting, iatrogenic causes, and trauma. Thirty-nine patients underwent primary repair of EPR, of whom 4 patients died. Forty patients underwent nonsurgical management, of whom 3 patients died. The remaining patients were discharged. Mortality correlated with the size of the EPR (> 25 mm) and the segmented neutrophil count percentage (> 86.5%) in the white blood cell test and differential. Conclusions The mortality risk was increased when the EPR size and the segmented neutrophil count percentage in the white blood cell test and differential was high. Delayed diagnosis, which was considered an important predictive factor in previous investigations, was not statistically significant in this study. Trial registration: Not applicable.
Collapse
Affiliation(s)
- Jong Duk Kim
- Department of Cardiothoracic Surgery, School of Medicine, Gyeonsang National University, Gyeongsang National University Hospital, Jin-Ju, 79 Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.
| |
Collapse
|
16
|
Camprodon G, Huguet F. Unrecognized digestive toxicities of radiation therapy. Cancer Radiother 2021; 25:723-728. [PMID: 34391649 DOI: 10.1016/j.canrad.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022]
Abstract
The aim of this article is to review unrecognized toxicities resulting from radiation therapy of digestive neoplasms. Due to their precocious occurrence, acute toxicities are well-known by radiation oncologist, and their treatment well-established. Thus, acute toxicities will not be described in this review. We will focus on incidence, diagnosis, and management of late and uncommon toxicities occurring in the digestive tract and digestive organs. Prevention, by respecting healthy tissues constraints, is the main tool to reduce incidence of those rare complications. Nonetheless, once installed, late toxicities remain a major burden in terms of quality of life and can even be life threatening. Hence, information and education about their diagnosis and management is important.
Collapse
Affiliation(s)
- G Camprodon
- Service d'Oncologie Médicale, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif, France.
| | - F Huguet
- Service d'Oncologie Radiothérapie, Hôpital Tenon, Sorbonne Université, AP-HP, Paris, France
| |
Collapse
|
17
|
Lin J, Jimenez CA. Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review. Semin Diagn Pathol 2021; 39:113-119. [PMID: 34176697 DOI: 10.1053/j.semdp.2021.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 11/11/2022]
Abstract
Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.
Collapse
Affiliation(s)
- Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
18
|
Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis. J Clin Med 2021; 10:jcm10112346. [PMID: 34071877 PMCID: PMC8197794 DOI: 10.3390/jcm10112346] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022] Open
Abstract
A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle-Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81-0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45-4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24-2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17-5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12-4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23-7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.
Collapse
|
19
|
Amirian A, Shahriarirad R, Mardani P, Salimi M. Non-operative management of bilateral contained thoracic esophageal perforation: a case report. BMC Surg 2021; 21:129. [PMID: 33711959 PMCID: PMC7953744 DOI: 10.1186/s12893-021-01121-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite profound advances in conservative management of esophageal perforation, patients' selection for this type of treatment requires expert clinical judgment. Surgical intervention has been historically introduced as the optimal management in multifocal ruptures. CASE PRESENTATION Here, we presented a 30-year-old man whose barium esophagogram confirmed bilateral perforations in the lower third of the esophagus contained in the mediastinum, and contrast drained back into the esophageal lumen. Concerning available contrast imaging studies and thoracic surgeons, conservative non-operative management was considered despite pneumomediastinum, a mild right-sided pleural effusion, and minimal leukocytosis. The patient was followed up for two months without any complications. CONCLUSIONS Bilateral and multifocal esophageal perforations can be managed conservatively provided that the leaks are confined to the mediastinum and drain back to the esophageal lumen, and other criteria for conservative management are met.
Collapse
Affiliation(s)
- Armin Amirian
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mardani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
20
|
Merzouqi B, El Bouhmadi K, Zouhair N, Oukessou Y, Rouadi S, Abada RL, Roubal M, Mahtar M. A rare cause of cervicomediastinal cellulitis: Oesophageal perforation case report. Ann Med Surg (Lond) 2021; 64:102195. [PMID: 33747496 PMCID: PMC7970054 DOI: 10.1016/j.amsu.2021.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 10/27/2022] Open
Abstract
Esophageal perforation following an impacted foreign body (FB) is a rare and potentially life-threatening condition. Early clinical suspicion and imaging are important for a targeted management to achieve a good outcome. Endoscopic extraction of esophageal FB is a good and safe treatment alternative while the surgical procedure remains a necessary option for many patients. We present the case of a 50 years old woman, with no relevant medical history, who accidently ingested a chicken bone during a meal causing mild dysphagia. The patient consulted immediately but was reassured after normal clinical examination. We received the patient 9 days later with severe dysphagia and cervicomediastinal cellulitis. The cervical CT scan showed the significant collection and the FB impacted in the cervical esophagus wall. A first endoscopic exploration drained the pus and allowed the placement of a nasogastric tube. However, the removal of the FB required an open cervical surgery with the evacuation of the collection and the suture of the esophageal perforation followed by the placement of a drainage tube. The patient medical state improved rapidly and no further incidents were noted. The diagnosis of esophageal FB should be meticulous in order to avoid such life-threatening complications.
Collapse
Affiliation(s)
- Boutaina Merzouqi
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Khadija El Bouhmadi
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Najib Zouhair
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Youssef Oukessou
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Sami Rouadi
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Redallah Larbi Abada
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Mohamed Roubal
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| | - Mohamed Mahtar
- Department of Otolaryngology, Head and Neck Surgery, 20 August 1953 Hospital, Casablanca, Morocco
| |
Collapse
|
21
|
Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process. Eur Arch Otorhinolaryngol 2021; 278:3613-3623. [PMID: 33417148 DOI: 10.1007/s00405-020-06569-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy. METHODS An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree. RESULTS This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies. CONCLUSION This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.
Collapse
|
22
|
Cerasoli B, Piro N, Mandelli C, Cesari M. Conservative management and healing of oesophageal perforation in a frail old woman. Age Ageing 2021; 50:265-266. [PMID: 32902607 DOI: 10.1093/ageing/afaa170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/07/2020] [Accepted: 06/23/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benedetta Cerasoli
- Specialisation School in Geriatrics and Gerontology, University of Milan, Milan, Italy
| | - Niccolò Piro
- Specialisation School in Geriatrics and Gerontology, University of Milan, Milan, Italy
| | - Clara Mandelli
- Geriatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Matteo Cesari
- Geriatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| |
Collapse
|
23
|
Allaway MGR, Morris PD, B Sinclair JL, Richardson AJ, Johnston ES, Hollands MJ. Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature. ANZ J Surg 2020; 91:1376-1384. [PMID: 33319446 DOI: 10.1111/ans.16501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature. METHODS A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed. RESULTS In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%. CONCLUSIONS We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.
Collapse
Affiliation(s)
- Matthew G R Allaway
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Paul D Morris
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Jane-Louise B Sinclair
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Arthur J Richardson
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Emma S Johnston
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Hollands
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| |
Collapse
|
24
|
Gao H, Li X, Wang C. Pharyngeal perforation following laryngoscopy in a patient with dysphagia secondary to diffuse idiopathic skeletal hyperostosis: A case report. Medicine (Baltimore) 2020; 99:e21526. [PMID: 32756197 PMCID: PMC7402913 DOI: 10.1097/md.0000000000021526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Dysphagia is a common presenting symptom in elderly people. Nevertheless, dysphagia resulting from diffuse idiopathic skeletal hyperostosis (DISH) of patients' cervical spine may be due to several factors. Despite computed tomography scan showing the size and shape of osteophytes, endoscopy may be necessary to exclude other intrinsic causes of dysphagia. Due to the anatomic variation of the pharynx secondary to DISH, patients undergoing endoscopy are at risk of perforation. Once perforation occurs, inappropriate treatments may finally lead to an irretrievable outcome. PATIENT CONCERNS A 58-year-old male patient with a 20-day history of dysphagia initially visited an ear-nose-throat (ENT) doctor. He had no neck pain and no other history of cervical disease. DIAGNOSIS This patient with dysphagia due to DISH of the cervical spine underwent laryngoscopy to exclude other causes. Pharyngeal perforation resulted as a complication of the procedure. INTERVENTIONS The patient underwent laryngoscopy and biopsy by an ENT doctor to exclude intrinsic causes. After the procedure, a perforation was formed on the posterior wall of the pharynx. Conservative management, that is, 1 week of nothing per oral, and 1 month of antibiotics, was adopted. On the 30th day after the examination, the patient was voluntarily discharged from the hospital and recommended to take antibiotics orally. OUTCOMES On the 56th day, the patient experienced fever and neck pain. Magnetic resonance imaging showed that the cervical vertebral bodies and spinal cord were infected. On the midday of the 60th day, the patient had a failed resuscitation and died. LESSONS DISH involving the cervical spine is a complicated cause of dysphagia. Due to the anatomic variation of the pharynx secondary to DISH, patients undergoing endoscopy are at risk of perforation. If other intrinsic causes of dysphagia have to be excluded with the aid of endoscopy, plain films and computed tomography images should be read carefully first. To minimize the risk of perforation, it is necessary to perform endoscopy extremely carefully, especially biopsy. Once perforation occurs, operative treatment may be more appropriate and effective.
Collapse
|
25
|
Sohda M, Kuwano H, Sakai M, Miyazaki T, Kakeji Y, Toh Y, Matsubara H. A national survey on esophageal perforation: study of cases at accredited institutions by the Japanese Esophagus Society. Esophagus 2020; 17:230-238. [PMID: 32415409 DOI: 10.1007/s10388-020-00744-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/26/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To get a clear view of the current state of treatment for esophageal perforation in Japan. Esophagus perforations are the most serious gastrointestinal tract perforations and are associated with high morbidity and mortality. The optimal treatment choice remains unknown. METHODS We conducted a retrospective clinical review of 182 esophageal perforation cases at 108 hospitals accredited by the Japanese Esophageal Society between January 2010 and December 2015. RESULTS We found that 20.9% of patients were incorrectly diagnosed initially. We observed mediastinum emphysema in 83.5% of patients, and serious abscess formations of the mediastinum and intrathoracic cavity in 38.6% and 29.6%, respectively. The lower esophagus was the most commonly perforated site (77.7%). Management of esophageal perforations included nonoperative treatment in 20 patients (11%) and operative treatment in 162 patients (89%). The overall mortality rate was 6.9%. The survivors had significantly shorter times from symptom appearance to visit (p = 0.0016), and from time to visit to diagnosis confirmation (p = 0.0011). Moreover, patients older than 65 years, white blood cells less than 3000/mm3, C-reactive protein > 10 mg/L, or abscesses in the thoracic cavity showed significantly higher mortality than others. CONCLUSION Shortening the time from onset to the start of treatment contributes to reduce mortality in patients with esophageal perforation. Moreover, strict medical treatment is necessary to lower the mortality rate of elderly patients with strong inflammation and abscesses in the thoracic cavity.
Collapse
Affiliation(s)
- Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yoshihiro Kakeji
- Division of Gastro-Intestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
26
|
Chen S, Shapira-Galitz Y, Garber D, Amin MR. Management of Iatrogenic Cervical Esophageal Perforations. JAMA Otolaryngol Head Neck Surg 2020; 146:488-494. [DOI: 10.1001/jamaoto.2020.0088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Sophia Chen
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Yael Shapira-Galitz
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - David Garber
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Milan R. Amin
- Department of Otolaryngology–Head and Neck Surgery, NYU Langone Health, New York, New York
| |
Collapse
|
27
|
Lampridis S, Mitsos S, Hayward M, Lawrence D, Panagiotopoulos N. The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions. J Thorac Dis 2020; 12:2724-2734. [PMID: 32642181 PMCID: PMC7330325 DOI: 10.21037/jtd-19-4096] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Savvas Lampridis
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Sofoklis Mitsos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Martin Hayward
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - David Lawrence
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Nikolaos Panagiotopoulos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| |
Collapse
|
28
|
Morais R, Vilas-Boas F, Silva M, Pereira P, Macedo G. Endoscopic Vacuum Therapy for Esophageal Perforation Treatment after Foreign Body Ingestion: Resolution after a Single Session. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:207-209. [PMID: 32509928 PMCID: PMC7250350 DOI: 10.1159/000503011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/29/2019] [Indexed: 06/11/2023]
Affiliation(s)
- Rui Morais
- *Rui Morais, Gastroenterology Department, Hospital de São João, Alameda Professor Hernâni Monteiro, PT–4200-319 Porto (Portugal), E-Mail
| | | | | | | | | |
Collapse
|
29
|
Rocha VAF, Reis WDC, Souza KDS, Stival RA, Nunes CDM, Santos WJD. LATE CONSERVATIVE TREATMENT FOR ESOPHAGEAL PERFORATION BY FOREIGN BODY. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2019; 32:e1467. [PMID: 31859920 PMCID: PMC6918763 DOI: 10.1590/0102-672020180001e1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 08/20/2019] [Indexed: 11/21/2022]
|
30
|
Hayakawa S, Mitsui A, Kato Y, Morimoto S, Watanabe K, Shamoto T, Wakasugi T, Kuwabara Y. Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report. Surg Case Rep 2019; 5:149. [PMID: 31641962 PMCID: PMC6805831 DOI: 10.1186/s40792-019-0711-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous esophageal rupture is a rare but serious disease with high mortality. Conservative treatment and endoscopic therapy have been reported, but surgical treatment is still a basic modality of therapy. In addition to thoracotomy, recent studies have reported treatment with thoracoscopic surgery and laparoscopic transhiatal repair. In this study, we report a patient who underwent laparoscopic transhiatal suture closure for spontaneous esophageal rupture with favorable postoperative course. We also discuss indication for laparoscopic surgery for spontaneous esophageal rupture. CASE PRESENTATION A 70-year-old man visited our hospital with chief complaints of epigastric pain and vomitus niger. He was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus by computed tomography and upper gastrointestinal (GI) series. At 11 h after the onset of symptoms, we performed laparoscopic transhiatal suture closure and lavage drainage. We performed transhiatal esophageal replacement using the 5-hole approach. We observed a perforation of 2 cm in diameter at the site of the rostral portion approximately 4 cm from the esophageal hiatus. All layers were closed with three stitches using 3-0 absorbable sutures. No perforation was observed in the thoracic cavity. The total operative time was 178 min, and total bleeding was 2 ml. He had no postoperative complications and was discharged on day 15 after the procedure. He received continuous proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by esophagogastroscopy. The patient was advised to improve his lifestyle and has shown no signs of recurrence over 2 years from the date of surgery. CONCLUSIONS Simple closure of all the layers using laparoscopic transhiatal simple closure was useful in the treatment of esophageal rupture as a less invasive approach for patients who meet the following conditions: stable general condition, intrathoracic perforation, and the perforation site is identified as the lower esophagus by pre-operative examination.
Collapse
Affiliation(s)
- Shunsuke Hayakawa
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan.
| | - Akira Mitsui
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Yuko Kato
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Shota Morimoto
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Kaori Watanabe
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Tomonari Shamoto
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Takehiro Wakasugi
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Yoshiyuki Kuwabara
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| |
Collapse
|
31
|
Chirica M, Kelly MD, Siboni S, Aiolfi A, Riva CG, Asti E, Ferrari D, Leppäniemi A, Ten Broek RPG, Brichon PY, Kluger Y, Fraga GP, Frey G, Andreollo NA, Coccolini F, Frattini C, Moore EE, Chiara O, Di Saverio S, Sartelli M, Weber D, Ansaloni L, Biffl W, Corte H, Wani I, Baiocchi G, Cattan P, Catena F, Bonavina L. Esophageal emergencies: WSES guidelines. World J Emerg Surg 2019; 14:26. [PMID: 31164915 PMCID: PMC6544956 DOI: 10.1186/s13017-019-0245-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023] Open
Abstract
The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.
Collapse
Affiliation(s)
- Mircea Chirica
- 1Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, NSW 2640 Australia
| | - Stefano Siboni
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Alberto Aiolfi
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Carlo Galdino Riva
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Emanuele Asti
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Davide Ferrari
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Ari Leppäniemi
- Department of Emergency Surgery, University Hospital Meilahti Abdominal Center, Helsinki, Finland
| | - Richard P G Ten Broek
- 5Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pierre Yves Brichon
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Yoram Kluger
- 7Department of General Surgery, Rambam Health Campus, Haifa, Israel
| | - Gustavo Pereira Fraga
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Gil Frey
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Nelson Adami Andreollo
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Federico Coccolini
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | | | | | - Osvaldo Chiara
- 12General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy
| | - Salomone Di Saverio
- 13Cambridge Colorectal Unit, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | | | - Dieter Weber
- 15Trauma and General Surgery, Royal Perth Hospital, Perth, Australia
| | - Luca Ansaloni
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | - Walter Biffl
- 16Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA USA
| | - Helene Corte
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Imtaz Wani
- 18Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Pierre Cattan
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Fausto Catena
- 20Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Luigi Bonavina
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| |
Collapse
|
32
|
|
33
|
Gregory J, Hecht J. Esophageal perforation: a research review of the anti-infective treatment. Int J Clin Pharm 2018; 40:953-962. [DOI: 10.1007/s11096-018-0680-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/22/2018] [Indexed: 01/15/2023]
|
34
|
Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma: A single-center review of 86 cases. J Trauma Acute Care Surg 2018; 85:541-548. [PMID: 29787546 DOI: 10.1097/ta.0000000000001973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM). METHODS This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation. RESULTS Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19-8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13-6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks. CONCLUSION Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration. LEVEL OF EVIDENCE Clinical Management Study, Level V evidence.
Collapse
|
35
|
Abstract
Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.
Collapse
|
36
|
Huh CW, Kim JS, Choi HH, Lee JI, Ji JS, Kim BW, Choi H. Treatment of benign perforations and leaks of the esophagus: factors associated with success after stent placement. Surg Endosc 2018; 32:3646-3651. [PMID: 29442243 DOI: 10.1007/s00464-018-6096-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 02/07/2018] [Indexed: 01/25/2023]
|
37
|
Eroglu A, Aydin Y, Yilmaz O. Thoracic perforations-surgical techniques. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:40. [PMID: 29610732 DOI: 10.21037/atm.2017.04.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.
Collapse
Affiliation(s)
- Atilla Eroglu
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Yener Aydin
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Omer Yilmaz
- Department of Gastroenterology, Medical Faculty, Ataturk University, Erzurum, Turkey
| |
Collapse
|
38
|
Abstract
Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms "non- iatrogenic", "esophageal", "trauma", "diagnosis", "management", and "prognosis". Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.
Collapse
|
39
|
Felmly LM, Kwon H, Denlinger CE, Klapper JA. Esophageal Perforation: A Common Clinical Problem with Many Different Management Options. Am Surg 2017. [DOI: 10.1177/000313481708300846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Esophageal perforation is a complex clinical entity that has multiple etiologies and variability in presentation, making it challenging to diagnose and treat. The mortality of esophageal perforation has improved because therapies have evolved. Whereas primary repair is the standard of care, multiple treatments may be employed successfully. We retrospectively reviewed all cases of suspected or confirmed esophageal perforation that were admitted to the thoracic surgery service at our institution between January 2011 and June 2016. We reviewed the charts of 61 patients. Twenty-three underwent primary repair, 13 underwent stent placement, 12 underwent drainage, 12 underwent medical management, and one underwent exclusion and diversion. All patients were included in the final analysis except the singular patient who underwent diversion. Overall mortality was 4.9 per cent. None of the studied variables were found to be associated with mortality (P > 0.05). Factors associated with choice of treatment were age (P < 0.0005), Charlson Index (P = 0.032), etiology (P < 0.0005), and location (P = 0.005). The application of different management options is based on a thorough understanding time course, patient anatomy, severity of presentation, and underlying disease process.
Collapse
Affiliation(s)
- Lloyd M. Felmly
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Hyejin Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Chadrick E. Denlinger
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jacob A. Klapper
- Division of Cardiothoracic Surgery, Duke University, Durham, North Carolina
| |
Collapse
|
40
|
Abstract
OPINION STATEMENT Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.
Collapse
|
41
|
Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children. J Pediatr Gastroenterol Nutr 2017; 64:e38-e43. [PMID: 28107284 DOI: 10.1097/mpg.0000000000001235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Surgery and conservative treatment of esophageal or gastric perforations are both often associated with poor results and carry a high morbidity and mortality rate. The aim of the present study was to evaluate the effectiveness and safety of using fully covered self-expending metallic stents (SEMS) in children with upper digestive leaks. METHODS This retrospective study reviewed all children with esophageal or gastric perforation who were treated with placement of an SEMS from January 2011 to January 2015. Closure of the perforation was the primary outcome measured. Secondary outcomes were the duration of antibiotic therapy and parenteral nutrition, adverse events, and length of hospitalization. RESULTS A total of 19 SEMS were placed in 10 patients (median age: 5.5 years; 5 girls) treated for postanastomotic leaks of esophageal atresia (n = 3), esophagogastroplasty (n = 4), resection of esophageal duplication (n = 1) or perforation during Toupet surgical dismantling (n = 1), and gastric rupture after Nissen surgery (n = 1). The perforation closed in 9 out of 10 patients in a mean of 36 days after stenting (range: 13-158 days). All patients received antibiotic therapy for an average of 17.5 days (3-109 days) and parenteral nutrition for 49 days (17-266 days). During a median follow-up of 8.9 months, 4 out of 9 sealed perforations developed stenosis, which was efficiently treated by endoscopic dilations in 2 patients and surgical redo in 2 patients with dilation-resistant stenosis. CONCLUSIONS Covered stents appear to be beneficial in closing esophageal perforations in children and can avoid the high morbidity of a surgical repair. Stenosis, however, occurred frequently after larger leakages.
Collapse
|
42
|
Virdis F, Chowdhury S, Nicol AJ, Navsaria PH. Conservative management of gunshot oesophageal injuries: A report of two consecutive exceptional cases. Afr J Emerg Med 2016; 6:144-147. [PMID: 30456081 PMCID: PMC6234164 DOI: 10.1016/j.afjem.2016.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/09/2016] [Accepted: 05/03/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Oesophageal trauma carries high mortality and morbidity. For penetrating intrathoracic oesophageal injury, surgical repair has been the standard for decades to avoid its devastating consequences. CASE REPORT Both patients presented with a thoracoabdominal gunshot wound and retained intraabdominal missile. Although there were no visible signs of perforation on oesophagoscopy or contrast swallow, the presence of an intraluminal bullet highly suggested a thoracic oesophageal injury. DISCUSSION Non-operative management of intrathoracic oesophageal perforation is controversial. Small perforations or contained leaks diagnosed within 24-48 h in a stable patient with no mediastinitis or empyema can be managed non-operatively with antibiotics and nasogastric feeds. These two case reports support the notion of selective non-operative management of asymptomatic patients with penetrating injury to the oesophagus.
Collapse
|
43
|
Gaucher S, Lococo F, Guinet C, Bobbio A, Magdeleinat P, Bouam S, Regnard JF, Alifano M. Indications and Results of Reconstructive Techniques with Flaps Transposition in Patients Requiring Complex Thoracic Surgery: A 12-Year Experience. Lung 2016; 194:855-63. [PMID: 27395425 DOI: 10.1007/s00408-016-9921-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 07/02/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Flap transposition is an infrequent but far from exceptional thoracic surgical procedure. The aim of this retrospective study was to report our experience in a referral unit of general thoracic surgery analyzing the early results after flap transposition. METHODS We retrospectively analyzed the clinical records, surgical notes, and postoperative results of a cohort of patients who underwent flap transposition in our unit from November 2000 to February 2013. RESULTS Overall, a surgical approach adopting flap reconstruction techniques was performed in 81 patients (54 males, 27 females) with a median age of 62 years (range 20-87). Flap transposition was necessary to reconstruct chest wall after resection for malignancy (27 patients), to repair intrathoracic viscera perforation (15 patients), and to fill residual cavities secondary to pulmonary/pleural infection (39 patients). A pedicle muscle flap was transposed in most of cases (64 pts, 79 %), while in the remaining 17 cases (11 %), an omental flap was used. There were no immediate postoperative complications, while three in-hospital deaths occurred due to respiratory or multiorgan failure. Among patients undergone flap transposition to fill a residual cavity, we observed a recurrent bronchopleural fistula in three patients (7.7 %); such patients were treated by repeat flap transposition (2 cases) and by repeat cavernostomy (1 case). CONCLUSION Flap transposition may be indicated as part of a multimodal treatment for severely ill patients requiring complex thoracic surgery.
Collapse
Affiliation(s)
- Sonia Gaucher
- Faculté de Médecine, Université Paris Descartes, Paris, France. .,Service de Chirurgie Thoracique, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France. .,Service de Chirurgie Générale, Plastique et Ambulatoire, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, 75 014, Paris, France.
| | - Filippo Lococo
- Unit of Thoracic Surgery, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Claude Guinet
- Service de Radiologie, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| | - Antonio Bobbio
- Service de Chirurgie Thoracique, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| | - Pierre Magdeleinat
- Service de Chirurgie Thoracique, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| | - Samir Bouam
- Département d'Information Médicale, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| | - Jean-François Regnard
- Faculté de Médecine, Université Paris Descartes, Paris, France.,Service de Chirurgie Thoracique, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| | - Marco Alifano
- Faculté de Médecine, Université Paris Descartes, Paris, France.,Service de Chirurgie Thoracique, AP-HP, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Paris, France
| |
Collapse
|
44
|
Zimmermann M, Hoffmann M, Jungbluth T, Bruch HP, Keck T, Schloericke E. Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients. Scand J Surg 2016; 106:126-132. [DOI: 10.1177/1457496916654097] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- M. Zimmermann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - M. Hoffmann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Jungbluth
- Department of Surgery, Klinikum Wolfsburg, Wolfsburg, Germany
| | - H. P. Bruch
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Keck
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - E. Schloericke
- Department of Surgery, Westküstenklinikum Heide, Heide, Germany
| |
Collapse
|
45
|
Zreik NH, Francis I, Ray A, Rogers BA, Ricketts DM. Blunt chest trauma: soft tissue injury in the thorax. Br J Hosp Med (Lond) 2016; 77:78-83. [DOI: 10.12968/hmed.2016.77.2.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Nasri H Zreik
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool L9 7AL
| | - Irene Francis
- Medical Student in the Department of Medicine and Dentistry, Brighton University, Brighton
| | - Arun Ray
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - Benedict A Rogers
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - David M Ricketts
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| |
Collapse
|
46
|
Esophageal perforation after anterior cervical surgery: a review of the literature for over half a century with a demonstrative case and a proposed novel algorithm. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:2037-49. [PMID: 26842882 DOI: 10.1007/s00586-016-4394-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To review relevant data for the management of esophageal perforation after anterior cervical surgery. METHODS A case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review. RESULTS The treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed. CONCLUSION Following anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.
Collapse
|
47
|
Deroy C, Corcuff JB, Billen F, Hamaide A. Removal of oesophageal foreign bodies: comparison between oesophagoscopy and oesophagotomy in 39 dogs. J Small Anim Pract 2015; 56:613-7. [DOI: 10.1111/jsap.12386] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 06/01/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023]
Affiliation(s)
- C. Deroy
- Department of Clinical Sciences (Companion Animals), College of Veterinary Medicine; University of Liège; 4000 Liège Belgium
- Veterinary Hospital Frégis, Small Animal Surgery; 94110 Arcueil France
| | | | - F. Billen
- Department of Clinical Sciences (Companion Animals), College of Veterinary Medicine; University of Liège; 4000 Liège Belgium
| | - A. Hamaide
- Department of Clinical Sciences (Companion Animals), College of Veterinary Medicine; University of Liège; 4000 Liège Belgium
| |
Collapse
|
48
|
Anderson RE, Wilcox S, Miller ES. A Rare but Lethal Cause of Chest Pain. J Emerg Med 2015; 49:698-702. [PMID: 26281817 DOI: 10.1016/j.jemermed.2015.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022]
Affiliation(s)
- R Eleanor Anderson
- Department of Emergency Medicine, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Susan Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
49
|
Conservative Management of an Iatrogenic Esophageal Tear in Kenya. Case Rep Surg 2015; 2015:102540. [PMID: 26257974 PMCID: PMC4516850 DOI: 10.1155/2015/102540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/28/2015] [Accepted: 07/01/2015] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
|
50
|
Emergent Esophagectomy for Esophageal Perforations: A Safe Option. Ann Thorac Surg 2015; 100:905-9. [PMID: 26188974 DOI: 10.1016/j.athoracsur.2015.04.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/06/2015] [Accepted: 04/09/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Esophageal perforation is an injury associated with high morbidity and mortality. Initial management ranges from observation to esophagectomy. The aim of this study was to evaluate the relative mortality and safety of emergent esophagectomy for acute esophageal rupture when compared with elective esophagectomies. METHODS We performed a retrospective review of a prospective esophagectomy database from a single institution from 1977 to 2013. Patients who were admitted for esophageal perforation and underwent esophagectomy were identified and compared with patients who underwent elective esophagectomy. RESULTS In all, 3,015 patients received an esophagectomy in elective and emergent settings; 90 esophagectomies were for acute injuries (52 for benign and 38 for malignant causes). A longer median length of stay was associated with emergent esophagectomy compared with elective esophagectomy (13 versus 10 days, p < 0.0001), and the complication rates were higher in the emergent group (51.1% versus 35.6%, p = 0.003). The survival rates at 30 days, 1 year, and 5 years after surgery were not significantly different between the emergent and nonemergent esophagectomy groups for patients with both benign and malignant underlying conditions. Within the emergent group, there was no difference in 30-day or 6-month survival based on benign or malignant causes, but a significant difference was seen at 1 year (85% for benign versus 65% for malignant, p = 0.025) and 5 years for survival (72% versus 21%, p < 0.001). CONCLUSIONS Emergent esophagectomy represents a safe option for the treatment of esophageal perforation, with mortality comparable to elective esophagectomy.
Collapse
|