Outcomes after oesophageal perforation: a retrospective cohort study of patients with different aetiologies

Idiopathic hypopharyngeal perforation presenting as supraglottitis and parapharyngeal abscess: case report and literature review

A 75-year-old healthy male reported odynophagia and severe neck pain with radiation to chest and shoulders. Cardiac causes were excluded. After re-presenting with dysphonia and complete dysphagia, he was treated for supraglottitis. Imaging showed a left parapharyngeal and retropharyngeal space abscess with mediastinal emphysema. Progressive emphysema prompted contrast swallow test followed by left neck exploration and pan-endoscopy, which confirmed mucosal hypopharyngeal perforations. Histopathology reported inflammation. Autoimmune and gastroenterological aetiologies were excluded. Following conservative management, healing was demonstrated on repeat pan-endoscopy. Two months’ follow-up imaging showed complete resolution. Spontaneous hypopharyngeal perforation, atypical of Boerrhave’s syndrome and without risk factors (iatrogenic, oesophageal disease and foreign body ingestion), is rare and often misdiagnosed, including masquerading as supraglottitis. Nasoendoscopy should be complemented by radiological imaging. Presence of deep neck space collections and surgical emphysema should prompt diagnostic pan-endoscopy. Although most rupture cases require surgery, conservative management of hypopharyngeal perforations can be considered when clinically appropriate.

Boerhaave's syndrome with late presentation. Experience in an Argentine single center: Case series

Background

In the year 1724, Hermann Boerhaave reported a case of a Dutch admiral who died due to spontaneous rupture of the esophagus following vomiting. The aim of this retrospective study is to analyze the therapeutic modality, morbidity and mortaliy of a group of patients with spontaneous esophageal rupture treated in our hospital.

Methods

Ten patients were treated from March 1990 to August 2016. Seven patients were males and three were females. The age range was, 52-72 years, with an average of 66.2 years. In four patients, the diagnosis and posterior treatment were performed within 24 h (Group I) and the remaining six patients after 24 h (Group II).

Results

The mean hospital stay was 36.6 days (range 17-62 days). The mortality rate was 50%, which was due to septic shock and the morbidity of patients who survived was 40% due to pneumonia in one case and fistula in another.

Discussions

This condition has a high mortality rate with a lethality that depends on the time between recognition of symptoms and proper surgical treatment.

Evaluation of the extent of damage to the esophageal wall caused by press-through package ingestion

Press-through package (PTP) is the most common accidentally ingested foreign body in Japan. Accidental ingestion of PTP can result in esophageal damage. An approach for evaluating the risk of esophageal injury has not been established. Therefore, we used porcine esophageal tissue and silicone sheets to establish a method for assessing the risk of esophageal damage on accidental PTP ingestion. We pathologically evaluated porcine lower esophageal tissue using a scratch tester. Using porcine esophageal tissue, scratch tests were performed with 4 test objects and pathological damage was compared. It was assumed that each object was accidentally ingested. The objects were polyvinylidene chloride (PVDC)-coated polyvinyl chloride (PVC) PTP, soft PThPa, round PTP, and a disposable scalpel. The porcine esophagus was replaced with a silicon sheet, and an automatic friction machine was used for quantitative evaluation. The silicon sheet was scratched using HHS 2000 with 750-g load at 50 mm/min. We investigated the frictional force exerted on the surface for each of the objects. The degree of damage (depth) was the highest for the disposable scalpel, followed by PVDC-coated PVC PTP, while the degree of damage (depth) was the lowest for soft PThPa and round PTP. The mean frictional forces on the silicon sheet were 524.0 gf with PVDC-coated PTP, 323.5 gf with soft PThPa, 288.7 gf with round PTP, and 922.7 gf with the disposable scalpel. We developed approaches to qualitatively and quantitatively evaluate the risk of esophageal damage after accidental PTP ingestion. Our findings indicate that the risk of gastrointestinal damage after accidental PTP ingestion is low with soft PTP and round PTP.

Oesophageal-pleural fistulation identified through repeated malpositioning of nasogastric tubes

Two previously fit and healthy males with acute onset dyspnoea and respiratory failure required invasive ventilation for respiratory failure. Insertion and correct positioning of nasogastric tubes (NGT) proved to be difficult repeatedly in both cases over the course of a number of days. Repeated imaging found NGT tips sited in varied, atypical positions including extension into the hemithoraces. Delineation of repeated malpositioned NGTs identified oesophageal perforations in the case of both patients, one with fistulation into the right pleura and the other into the left pleura. Both patients developed an empyema ipsilateral to the side of fistulation. Both patients died, with subsequent postmortems concluding one patient to have experienced a spontaneous out-of-hospital oesophageal perforation, and the second patient's perforation developing as a consequence of a distal oesophageal squamous cell carcinoma. These two cases highlight the importance of questioning the possibility of underlying oesophageal pathology promptly if repeated NGT insertions are unsuccessful or imaging reveals unusual transit paths of NGTs.