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Ashbrook MJ, Theeuwen HA, Cheng V, Harano T, Wightman SC, Atay SM, Rosenberg GM, Udelsman BV, Kim AW. Initial management and outcomes of nonmalignant esophageal perforations: A Nationwide Inpatient Sample analysis. Surgery 2024; 176:1115-1122. [PMID: 39025691 DOI: 10.1016/j.surg.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/11/2024] [Accepted: 06/02/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Management of esophageal perforation includes open surgery, minimally invasive surgery, and endoscopic stent placement. This study analyzed initial treatment and the associated short-term outcomes. METHODS A retrospective study using the National Inpatient Sample between October 2015 and December 2019 identified adults >18 years with esophageal perforation undergoing an initial nonelective esophageal procedure categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement. Patients with esophageal cancer were excluded. Baseline characteristics and the van Walraven-weighted Elixhauser Comorbidity Index were identified. Outcomes included in-hospital mortality and postintervention complications. Univariable and multivariable Cox regression was used to compare in-hospital survival. RESULTS In total, 3,345 patients met inclusion criteria: the median age was 62 years (interquartile range 50-72 years), and 1,310 (39%) were female. Open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%) with no differences in van Walraven-weighted Elixhauser Comorbidity Index or mortality. Patients who underwent minimally invasive surgery had a greater proportion of gastrointestinal complications (P = .006); otherwise, there were no differences in postintervention complications. In total, 380 (11%) patients died and were significantly older, with greater van Walraven-weighted Elixhauser Comorbidity Index, and had more postintervention complications. Univariable Cox regression identified age (hazard ratio 1.95, P < .001), van Walraven-weighted Elixhauser Comorbidity Index (hazard ratio 1.06, P < .001), stent placement (hazard ratio 1.93, P = .045), and transfer from a health facility (HR 2.40, P = .049) as associated with decreased in-hospital survival. Multivariable Cox regression revealed age (hazard ratio 1.041, P < .001) and van Walraven-weighted Elixhauser comorbidity index (hazard ratio 1.055, P < .001) were associated with decreased in-hospital survival. CONCLUSION Patients with esophageal perforation had an 11% in-hospital mortality rate and significant associated complications regardless of intervention. Increasing age and comorbidities are associated with poorer in-hospital survival.
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Affiliation(s)
- Matthew J Ashbrook
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Hailey A Theeuwen
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Vincent Cheng
- Division of Bariatric Surgery, Kaiser Permanente - Ontario Medical Center, Ontario, CA
| | - Takashi Harano
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Sean C Wightman
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Scott M Atay
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Graeme M Rosenberg
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Brooks V Udelsman
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA
| | - Anthony W Kim
- Department of Surgery, University of Southern California, Los Angeles, CA; Division of Thoracic Surgery, University of Southern California, Los Angeles, CA.
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de Oliveira AT, Barreira MA, da Cunha Parente Júnior JW, Junior JRLH, Ribeiro JBES, de Azevedo OGR, de Vasconcelos PRC. Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study. Surg Endosc 2024; 38:2142-2147. [PMID: 38448621 PMCID: PMC10978687 DOI: 10.1007/s00464-024-10755-5] [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] [Received: 12/14/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Traumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP. METHODS Retrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome. RESULTS Patients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant. CONCLUSION E-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.
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Affiliation(s)
- Alessandrino Terceiro de Oliveira
- Department of Digestive Endoscopy, Dr. José Frota Institute, Fortaleza, CE, Brazil.
- Department of Surgery, Federal University of Ceara, Fortaleza, CE, Brazil.
- Department of Digestive Endoscopy, General Hospital of Fortaleza, Fortaleza, CE, Brazil.
- Department of Surgery, Federal University of Ceara, 1608 N. Prof Costa Mendes St, 3rd Floor, Fortaleza, CE, 60416-200, Brazil.
| | - Márcio Alencar Barreira
- Department of Surgery, Federal University of Ceara, Fortaleza, CE, Brazil
- Department of Surgery, Dr. José Frota Institute, Fortaleza, CE, Brazil
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3
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Donado Jimenez MJ, Jimenez MC, Cubas R. Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation. BMJ Case Rep 2024; 17:e258060. [PMID: 38216165 PMCID: PMC10806898 DOI: 10.1136/bcr-2023-258060] [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: 01/14/2024] Open
Abstract
Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.
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Affiliation(s)
| | - Maria Carolina Jimenez
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert Cubas
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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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.
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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
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Zethof S, Borstlap C, Vroomans M, Groenendijk M. Pneumomediastinum complicating diabetic ketoacidosis. BMJ Case Rep 2023; 16:e255018. [PMID: 37137549 PMCID: PMC10163478 DOI: 10.1136/bcr-2023-255018] [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: 05/05/2023] Open
Abstract
Pneumomediastinum is an uncommon finding in patients with diabetic ketoacidosis (DKA) and may occur spontaneously or secondary to an effort rupture of the oesophagus. Excluding oesophageal rupture is important, as delaying treatment increases the risk of mortality. We discuss a case of DKA complicated by vomiting, pneumomediastinum, pneumopericardium and air in the epidural space. Instead of fluoroscopic oesophagography, chest CT was used to investigate oesophageal rupture. We present an overview of case reports and retrospective studies illustrating the utility of chest CT in the investigation of oesophageal rupture over fluoroscopic oesophagography.
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Affiliation(s)
- Siem Zethof
- Intensive Care, Alrijne Zorggroep, Leiderdorp, Netherlands
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Cheng YF, Chen CM, Chen YL, Cheng CY, Huang CL, Hung WH, Wang BY. The outcomes of thoracoscopic decortication between fungal empyema and bacterial empyema. BMC Infect Dis 2023; 23:8. [PMID: 36609233 PMCID: PMC9817236 DOI: 10.1186/s12879-022-07978-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Fungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were no studies that reported the outcomes of surgery for fungal empyema. METHODS This study is a retrospective analysis in a single institute. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. We separated the patients into a fungal empyema group and a bacterial empyema group according to culture results. We used 1:3 propensity score matching to reduce selection bias. RESULTS There were 1197 empyema patients who received surgery. Of these, 575 patients showed positive culture results and were enrolled. Twenty-eight patients were allocated to the fungal empyema group, and the other 547 patients were placed in the bacterial empyema group. Fungal empyema showed significantly longer intensive care unit stay (16 days vs. 3 days, p = 0.002), longer median ventilator usage duration (20.5 days vs. 3 days, p = 0.002), longer hospital stay duration (40 days vs. 17.5 days, p < 0.001) and a higher 30-day mortality rate (21.4% vs. 5.9%, p < 0.001). Fungal empyema revealed significantly poorer 1-year survival rate than bacterial empyema before matching (p < 0.001) but without significant difference after matching. CONCLUSIONS The fungal empyema patients had much worse surgical outcomes than the bacterial empyema patients. Advanced age and high Charlson Comorbidity Index score are independent predictors for poor prognosis. Prompt surgical intervention combined with the use of antifungal agents was the treatment choice for fungal empyema.
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Affiliation(s)
- Ya-Fu Cheng
- grid.413814.b0000 0004 0572 7372Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, No. 135 Nanxiao St., 500 Changhua City, Taiwan
| | - Chun-Min Chen
- grid.413814.b0000 0004 0572 7372Big Data Center, Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yi-Ling Chen
- grid.413814.b0000 0004 0572 7372Surgery Clinical Research Center, Changhua Christian Hospital, Changhua City, Taiwan
| | - Ching-Yuan Cheng
- grid.413814.b0000 0004 0572 7372Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, No. 135 Nanxiao St., 500 Changhua City, Taiwan
| | - Chang-Lun Huang
- grid.413814.b0000 0004 0572 7372Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, No. 135 Nanxiao St., 500 Changhua City, Taiwan
| | - Wei-Heng Hung
- grid.413814.b0000 0004 0572 7372Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, No. 135 Nanxiao St., 500 Changhua City, Taiwan
| | - Bing-Yen Wang
- grid.413814.b0000 0004 0572 7372Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, No. 135 Nanxiao St., 500 Changhua City, Taiwan ,grid.260542.70000 0004 0532 3749Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan ,grid.411641.70000 0004 0532 2041School of Medicine, Chung Shan Medical University, Taichung, Taiwan ,grid.412019.f0000 0000 9476 5696School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ,grid.260542.70000 0004 0532 3749Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, Taiwan ,Center for General Education, Ming Dao University, Changhua City, Taiwan
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7
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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.
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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
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Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, Worrell SG, Ho VP, Argote-Greene LM, Towe CW. Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis. Ann Thorac Surg 2022; 115:1378-1384. [PMID: 35921860 DOI: 10.1016/j.athoracsur.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.
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Affiliation(s)
- Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Anuja Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Phillip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Moletta L, Pierobon ES, Capovilla G, Valotto G, Gavagna L, Provenzano L, Zanchettin G, Salvador R, Costantini M, Merigliano S, Valmasoni M. Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center. J Trauma Acute Care Surg 2022; 92:108-116. [PMID: 34561399 DOI: 10.1097/ta.0000000000003417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions. METHODS All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and >5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention. RESULTS Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p < 0.01), in-hospital mortality (p = 0.01), ICU admission (p < 0.01), need for surgical treatment (p < 0.01), and need for reintervention (p = 0.02). CONCLUSION Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation. LEVEL OF EVIDENCE Management, Therapeutic/Care; level IV.
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Affiliation(s)
- Lucia Moletta
- From the Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
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10
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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.
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11
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Scutaru TT, Kupcsulik P, Sahin P, Szücs Á. From eosinophilic esophagitis to esophagus perforation: clinical management strategies. Arch Clin Cases 2021; 6:37-47. [PMID: 34754907 PMCID: PMC8565702 DOI: 10.22551/2019.23.0602.10152] [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] [Indexed: 11/25/2022] Open
Abstract
Introduction: Eosinophilic esophagitis is a chronic, antigen-mediated inflammation of the esophagus. The disease is most common at young ages, with a male to female ratio of 3:1. Eosinophilic granulocyte infiltration induced by oral/aeroantigens in the esophagus, mucosal hyperplasia, and fibrosis of the subepithelial layers can lead to constriction, dysphagia, blockage and esophageal perforation. Case report: A 36-year-old male patient presented in June 2016 with dysphagia as the main complaint. Workup with plain chest radiography with a water soluble contrast swallow did not reveal any pathological lesions. The patient's swallowing difficulties persisted and one year later he was treated by esophageal food bolus impaction (EFBI) in another institution. A new plain chest radiography with a water soluble contrast swallow confirmed a 9 cm long stricture in the middle third with an EFBI. During gastroscopy, a clinical picture of eosinophilic esophagitis was noted, with partially destroyed foreign body at 25cm and iatrogenic perforation at the upper half of the esophagus. After preoperative intensive care unit valuation and preparation, transhiatal esophagectomy without thoracotomy and cervical esophagostomy was performed with pyloromyotomy and feeding jejunostomy. The postoperative period was uneventful. Histological examination confirmed the presence of strictures and perforation on the background of eosinophilic esophagitis. Elective esophageal reconstruction with cervical esophagogastric anastomosis was performed on January 2018. Control blood tests revealed persistent eosinophilia, while the plain chest radiography with a water soluble contrast swallow showed no contrast leakage. Per os nutrition was resumed and the patient was discharged in good general condition. Conclusions: Eosinophilic esophagitis is a rare and difficult to diagnose entity due to its non-specific clinical presentation. In order to avoid complications and undesired delay in diagnosis, one should take into consideration this entity in every clinical situation of a young male patient with swallowing complaints.
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Affiliation(s)
| | - Péter Kupcsulik
- Semmelweis University's First Department of Surgery, Budapest, Hungary
| | - Péter Sahin
- Jahn Ferenc South-Pest Hospital and Clinic, Budapest, Hungary
| | - Ákos Szücs
- Semmelweis University's First Department of Surgery, Budapest, Hungary
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12
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Shennib H, Baribault M, Heuser R. Bovine xenograft pericardial patch use for definitive single stage repair of a large esophageal defect: a case report. J Cardiothorac Surg 2021; 16:300. [PMID: 34645503 PMCID: PMC8515757 DOI: 10.1186/s13019-021-01670-0] [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: 06/12/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Large esophageal perforations are challenging and often treated with exclusion or resection. This case demonstrates the feasibility of definitive surgical repair of a large esophageal perforation using large bovine pericardial patch. Case A patient with missed Boerhaave Syndrome underwent transesophageal echocardiography causing worsening perforation and sepsis. At thoracotomy and faced with a large esophageal defect, a large Bovine pericardial patch was used for repair with omentopexy. The patient recovered promptly and at 8 months was asymptomatic with satisfactory studies. Conclusion Xenograft pericardium is available and widely used for vascular reconstructions. It’s use for primary repair of large esophageal perforations should be considered.
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Affiliation(s)
- Hani Shennib
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA.
| | - Michelle Baribault
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA
| | - Richard Heuser
- Department of Surgery, College of Medicine, University of Arizona, 6122 33rd St, Paradise Valley, Phoenix, AZ, 85253, USA
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13
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Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:54-59. [PMID: 34516474 DOI: 10.1097/sle.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence. PATIENTS AND METHODS A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality. RESULTS Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drain insertion for those treated with TGD alone was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality. CONCLUSION These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.
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14
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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.
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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.
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15
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Senger SS, Thompson GR, Samanta P, Ahrens J, Clancy CJ, Nguyen MH. Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes. Open Forum Infect Dis 2021; 8:ofaa656. [PMID: 33889656 PMCID: PMC8052497 DOI: 10.1093/ofid/ofaa656] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown. Methods This is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015. Results We identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046). Conclusions Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.
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Affiliation(s)
- Suheyla S Senger
- Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences Turkey, Tepecik Training and Research Hospital, Izmir, Turkey.,Division of Infectious Diseases, Department of Internal Medicine University of California Davis Medical Center, Sacramento, California, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine University of California Davis Medical Center, Sacramento, California, USA.,Department of Medical Microbiology and Immunology, University of California Davis Medical Center, Sacramento, California, USA
| | - Palash Samanta
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jillian Ahrens
- Division of Infectious Diseases, Department of Internal Medicine University of California Davis Medical Center, Sacramento, California, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - M Hong Nguyen
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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16
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Khoche S, Hashmi N, Bronshteyn YS, Choi C, Poorsattar S, Maus TM. The Year in Perioperative Echocardiography: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2559-2568. [PMID: 33934985 DOI: 10.1053/j.jvca.2021.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 11/11/2022]
Abstract
This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.
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Affiliation(s)
- Swapnil Khoche
- Department of Anesthesiology, University of California San Diego Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Nazish Hashmi
- Department of Anesthesiology, Duke University, School of Medicine, Durham, NC
| | - Yuriy S Bronshteyn
- Department of Anesthesiology, Duke University, School of Medicine, Durham, NC
| | - Christine Choi
- Department of Anesthesiology, University of California San Diego Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA
| | - Sophia Poorsattar
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA
| | - Timothy M Maus
- Department of Anesthesiology, University of California San Diego Medical Center - Sulpizio Cardiovascular Center, La Jolla, CA.
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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18
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Abila AW, Nditika ME, Kipkemoi RD, Ondigo S, Khwa-Otsyula BO. Primary repair of esophageal perforation: Case report. Int J Surg Case Rep 2020; 71:159-162. [PMID: 32454452 PMCID: PMC7248577 DOI: 10.1016/j.ijscr.2020.04.026] [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: 02/18/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mortality after esophageal perforation is high irrespective of the treatment modality. The rarity of traumatic esophageal perforations has made it difficult to conduct comprehensive studies that can answer pertinent questions with regard to management. PRESENTATION OF CASE We report a case of through and through thoracic esophageal injury caused by an assailant's arrow in a young physically active male adult. Diagnosis was made on-table. He successfully underwent primary repair of the esophageal injury 16 h post injury via a left thoracotomy. Recurrent lung collapse and pleural effusion was managed with tube thoracostomy and chest physiotherapy. DISCUSSION Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion. CONCLUSION Primary repair of traumatic injury to a healthy esophagus is feasible for cases diagnosed early and without significant mediastinal contamination as in our case. Associated injuries are more likely in such cases to lead to increased morbidity and prolonged hospital stay and must be handled carefully.
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Affiliation(s)
- Akello W Abila
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Faculty of Health Sciences, Egerton University, Nakuru, Kenya.
| | - Mburu E Nditika
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya
| | - Rono D Kipkemoi
- Faculty of Health Sciences, Egerton University, Nakuru, Kenya
| | - Stephen Ondigo
- Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barasa O Khwa-Otsyula
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
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Onodera Y, Nakano T, Fukutomi T, Naitoh T, Unno M, Shibata C, Kamei T. Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report. Transplant Proc 2018; 50:3964-3967. [PMID: 30577297 DOI: 10.1016/j.transproceed.2018.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.
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Affiliation(s)
- Y Onodera
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Nakano
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan.
| | - T Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Naitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - M Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - C Shibata
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan
| | - T Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
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