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Triantafyllou T, Lamb P, Skipworth R, Couper G, Deans C. Surgical treatment of Boerhaave syndrome in the past, present and future: updated results of a specialised surgical unit. Ann R Coll Surg Engl 2024. [PMID: 38563067 DOI: 10.1308/rcsann.2024.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis. METHODS This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade. RESULTS Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011. CONCLUSIONS Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.
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Affiliation(s)
- T Triantafyllou
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - P Lamb
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - R Skipworth
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - G Couper
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - C Deans
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
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Anundsen TK, Førland DT, Johannessen HO, Johnson E. Outcome after stent and endoscopic vacuum therapy-based treatment for postemetic esophageal rupture. Scand J Gastroenterol 2024; 59:1-6. [PMID: 37592384 DOI: 10.1080/00365521.2023.2248537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/11/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES Extent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment. MATERIALS AND METHODS 17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie's score). RESULTS Seventeen patients aged median 67 years (range 34-88), had a primary hospital stay of 38 days (7-68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2-62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population. CONCLUSION Mortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.
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Affiliation(s)
- Tommy Kallåk Anundsen
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Dag Tidemann Førland
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Hans-Olaf Johannessen
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Egil Johnson
- Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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de Armas Conde M, Rojas Estévez M, Díaz López C, Concepción Martín V, Gianchandani Moorjani R, Borque Barrera MDP, García Romero DM, Moneva Arce ME. Effective and alternative treatment of anastomotic leak after gastrojejunal bypass: endoluminal vacuum therapy. Rev Esp Enferm Dig 2024; 116:52-53. [PMID: 37204079 DOI: 10.17235/reed.2023.9675/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Anastomotic leak (AL) after with Roux-en-Y gastric bypass (RYGB) has a morbidity rate to 53% and it can be potentially lethal (mortality rate from 0.5 to 10%). In these cases, surgery is usually a challenge, so in recent years minimally invasive endoscopic treatment is gaining ground. Endoluminal vacuum therapy (EVAC) is a promising treatment that is being used in esophagogastric and rectal surgery for the management of AL. We present the case of a patient on his 5th postoperative day of bariatric surgery (RYGB) with an acute abdomen. He was diagnosed of dehiscence of gastrojejunal anastomosis and he needed urgent surgery twice. Subsequently, in control CT, a new anastomotic leak is evidenced. However, given the clinical stability of the patient, it was decided to start EVAC type ESO-Sponge® placed by endoscopy. A total of 4 changes are made every 3-4 days with a total duration of treatment of 15 days. EVAC was removed when the defect presented a 1 mm sized.
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Affiliation(s)
- María de Armas Conde
- Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de la Candelaria, España
| | - Marta Rojas Estévez
- Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de la Candelaria
| | - Carmen Díaz López
- Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de la Candelaria, España
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Monino L, Moreels TG. Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks: How to Deal with the Challenges (with Video). Life (Basel) 2023; 13:1412. [PMID: 37374194 DOI: 10.3390/life13061412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/19/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Anastomotic leaks after gastrointestinal surgery have an important impact on surgical outcomes because of the high morbidity and mortality rates. Multiple treatment options exist requiring an individualized patient-tailored treatment plan after multidisciplinary discussion. Endoscopic vacuum therapy (EVT) is a novel treatment option that is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. EVT has a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient. To the unexperienced, the EVT technique may be prone to several hurdles which may deter endoscopists from using it and depriving patients from a potentially life-saving therapeutic option. The current review highlights the possible difficulties of the EVT procedure and aims to provide some practical solutions to facilitate its use in daily clinical practice. Personal tips and tricks are shared to overcome the pre-, intra- and post-procedural hurdles. An instructive video of the procedure helps to illustrate the technique of EVT.
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Affiliation(s)
- Laurent Monino
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Tom G Moreels
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
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Ostapenko A, Liechty S, Kleiner D. Endoluminal vacuum therapy for rectal anastomosis is safe and does not increase risk of strictures in a swine model. J Clin Transl Res 2022; 8:453-464. [PMID: 36452003 PMCID: PMC9706313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/28/2022] [Accepted: 07/27/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Endoluminal vacuum therapy has been experimentally used in patients with esophageal, rectal, and Roux-en-Y bypass surgery. Yorkshire pigs are good animal models for studying the safety and efficacy of endoluminal vacuum therapy and prior studies have employed these devices in rectal anastomotic defects, as rescue therapy for early anastomotic leaks, as well as prophylactic therapy as a means of protecting high risk anastomosis. AIM The objective of this study is to assess the effects of a prophylactic vacuum assist device on bowel tissue surrounding an intact anastomosis at 30 days post device removal. METHODS A total of seven pigs underwent a rectal resection with primary anastomosis: five experimental pigs with a prophylactic endoluminal vacuum device in place for 5 days post-surgery and two control pigs with no device. All animals were euthanized on the 35th post-operative day and subjected to a necropsy with a histopathological evaluation of the rectal anastomosis. RESULTS No significant difference in inflammation or strictures was observed between the anastomosis of animals with the endoluminal vacuum devices and controls. CONCLUSION We, therefore, conclude that endoluminal vacuum therapy is safe for prophylactic use in pigs undergoing low anterior resection and does not cause significant strictures. RELEVANCE FOR PATIENTS Anastomotic leak is a feared complication resulting in increased costs, length of stay, and emotional distress. Endoluminal negative pressure vacuum therapy is a new technology that has been used in experimental models in both animals and humans for prevention and treatment of anastomotic leak. In this series we demonstrate endoluminal vacuum therapy is safe in a porcine model and does not result in stricture or increased adhesion formation. We expect endoluminal vacuum therapy to become more widely used in the future in both prevention and treatment of anastomotic leaks.
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Affiliation(s)
| | - Shawn Liechty
- Department of General Surgery, Nuvance Health, CT, USA
| | - Daniel Kleiner
- Department of General Surgery, Waterbury Hospital, CT, USA
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Dobashi A, Li DK, Mavrogenis G, Visrodia KH, Bazerbachi F. Endoscopic Management of Esophageal Cancer. Thorac Surg Clin 2022; 32:479-495. [DOI: 10.1016/j.thorsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wichmann D, Fusco S, Werner CR, Voesch S, Duckworth-Mothes B, Schweizer U, Stüker D, Königsrainer A, Thiel K, Quante M. Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers (Basel) 2022; 14:980. [PMID: 35205730 DOI: 10.3390/cancers14040980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments. Abstract Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.
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Tuñon C, De Lucas J, Cubilla J, Andrade R, Aguirre M, Zúñiga Cisneros J. Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis. BMC Gastroenterol 2021; 21:484. [PMID: 34930127 PMCID: PMC8685809 DOI: 10.1186/s12876-021-02058-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation. CASE PRESENTATION We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis. CONCLUSION Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.
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Affiliation(s)
- Carlos Tuñon
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Juan De Lucas
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Jan Cubilla
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Rafael Andrade
- Department of Thoracic Surgery, Santo Tomas Hospital, Panama City, Panama
| | - Miguel Aguirre
- Department of Thoracic Surgery, Santo Tomas Hospital, Panama City, Panama
| | - Julio Zúñiga Cisneros
- Department of Internal Medicine, Santo Tomas Hospital, Bella Vista, Panama City, Panama.
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Kim Y, Kang S, Ahn JY. Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation. Korean J Helicobacter Up Gastrointest Res 2021. [DOI: 10.7704/kjhugr.2021.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.
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