Esophageal Perforations: New Perspectives and Treatment Paradigms

Sudden detection of pyriform sinus carcinoma during endoscopic retrograde cholangiopancreatography

Iatrogenic trauma and perforation are among the most concerning complications of endoscopic retrograde cholangiopancreatography (ERCP). A 76-year-old man presented for management of obstructive jaundice caused by pancreatic cancer. The ERCP was planned for further evaluation of pancreatic cancer and endoscopic biliary drainage. The ERCP scope could not pass because of resistance during the initial attempt to insert it through the pyriform sinus. After two attempts, mild bleeding occurred in the oral cavity, and the ERCP scope was successfully inserted in the esophagus. Tissue debris was observed in the esophagus; however, it was considered attributable to damage during insertion. Because passage was difficult, we placed a guidewire deep in the duodenum to ensure an accurate route and removed the ERCP scope. Then, we switched to direct-view esophagogastroduodenoscopy (EGD) and observed the pyriform sinus. EGD showed an irregular ridge and stenosis, which were determined to comprise a pyriform sinus tumor. Tissue fragments at the ERCP insertion site were retrieved for pathological examination. The ERCP scope was inserted using a guidewire, and biliary drainage was completed. When unexpected resistance is noticed, endoscopic manipulation should be stopped, and a detailed evaluation should be conducted. Endoscopists, particularly trainees with limited procedural experience, should be vigilant of these potential complications.

The Management of Esophageal Perforation: A Systematic Review

Esophageal perforation, a rare and serious condition, has seen a reduction in mortality from 30% to 15% over the last three decades due to advancements such as gastrointestinal stents, minimally invasive surgeries, and improved interventional radiology techniques. This review analyzes management strategies for esophageal perforation based on 14 English-language articles published from 2009 to 2024, primarily utilizing surveys and national database analyses. The management of esophageal perforation is complex, with challenges in diagnosis and treatment strategy. Despite surgery being the traditional treatment, the role of less invasive methods is growing. Effective management of esophageal perforation involves advanced imaging for diagnosis, hemodynamic stabilization, and a multidisciplinary approach to treatment, including surgical and non-surgical interventions. The evidence for different treatment outcomes remains limited, highlighting the need for comprehensive care involving thoracic surgery, interventional radiology, gastroenterology, and critical care in an intensive care unit setting.

A Case of an Atypical Presentation of Spontaneous Esophageal Rupture

Spontaneous esophageal rupture is an uncommon medical phenomenon that involves a sudden increase in intraesophageal pressure with negative intrathoracic pressure. Here, a 21-year-old female with no history of medical illness was admitted to our accident and emergency department with a one-day history of sudden retrosternal chest pain with other symptoms. There was no foreign body ingestion, vomiting, fever, cough, trauma, or recent procedures. Physical examination revealed a soft abdomen with epigastric tenderness and normal respiratory and cardiovascular examinations. The patient underwent a chest X-ray and a computed tomography scan of the neck and chest, which revealed retropharyngeal air extending to the mediastinum with anterior chest surgical emphysema. Oesophago-gastro-duodenoscopy revealed mild gastritis with no evidence of foreign body or esophagus injury. The patient was prescribed paracetamol, pantoprazole, and clindamycin. On follow-up, the patient was doing well with no active complaints. Conservative management of spontaneous esophageal rupture can result in good clinical outcomes with no requirement for additional interventions.

Isolated Blowout Distal Esophageal Injury From Blunt Thoraco-Abdominal Trauma Following Airbag Deployment in an Unrestrained Driver: A Case Report

Esophageal perforation from blunt trauma is rare. It is more frequently encountered in a penetrative mechanism where the cervical esophagus is most commonly injured. Blunt esophageal injury is challenging to diagnose with nonspecific findings clinically and radiologically within trauma settings. The main factors contributing to difficulty in early recognition are its scarce occurrence combined with nonspecific manifestations clinically on patient examination and radiologically on usual trauma computed tomography with intravenous contrast. We report a case of a 15-year-old young man who sustained an isolated distal blowout esophageal perforation as a result of blunt thoraco-abdominal trauma. Despite early primary surgical repair, a leak developed later on, which was managed with stent placement. The leak and associated sepsis were resolved, with an overall status improvement and no subsequent complications. We report an unusual presentation of esophageal perforation from blunt trauma, which was promptly diagnosed and managed with multiple modalities. This case highlights the importance of early recognition and management of esophageal injury and, furthermore, the role of multiple diagnostic and therapeutic modalities that lead to a successful outcome.

Two cases of cervical esophageal perforation treated by surgery

Cervical esophageal perforation is rare, but it is associated with high mortality. We describe two patients with cervical esophageal perforation that required surgical treatment. In both cases, good outcomes were evenly achieved, despite the presence of risk factors. A prompt diagnosis and treatment with collaboration between a surgeon and a gastroenterologist are important.

Hypopharynx injury in anterior cervical discectomy: Failure of surgical repair: Case report

Hypopharynx injury is a very rare complication of the anterior cervical spine surgery. It is imperative that the complication is managed appropriately with a multidisciplinary approach. In this case, 52 year old male patient underwent C3-4, C4-5, and C5-6 anterior cervical microdiscectomy with interbody fusion and anterior cervical plate surgery. Patient was discharged on the postoperative day 2 with full recovery. During the first follow up at week 1, the patient was found to have leakage of sputum from the incision line. Radiological imaging studies revealed a hypopharynx fistula. First prophylactic course of antibiotic therapy was given; upon persistent leakage from the incision site, it was deemed appropriate to perform hypopharynx repair surgery. However, surgical treatment was not successful, and leakage continued. Thereupon, a controlled sterile environment for secondary granulation was created. Eventually, the leakage was stopped with antibiotic and supporting treatment at the end of week 6. The patient was closely followed for one year. During the one year follow up, the patient did not have any complaints, such as discharge, nor he had any infections. The use of methylene blue in the diagnosis of esophagus perforation, which has high mortality and morbidity rate, provided great benefit. The risk of infection was prevented by creating a sterile environment with a mini colostomy bag.

Hypopharynx injury in anterior cervical discectomy: Failure of surgical repair: Case report

Hypopharynx injury is a very rare complication of the anterior cervical spine surgery. It is imperative that the complication is managed appropriately with a multidisciplinary approach. In this case, 52 year old male patient underwent C3-4, C4-5, and C5-6 anterior cervical microdiscectomy with interbody fusion and anterior cervical plate surgery. Patient was discharged on the postoperative day 2 with full recovery. During the first follow up at week 1, the patient was found to have leakage of sputum from the incision line. Radiological imaging studies revealed a hypopharynx fistula. First prophylactic course of antibiotic therapy was given; upon persistent leakage from the incision site, it was deemed appropriate to perform hypopharynx repair surgery. However, surgical treatment was not successful, and leakage continued. Thereupon, a controlled sterile environment for secondary granulation was created. Eventually, the leakage was stopped with antibiotic and supporting treatment at the end of week 6. The patient was closely followed for one year. During the one year follow up, the patient did not have any complaints, such as discharge, nor he had any infections. The use of methylene blue in the diagnosis of esophagus perforation, which has high mortality and morbidity rate, provided great benefit. The risk of infection was prevented by creating a sterile environment with a mini colostomy bag.

Medical management of esophageal perforation secondary to esophageal foreign bodies in 5 dogs

OBJECTIVE

To describe 5 cases of conservative management of substantial esophageal perforation in dogs.

SERIES SUMMARY

Five dogs presented with an esophageal foreign body (EFB) and resultant esophageal perforation. Clinical signs at presentation included tachycardia, tachypnea, and increased respiratory effort. Thoracic radiography was performed in all cases, and in each case, pleural and mediastinal effusion was present, suggesting esophageal perforation prior to endoscope-guided removal. A full thickness esophageal defect was visualized after foreign body removal in 4/5 cases. Treatment included IV crystalloid fluid therapy, IV antimicrobials, analgesia, and proton pump inhibitors in all cases. Two dogs had a percutaneous endoscopically placed gastrostomy feeding tube placed and 1 dog received prednisolone sodium succinate IV because of marked pharyngeal inflammation. Complications after EFB removal included pneumothorax (n = 2) and pneumomediastinum (n = 4). Four of the 5 dogs survived to discharge and did not have complications 2-4 weeks following discharge. One dog was euthanized as result of aspiration pneumonia following EFB removal.

NEW OR UNIQUE INFORMATION PROVIDED

Traditionally, surgical management of esophageal perforations has been recommended. This can be a costly and invasive procedure and requires a high degree of surgical skill. In this report, conservative management of substantial esophageal perforation in 5 dogs is described; medical management may be a viable treatment option in dogs with perforation of the esophagus due to EFB.

Tension hydropneumothorax as the initial presentation of Boerhaave syndrome

Boerhaave syndrome, a rare yet frequently fatal diagnosis, is characterized by the spontaneous transmural rupture of the esophagus. The classic presentation of Boerhaave syndrome is characterized by Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema. However, Boerhaave syndrome rarely presents with all the features of Mackler's triad; instead, the common presentation of Boerhaave syndrome includes chest or epigastric pain, severe retching and vomiting, dyspnea, and shock. These symptoms are typically misdiagnosed as cardiogenic in origin. Due to its atypical presentation, rarity, and mimicry of emergent conditions, diagnosis of Boerhaave syndrome is often delayed, resulting in a high mortality rate at the time of diagnosis and with a subsequent exponential increase in mortality if treatment is delayed by greater than 48 hours. Here, we report two atypical presentations of Boerhaave syndrome presenting as tension hydropneumothorax and review ten previously reported cases of Boerhaave syndrome presenting as tension hydropneumothorax. This review serves to raise clinician awareness about the expansive and elusive ways by which esophageal perforation may present, and thereby facilitate timely and potentially life-saving diagnosis.

Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center

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.

Accuracy of CT chest without oral contrast for ruling out esophageal perforation using fluoroscopic esophagography as reference standard: a retrospective study

PURPOSE

Esophageal perforation has a high mortality rate. Fluoroscopic esophagography (FE) is the procedure of choice for diagnosing esophageal perforation. However, FE can be difficult to perform in seriously ill patients.

METHODS

We retrospectively reviewed charts and scans of all patients who had undergone thoracic CT (TCT) without oral contrast and FE for suspicion of esophageal perforation at our hospital between October, 2010 and December, 2015. Scans were interpreted by a single consultant radiologist having > 5 years of relevant experience. Statistical analysis was performed using SPSS version 20. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TCT were computed using FE as reference standard.

RESULTS

Of 122 subjects, 106 (83%) were male and their median age was 42 [inter-quartile range (IQR) 29-53] years. Esophageal perforation was evident on FE in 15 (8%) cases. Sensitivity, specificity, PPV and NPV of TCT for detecting esophageal perforation were 100, 54.6, 23.4 and 100%, respectively. When TCT was negative (n = 107), an alternative diagnosis was evident in 65 cases.

CONCLUSION

Thoracic computed tomography (TCT) had 100% sensitivity and negative predictive value for excluding esophageal perforation. FE may be omitted in patients who have no evidence of mediastinal collection, pneumomediastinum or esophageal wall defect on TCT. However, in the presence of any of these features, FE is still necessary to confirm or exclude the presence of an esophageal perforation.

Evaluation of risk factors for perforated peptic ulcer

Background

The aim of this study was to evaluate the prediction factors for perforated peptic ulcer (PPU).

Methods

At St. Luke’s International Hospital in Tokyo, Japan, a case control study was performed between August 2004 and March 2016. All patients diagnosed with PPU were included. As control subjects, patients with age, sex and date of CT scan corresponding to those of the PPU subjects were included in the study at a proportion of 2 controls for every PPU subject. All data such as past medical histories, physical findings, and laboratory data were collected through chart reviews. Univariate analyses and multivariate analyses with logistic regression were conducted, and receiver operating characteristic curves (ROCs) were calculated to show validity. Sensitivity analyses were performed to confirm results using a stepwise method and conditional logistic regression.

Results

A total of 408 patients were included in this study; 136 were a group of patients with PPU, and 272 were a control group. Univariate analysis showed statistical significance in many categories. Four different models of multivariate analyses were conducted, and significant differences were found for muscular defense and a history of peptic ulcer disease (PUD) in all models. The conditional forced-entry analysis of muscular defense showed an odds ratio (OR) of 23.8 (95% confidence interval [CI]: 5.70–100.0), and the analysis of PUD history showed an OR of 6.40 (95% CI: 1.13–36.2). The sensitivity analysis showed consistent results, with an OR of 23.8–366.2 for muscular defense and an OR of 3.67–7.81 for PUD history. The area under the curve (AUC) of all models was high enough to confirm the results. However, anticoagulants, known risk factors for PUD, did not increase the risk for PPU in our study. The conditional forced-entry analysis of anticoagulant use showed an OR of 0.85 (95% CI: 0.03–22.3).

Conclusions

The evaluation of prediction factors and development of a prediction rule for PPU may help our decision making in performing a CT scan for patients with acute abdominal pain.

Thoracic perforations-surgical techniques

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.

Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation

BACKGROUND

Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches.

METHODS

We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy.

RESULTS

From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%.

CONCLUSIONS

Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.

Thoracic damage control surgery

The damage control surgery came up with the philosophy of applying essential maneuvers to control bleeding and abdominal contamination in trauma patients who are within the limits of their physiological reserves. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. This article aims to revise the various damage control techniques in thoracic organs that must be known to the surgeon engaged in emergency care. RESUMO A cirurgia de controle de danos surgiu com a filosofia de se aplicar manobras essenciais para controle de sangramento e contaminação abdominal, em doentes traumatizados, nos limites de suas reservas fisiológicas. Este conceito se estendeu para as lesões torácicas, onde manobras relativamente simples, podem abreviar o tempo operatório de doentes in extremis. Este artigo tem como objetivo, revisar as diversas técnicas de controle de dano em órgãos torácicos, que devem ser de conhecimento do cirurgião que atua na emergência.

Defining the gastroesophageal junction in trauma: Epidemiology and management of a challenging injury

BACKGROUND

Injuries to the gastroesophageal (GE) junction are infrequently encountered because of the high mortality of associated injuries. Consequently, there is a paucity of literature on the patient demographics and treatment options. The aim of this study was to examine the epidemiology, surgical management, and outcomes of these rare injuries.

METHODS

Patients presenting to LAC + USC Medical Center (January 2008 to August 2016) with traumatic esophageal or gastric injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification and 10th Rev. codes) were extracted from the trauma registry. Patient charts were reviewed, and all patients who sustained an injury to the GE junction were enrolled. Patient demographics, injury characteristics, procedures, and outcomes were analyzed.

RESULTS

Of the 238 patients who sustained an injury to the esophagus or stomach during the study period, 28 (12%) were found to have a GE junction injury. Mean age was 26 years (range, 14-57 years), 89% male. Mechanism of injury was penetrating in 96% (n = 27), the majority of which were gunshot wounds (n = 22, 81%). Most patients (n = 18, 64%) were taken directly to the operating room. Ten (36%) underwent computed tomography scan before going to the operating room, all demonstrating a GE junction injury. All patients underwent repair via laparotomy. One (4%) also required thoracotomy to facilitate delayed reconstruction. GE junction injuries were typically managed with primary repair (n = 22, 79%). Associated injuries were frequent (n = 26, 93%), and injury severity was high (mean Injury Severity Score, 25 [9-75]). Mortality was 25% (n = 7), and all patients required intensive care unit admission. Most did not require total parenteral nutrition (n = 25, 89%) or a surgically placed feeding tube (n = 26, 93%). Of the 13 patients who presented for clinical follow-up, all but one (n = 12, 92%) were eating independently by the first clinic visit.

CONCLUSION

GE junction injuries are uncommon and occur almost exclusively after penetrating trauma. Patients are severely injured with a high mortality rate and frequently have associated intracavitary injuries. Most can be fixed through the abdomen alone and do not require thoracotomy for repair. Despite the severity of injuries, the majority of survivors are eating independently by the first clinic visit.

LEVEL OF EVIDENCE

Epidemiological, level V.

A Rarely Seen Complication That Causes Increase in Morbidity in Tetraplegic Patients: Zenker Diverticula

Although spinal cord injury (SCI) damages the spinal cord, physiological changes due to SCI can affect many organs and systems of the human body. While respiratory problems are common following cervical SCI, dysphagia is a relatively uncommon secondary complication that occurs after cervical SCI. We report a case of recurrent aspiration pneumonia due to Zenker diverticulum in 26-year-old tetraplegic patient with a chronic history of silent aspirations and dysphagia contributing to functional disability.

Traumatic esophageal perforation by a self bougienage

The case report describes a 75-year-old female with esophageal perforation by a self bougienage. From a decade ago, she had performed an esophageal bougienage by herself with a 70 cm long self-made bougie whenever she suffered from food impaction. On the day of the accident, she went on an outing without carrying the bougie, she pushed a broken bough into her esophagus, eventually the bough perforated her thoracic esophagus. We found some food particles in a large mediastinal abscess cavity, and the perforated esophagus was repaired by interrupted sutures and reinforced with a pedicled intercostal musculopleural flap. We report an extremely rare case of esophageal perforation by a self bougienage.

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature

STUDY DESIGN

Multicenter retrospective case series and review of the literature.

OBJECTIVE

To determine the rate of esophageal perforations following anterior cervical spine surgery.

METHODS

As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis.

RESULTS

The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired.

CONCLUSIONS

Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.

Systematic review of the use of endo-luminal topical negative pressure in oesophageal leaks and perforations

Topical negative pressure is widely used in the management of superficial wounds. The use of this technology in the management of oesophageal perforations is becoming increasingly common. This systematic review aims to capture available evidence about its use in this setting. Medline and Embase were searched using MeSH terms and free text: esophageal perforation; esophageal injury; vacuum assisted closure; vacuum therapy device; esophagus; wounds penetrating; esophageal perforation; wound healing; negative pressure wound therapy. Searches were carried out between April and November 2015. Case series, cohort trials and controlled trials were included. Additional studies were found by hand searching reference lists. Eleven studies met the inclusion criteria with 180 patients. Nine of the studies were case series and two were retrospective comparisons of negative pressure with stents or clips. Healing of the perforation occurred in 163/179 patients and the overall mortality was 12.8%. Compared with published data on mortality from oesophageal perforation, the application of negative pressure appears to be beneficial. The studies are, however, limited to case series and retrospective cohort studies. The number of patients in each study is small and in the absence of randomized trials demonstrating a lack of bias firm conclusions cannot be made.

Incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation in children with benign strictures

OBJECTIVES

The purpose of this study is to investigate the incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation (FBD) in children with benign oesophageal strictures.

METHODS

Sixty-two children with benign oesophageal strictures underwent FBDs. Oesophageal rupture was categorized as intramural (type 1), transmural (type 2), or transmural with free leakage (type 3). The possible risk factors for oesophageal ruptures were analyzed.

RESULTS

One hundred and twenty-nine FBDs were performed in these patients. The oesophageal rupture rate was 17.1 % (22/129). The majority (21/22) of ruptures were type 1 and type 2, both were treated conservatively. Only one patient had a type 3 rupture and underwent oesophagoesophagostomy. The patient gender, age, and the length and cause of the stricture showed no significant effect on the rupture (P > 0.05). However, for the patients ≤2 years old, the initial balloon with a diameter ≥10 mm showed a higher oesophageal rupture rate than those <10 mm during the first session (P = 0.03).

CONCLUSIONS

Although the oesophageal rupture rate in children was 17.1 %, the type 3 rupture rate was 0.8 %, which usually requires aggressive treatment. For children ≤2 years old, the initial balloon diameter should be <10 mm in the first session for decreasing the risk of oesophageal rupture.

KEY POINTS

• The oesophageal rupture rate following balloon dilatation in children was 17.1 %. • The incidence of transmural rupture with free leakage is very low. • Only transmural rupture with free leakage needs aggressive treatment. • For children ≤2 years, the initial balloon diameter should be <10 mm.

Traumatic isolated perforation of lower oesophagus

One of the rarest cases of non-iatrogenic oesophageal perforation is falling from height. We report a case of a 26 year old man with oesophageal perforation resulting from a fall of 12 meter height. A pneumomediastinum in the absence of a pneumothorax and contrast extravasation from the oesophagus on CT evoked a perforation of the aerodigestive tract. No other injuries were seen. A non-operative management was pursued with good outcomes.

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

Background and Aims:

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

Patients and Methods:

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

Results:

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

Conclusion:

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

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.

Aortic Pseudoaneurysm Secondary to Mediastinitis due to Esophageal Perforation

Esophageal perforation is a condition associated with high morbidity and mortality rates; it requires early diagnosis and treatment. The most common complication of esophageal rupture is mediastinitis. There are several case reports in the literature of mediastinitis secondary to esophageal perforation and development of aortic pseudoaneurysm as a complication. We report the case of a patient with an 8-day history of esophageal perforation due to foreign body (fishbone) with mediastinitis and aortic pseudoaneurysm. The diagnosis was made using Computed Tomography (CT) with intravenous and oral water-soluble contrast material. An esophagogastroduodenoscopy did not detect the perforation.

Cadaveric Analysis of Posterior Pharyngoesophageal Wall Thickness: Implications for Anterior Cervical Spine Surgery

STUDY DESIGN

A cadaveric study.

OBJECTIVE

To investigate possible variations of posterior pharyngoesophageal (PE) wall thickness in the horizontal plane and their implications for anterior spine surgery.

SUMMARY OF BACKGROUND DATA

Lower cervical levels (C5-7) are most commonly involved in cases of PE injury, and PE wall thickness could be one of the proposed reasons for the high incidence of PE injuries at these levels. The purpose of this study was to document thickness variations of the posterior PE wall at different cervical spine levels, because the study could provide valuable anatomical information that could reduce iatrogenic injuries caused by retractors or instrumentation.

METHODS

Thirteen formaldehyde-fixed cadaveric specimens were included in current study. PE specimens were harvested from epiglottis to suprasternal notch within 2 months of formaldehyde fixation and sectioned axially. Four slices corresponding to the superior and inferior borders of thyroid cartilage, cricoid cartilage, and 2  cm below cricoid cartilage were sectioned. Posterior PE wall thickness was measured at three zones as follows: median, lateral, and paramedian. Posterior PE wall thicknesses were measured by a pathologist.

RESULTS

Based on one-way ANOVA, posterior PE wall thickness showed several significantly different variations depending on cervical level and horizontal plane. PE walls were thinnest at the level of cricoid cartilage (P < 0.05). This difference was more pronounced in the median zone, because of thickness variations in the muscular layer (P < 0.001).

CONCLUSION

The posterior PE wall was thinnest in the median zone at the cricoid cartilage level. Variations in muscle layer thickness caused PE wall thickness differences. The smaller wall thickness at the level of the cricoids cartilage and in the midline zone may place it at higher risk of injury, and special care should be taken during dissection, retraction, and instrument placement.

LEVEL OF EVIDENCE

3.

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

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.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Missed diagnosis of oesophageal perforation in ankylosing spondylitis cervical fracture: Two case reports and literature review

Oesophageal perforation after blunt injury cervical fracture in patients with ankylosing spondylitis (AS) is rarely reported. The early diagnosis of oesophageal perforation is extremely important. We present two cases of patients with AS who sustained cervical fracture dislocation and spinal cord injury. The ossified sharp fragments caused oesophageal perforation, and the delayed diagnoses had serious consequences. Oesophageal perforation should be suspected in patients with AS and cervical fracture if bone fragments are pressing against the oesophagus and a gas shadow is visible around the fracture site on computed tomography imaging.

Penetrating Cervical Trauma. "Current Concepts in Penetrating Trauma", IATSIC Symposium, International Surgical Society, Helsinki, Finland, August 25-29, 2013

Patients with penetrating wounds to the neck present with overt symptoms and/or signs or are asymptomatic or modestly/moderately symptomatic. With overt symptoms and/or signs, immediate resuscitation and an emergency operation are appropriate. Asymptomatic patients or those with modest or moderate symptoms and/or signs undergo observation or a diagnostic evaluation to avoid the 45% "negative" exploration rate documented in the past (denominator = all patients). Asymptomatic patients with penetration of the platysma muscle, but no signs of a visceral or vascular injury, should undergo serial physical examinations every 6-8 for 24-36 h before discharge. Noncontrast CT does not add to the accuracy of serial physical examinations. In stable patients with a variety of modest/moderate symptoms or signs possibly related to an injury to the carotid artery, CT-arteriography has become the diagnostic modality of choice. Patients with possible injuries to the cervical esophagus are often still evaluated with a Gastrografin swallow and, if needed, a "thin" barium swallow prior to fiberoptic esophagoscopy. CT-esophagograms are likely to replace these time-honored studies in the near future. Over 85% of patients with injuries to the trachea present with overt symptoms or signs, while the remainder have historically been evaluated with laryngoscopy and fiberoptic bronchoscopy. Again, cervical multislice CT is likely to replace these studies. Operative repair of the carotid artery with 6-0 polypropylene sutures requires heparinization and shunting on rare occasions. Both the trachea and esophagus are repaired with 3-0 absorbable sutures, and tracheostomy and esophageal diversion are used in only large and/or complex injuries. Sternal head or sternocleiodomastoid interposition flaps are used when combined visceral and vascular injuries are present.

A Successful Strategy for Surgical Treatment of Boerhaave's Syndrome Sans Thoracotomy

Boerhaave's syndrome is a rare life threatening condition that is often misdiagnosed and fatal if not treated promptly. While the gold standard is early surgical intervention, recent studies have showed success with conservative management. We report a case of Boerhaave's syndrome that was managed conservatively by decompressive gastrostomy, feeding jejunostomy, bilateral intercostal drainage tubes with added proximal diverting cervical esophagostomy. The patient recovered completely and stoma closure was done two months later.

Intrathoracic esophageal rupture distal to the carina after blunt chest trauma: Case-report

Introduction

Esophageal rupture caused by blunt chest trauma is a very rare entity, with an incidence of 0.001%. Eighty two percent of the esophageal perforation secondary to blunt chest trauma occur above the level of the carina, with the lowest reported incidence in the intrathoracic region distal to the carina.

Presentation of case

We report on the case of a 48-year-old Hispanic male with intrathoracic esophageal rupture. Exploration revealed a right lateral, mid esophageal, longitudinal 1.5 cm perforation. The defect was repaired using a double-layered primary closure reinforced with an intercostal muscle flap. The patient tolerated the procedure and the recovery was complicated by a pneumonic process which was treated accordingly. No leakage was found.

Discussion

A five-year retrospective review (2009–2013) at our institution identified 5586 trauma cases with only one case with esophageal rupture. This represents a 0.0002% of incidence of blunt esophageal rupture. This estimate is consistent with what has been previously reported in the medical literature. Our case represents a uniquely rare presentation of traumatic esophageal rupture due to the underline mechanism of injury and its anatomical location. A high index of suspicion and early intervention are critical in assuring a favorable outcome.

Conclusion

Diagnosis and surgical intervention with primary repair completed in the first twenty-four hours after presentation is fundamental to achieve a good outcome after esophageal rupture.

Right-sided hydropneumothorax as a presenting symptom of Boerhaave's syndrome (spontaneous esophageal rupture)

Boerhaave's syndrome, or spontaneous esophageal rupture, is a rare condition that classically presents with Mackler's triad of vomiting, subcutaneous emphysema, and severe sudden onset of chest pain and requires immediate medical attention. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. Less than 10% of patients have bilateral effusions, and few patients have a right-sided pleural effusion only. We present the case of a 59-year-old man with spontaneous esophageal rupture. His clinical presentation is of interest since he had no inciting event for spontaneous esophageal rupture and had a delayed presentation with a right-sided hydropneumothorax.

Full-thickness esophageal perforation after fluoroscopic balloon dilation: incidence and management in 820 adult patients

OBJECTIVE

The purpose of this study is to investigate the incidence, management, and outcomes of esophageal perforation after fluoroscopic balloon dilation in 820 adult patients with esophageal diseases.

MATERIALS AND METHODS

Between December 1990 and April 2014, a total of 820 adult patients (age range, 21-93 years) underwent 1869 fluoroscopic balloon dilation sessions (mean, 2.3 sessions/patient; range, 1-29 sessions/patient) for esophageal diseases. We retrospectively reviewed the prospectively collected medical records and images of these patients and collected the data of patients who developed esophageal perforations after fluoroscopic balloon dilation.

RESULTS

During this period, 12 patients (six men and six women; mean age, 51 years; age range, 28-69 years) developed perforations. The perforation rate was 1.5% per patient and 0.6% per dilation. Among the first eight patients, four who were treated with surgery had perforations 2 cm or larger, and the other four who underwent fasting, parenteral alimentation, and treatment with antibiotics had perforations smaller than 2 cm. The last four patients underwent stent placement immediately after the diagnosis, regardless of the perforation's size. The median hospital stay was 11.5 days.

CONCLUSION

Fluoroscopic balloon dilation of esophageal diseases is a safe procedure with a low perforation rate. A perforation size greater than 2 cm is considered large and requires aggressive treatment. Although the number of patients with esophageal perforation we treated is relatively small and further clinical trials are needed, temporary stent placement seems to be an initial choice in the management of esophageal perforations after fluoroscopic balloon dilation.

The effects of ankaferd blood stopper on the recovery process in an experimental oesophageal perforation model

BACKGROUND

Oesophageal perforation is a life-threatening pathology that is generally treated conservatively; however, surgical procedures are frequently performed. A topical haemostatic agent, Ankaferd Blood Stopper (ABS), also has beneficial wound-healing effects.

AIMS

This study aimed to determine the effects of ABS following experimental oesophageal perforations.

STUDY DESIGN

Animal experiment.

METHODS

The experimental rats were classified into 6 groups (with 7 rats in each group). Pairs of groups (primary repair alone and primary repair + ABS) were terminated in the 1(st), 2(nd), and 3(rd) weeks following injury. The oesophageal perforations, which were 8-10 mm in length, were created using a nasogastric tube. The perforation sites were repaired with a 6-0 polyglactine thread in the primary repair groups. Additionally, ABS was sprayed over the perforation site in the treatment groups. Each oesophagus was evaluated histopathologically.

RESULTS

There were fewer microabscesses and areas of necrosis in the ABS groups compared with the primary repair groups. The histopathological evaluation revealed that the ABS groups had less inflammation and more re-epithelisation compared to the primary repair groups (p=0.002 and p=0.003, respectively). Fibrosis in the ABS groups was moderate in the 2(nd) week and mild in the 3(rd) week. Comparing the groups with respect to the time intervals, only the 1(st) week groups showed a significant difference in terms of re-epithelialisation (p=0.044).

CONCLUSION

Topical ABS application on the repaired experimental oesophageal perforation regions led to positive wound-healing effects compared with the rats that were administered the primary repair alone.

Rare cause of oesophagus perforation

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Oesophagus perforation is a very serious clinical event.

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Mortality rates increase because inexperienced physicians cannot make a diagnosis.

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Although there is no consensus in literature on surgical treatment choices.

INTRODUCTION

Oesophagus perforations, which are generally caused by iatrogenic injuries, are a serious clinical event. There are still high rates of mortality and morbidity and there is no gold standard of surgical treatment.

PRESENTATION OF CASE

The case is here presented of a 54-year old female with complaints of dysphagia after having swallowed a bone in food, who was determined with oesophagus perforation on CT examination.

DISCUSSION

Oesophagus perforation generally occurs secondary to interventional procedures and rarely develops associated with foreign bodies. Treatment depends on the perforation site and dimension.

CONCLUSION

While conservative primary surgical repair may be chosen for cervical lesions, more aggressive approaches such as resection and delayed reconstruction are recommended for thoracic lesions. Early determination and appropriate treatment are life-saving.

Blunt trauma patient with esophageal perforation

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient.