Endoscopic iatrogenic esophageal perforation and management: a retrospective outcome analysis in the modern era

INTRODUCTION

Iatrogenic esophageal perforation (IEP) is a severe adverse event (AE) of upper endoscopy procedures (UEPs) associated with morbidity. Management has shifted from surgery to endotherapy with clip closure (CC), self-expanding metal stent (SEMS), and vacuum therapy (VT). Limited analyses measure outcomes during contemporary interventional endoscopy periods.

METHODS

IEPs associated with EGD, upper EUS, small bowel enteroscopy (SBE), and ERCP at a 3-hospital academic center from January 2011 to December 2023 were identified retrospectively from a centralized AE database. Additional information was obtained from medical records. Statistical analysis was performed using Microsoft Excel and STATA.

RESULTS

Thirty-two IEPs from 26 EGDs, 4 EUS, 1 SBE, and 1 ERCP were identified. IEPs occurred mostly after dilation (bougie N = 7; balloon, N = 5) or foreign body removal (N = 6). Most IEPs occurred in the lower esophagus (N = 10) or gastroesophageal junction (N = 8). Diagnosis was made at a median 2 h after the injury by endoscopy (N = 14), CT scan (N = 12), esophagram (N = 5), or x-ray (N = 1). Initial treatment included conservative therapy alone (N = 7), CC (N = 3), SEMS (N = 14), SEMS plus CC (N = 3), or surgery (N = 3). Eleven patients required additional treatment including repeat SEMS or adjustment (N = 4) or VT (N = 1). No surgical interventions were required after 2013. The median hospital stay was 3 days. Disposition included discharge to home (N = 25), long-term care facility (N = 2), 4 deaths (12.5% of IEPs), and 1 unknown.

CONCLUSIONS

IEPs are rare and occur throughout the esophagus after any UEP. The majority are recognized immediately and managed with endotherapy, or rarely, surgery today. These characteristics likely explain the low mortality in this study.

Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience

INTRODUCTION

The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option.

OBJECTIVES

To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation.

METHODS

Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile.

RESULTS

Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% (n=17). Among the complications, stent migration was present in 21.7% of the patients (n=5), in whom the incident was solved by endoscopic means.

CONCLUSIONS

According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery.

Safety and Efficacy of Nonoperative Treatment in Esophageal Perforation Caused by Foreign Bodies

INTRODUCTION

Esophageal foreign bodies are often treated by endoscopy, but the treatment of esophageal perforation caused by foreign bodies remains controversial. The purpose of this study was to investigate the safety and efficacy of nonoperative treatment of esophageal perforation caused by foreign bodies.

METHODS

We retrospectively analyzed 270 patients admitted to our hospital for esophageal perforation caused by foreign bodies from January 2012 to December 2020, all of whom received nonoperative treatment.

RESULTS

The mean age of the patients was 56 ± 17 years, and fish bones were the most common type of foreign body. A total of 61.2% of the perforations were in the cervical esophagus. All patients received nonoperative treatment initially, and the foreign body removal rate using endoscopy reached 97%. The perforation healing rate reached 94.8%, whereas 3 patients (1.1%) died during hospitalization. The median (range) duration of hospitalization was 4 days (3-6). Multivariable analysis showed age ≥ 66 years (odds ratio [OR]: 2.196; 95% confidence interval [CI]: 1.232-3.916; P = 0.008), men (OR: 1.934; 95% CI: 1.152-3.246; P = 0.013), and time to treatment (OR: 1.126; 95% CI: 1.027-1.233; P = 0.011) were independent risk factors for infection, whereas the risk of infection was lower when the foreign body type was fish bone (OR: 0.557; 95% CI: 0.330-0.940; P = 0.028).

DISCUSSION

Nonoperative treatment is safe and effective for esophageal perforation caused by foreign bodies. Even if perforation is combined with infection, active nonoperative treatment can still achieve a good effect. Early intervention can effectively reduce the risk of infection and improve patient outcomes.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

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.

Hypopharyngeal perforation caused by blunt trauma during consensual fellatio: an expectant management approach

Perforation of the pharynx is a rare occurrence but has the potential to cause mediastinitis and has an attendant mortality risk. Though numerous mechanisms have been described, we report a unique case of a young woman who presented with a sore throat, odynophagia and subcutaneous emphysema, a short time after performing fellatio. A contrast swallow confirmed hypopharyngeal perforation. She was managed expectantly with nasogastric feeding and empirical antibiotics. The perforation took 4 weeks to heal, but there were no residual swallowing problems at 3-month follow-up. We will explore the incidence and causes of pharyngeal perforation and discuss the options for and risks of surgical repair. This case highlights that non-surgical management of such injuries can be both safe and feasible, and reinforces the importance of ensuring confidentiality and the need for vigilance regarding potential non-consensual injury.

Current treatment and outcome of esophageal perforation: A single-center experience and a pooled analysis

BACKGROUND

Esophageal perforation has been one of the serious clinical emergencies, because of the high mortality and complication rates. However, the current prognosis of esophageal perforation and the outcomes of available treatment methods are not well defined. This study attempted to pool the immediate outcomes of esophageal perforation in the past 2 decades.

METHODS

The clinical data of 22 consecutive adult patients with esophageal perforation in our center were analyzed. A pooled analysis was also conducted to summarize results from the literatures published between 1999 and 2020. Studies that met the inclusion criteria were assessed, and their methodological quality was examined.

RESULTS

The mortality and complication rates in our center were 4.55% and 31.82%, separately. The pooled analysis included 45 studies published between 1999 and 2019, which highlighted an overall immediate mortality rate of 9.86%. Surgical treatments were associated with a pooled immediate mortality of 10.01%, and for conservative treatments of 6.49%. Besides, in the past decade, the mortality and complication rates decreased by 27.12% and 46.75%, respectively.

CONCLUSIONS

In the past 2 decades, the overall immediate mortality rate of esophageal perforation was about 10% in the worldwide, and the outcomes of esophageal perforation treatment are getting better in the last 10 years.

ETHICS REGISTRATION INFORMATION

LW2020011.

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

INTRODUCTION

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.

METHODS

A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

RESULTS

A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001).

CONCLUSIONS

Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

[A man with vomiting and retrosternal pain and dysphagia]

A 67-year-old male presents with complaints of severe retrosternal pain, frequent vomiting and dysphagia. Endoscopy revealed a very large intramural oesophageal hematoma, obliterating the lumen. Additional CT-imaging showed peri-oesophageal air collections, indicative for oesophageal perforation (compatible with Boerhaave's syndrome). Patient was treated successfully with intravenous antibiotics and fluid. Follow-up endoscopy after one year showed full recovery of the oesophageal wall.

Esophageal perforation in eosinophilic esophagitis: A systematic review on clinical presentation, management and outcomes

There is evidence of an increased fragility in the inflamed esophagus of patients with eosinophilic esophagitis (EoE). We performed a systematic review on presentation, management and outcomes of and surgical interventions for esophageal perforation in these patients, by searching in the MEDLINE, Embase and Scopus databases. Of the 599 references identified, 41 full-papers and 9 abstract met the inclusion criteria. Overall, 76 esophageal perforation episodes in 70 individual patients aged between 9 and 65 years were reported. 51 patients had not been diagnosed with EoE at the time of perforation; 14 patients had an untreated disease and the remaining were non responsive to therapy. Acute or progressive pain after long-lasting dysphagia and food impaction was the most common symptom leading to diagnosis in 42 patients who presented with Boerhaave syndrome. Pushing impacted food into the stomach led to perforation in 5 cases. Eight episodes appeared after dilation. CT scans demonstrated perforation in 82.4% of patients. Conservative management (including esophageal stenting) was used in 67.1% patients. The 25 remaining patients underwent surgery. Recovery was uneventful in the vast majority of patients. No death was reported. Active inflammation due to undiagnosed or untreated EoE was present in most cases of esophageal perforation. Conservative treatment of perforation should always be considered in EoE.

Endoscopic vacuum-assisted closure therapy for the treatment of oesophageal anastomotic leaks

Persisting suture dehiscence with oesophageal anastomotic leaks after thoracic surgery is a difficult complication, especially when a surgical repair fails. We report here endoscopic vacuum-assisted closure therapy as a novel endoscopic treatment for the management of oesophageal anastomotic leaks. Endoscopic vacuum-assisted closure therapy is a minimally invasive method to treat anastomotic leakage by positioning an open-pored polyurethane sponge and a suction tube connected to a wound drainage system into the opening of the wound cavity. This multidisciplinary endoscopic and surgical approach is a successful therapy for the management of suture dehiscence with oesophageal anastomotic leaks after thoracic surgery or oesophageal perforations.

Perforation following pneumatic dilation of achalasia cardia in a university hospital in northern India: A two-decade experience

Pneumatic dilation (PD) is a cost-effective first-line treatment for achalasia. The most feared complication of PD is esophageal perforation (EP). As data on EP after PD for achalasia are not widely reported, we present the frequency, risk factors, and treatment-outcome of EP. Records of patients undergoing PD for achalasia (January 1995 to September 2015) were retrospectively reviewed. Of 433 patients (age 38 years, 13-88, 57% male), and 521 dilations, 12 were complicated by EP (2.7% of patients and 2.3% of PD). EP occurred in 7 (3.4%), 4 (1.7%), and 1 (4.1%) with use of balloon diameters 30, 35, and 40 mm, respectively. In most (11/12, 92%), EP occurred during the first PD. No risk factor for EP was identified (p = 0.65 for the first dilation vs. > 1 dilation, and 0.75 for balloon size of 30 mm vs. > 30 mm). Seven patients with contrast leak on esophagogram and/or computed tomography scan underwent surgery. One other with contrast leak was successfully treated with a fully covered self-expandable metal stent (FC-SEMS); the remaining four with small leak/pneumomediastinum were managed conservatively. The median duration of hospital stay following perforation was 13 days (7-26) and 8 days (6-10) in surgery and conservative groups, respectively. No mortality was observed in either group. The frequency of EP with PD was 2.3%. Though most EP (92%) occurred during the first dilation, neither the balloon size nor repeated dilations were identified as risk factors. Both surgical and conservative approaches had a favorable outcome in appropriate settings.

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.

[Ankylosing spinal fractures may result in perforation of oesophagus]

Oesophageal lesions due to spinal fractures are very rare and easily overlooked. In this case report a woman was involved in a minor car accident, and she was primarily examined at the accident and emergency department with no signs of fractures. Ten days later, she was readmitted due to high infection counts and back pain. She had an unstable fracture of Th4 and a perforation of the oesophagus due to ankylosing fractures. The case emphasises the need to pay attention to a possible development of secondary oesophageal perforation in ankylosing spines and unstable fractures, and the need for a special attention when examinating this group of patients.

[Boerhaave syndrome: update on physiopathology, diagnosis and early management]

Boerhaave syndrome is a rare condition, usually associated with a delay in diagnosis. It is fatal in the absence of therapy. The nonspecific nature of the clinical signs contributes to the poor outcome. This syndrome should be suspected in patients with severe chest or abdominal pain, associated with a history of vomiting, clinical signs of pneumomediastinum (subcutaneous emphysema, pleural effusion) and rapid clinical deterioration. Prompt diagnosis and initial management by the primary care physician and the emergency department physician are key elements of a better outcome. This article will review the pathogenesis, clinical manifestations, diagnosis and treatment of Boerhaave syndrome in adults.

Esophageal Perforation: A Common Clinical Problem with Many Different Management Options

Esophageal perforation is a complex clinical entity that has multiple etiologies and variability in presentation, making it challenging to diagnose and treat. The mortality of esophageal perforation has improved because therapies have evolved. Whereas primary repair is the standard of care, multiple treatments may be employed successfully. We retrospectively reviewed all cases of suspected or confirmed esophageal perforation that were admitted to the thoracic surgery service at our institution between January 2011 and June 2016. We reviewed the charts of 61 patients. Twenty-three underwent primary repair, 13 underwent stent placement, 12 underwent drainage, 12 underwent medical management, and one underwent exclusion and diversion. All patients were included in the final analysis except the singular patient who underwent diversion. Overall mortality was 4.9 per cent. None of the studied variables were found to be associated with mortality (P > 0.05). Factors associated with choice of treatment were age (P < 0.0005), Charlson Index (P = 0.032), etiology (P < 0.0005), and location (P = 0.005). The application of different management options is based on a thorough understanding time course, patient anatomy, severity of presentation, and underlying disease process.

Management of Esophageal and Pharyngeal Perforation as Complications of Anterior Cervical Spine Surgery

OBJECTIVE

To describe our experience in treating esophageal and pharyngeal perforation after anterior cervical spine surgery.

METHODS

Six patients with esophageal injury and one patient with pharyngeal injury after anterior cervical spinal surgery, managed at our department between 2000 and 2015, were analyzed retrospectively.

RESULTS

During the study period, 7 patients (6 male and 1 female; mean age, 45 years) presented with esophageal perforation. The original anterior cervical spinal surgery was performed due to trauma in 2 patients and because of a degenerative cervical disorder in 5. Early esophageal perforation was diagnosed in 2 patients, and delayed esophageal injury due to chronic irritation with the cervical implants was noted in 5. Three of the five delayed perforation cases were related to cervical instrument displacement. Two patients showed no definite signs of infection, whereas 5 patients had various symptoms, including fever, neck pain, odynophagia, neck swelling, and upper extremity weakness. Two patients with a large defect underwent surgical repair and three with minimal perforation due to chronic irritation from the implants underwent instrument removal without direct repair of defect. Two asymptomatic patients received no intervention. Six patients with infection completely recovered from esophageal injury after treatment for a mean duration of 5.2 weeks (range, 4-8 weeks). One patient died because of postoperative pneumonia and sepsis after implant removal.

CONCLUSIONS

Esophageal and pharyngeal injury after cervical spinal surgery may occur either directly due to spinal trauma and vigorous intraoperative retraction or due to chronic irritation with cervical implants. In cases of perforation associated with infection, various surgical modalities, including primary closure and reinforcement with a flap, could be considered depending on factors such as esophageal defect size, infection severity, and timing of recognition of injury.

Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma

AIM

To identify the risk factors and clarify the subsequent clinical courses.

METHODS

This study retrospectively analyzed consecutive patients with esophageal squamous cell carcinoma (ESCC) treated using endoscopic submucosal dissection (ESD) between April 2008 and October 2012. We divided the ESCC lesions into perforation cases and non-perforation cases, and compared characteristics and endoscopic findings between the two groups. "Intraoperative perforation" was defined as the detection of a perforation site during ESD and the presence of mediastinal emphysema.

RESULTS

In total, 147 patients with 156 ESCC lesions were treated by ESD. Intraoperative perforation was recorded for nine lesions (5.8%) from nine patients. Multivariate analysis identified mucosal deficiency larger than 75% of the circumference of the esophagus as an independent risk factor for intraoperative perforation (OR = 7.37, 95%CI: 1.45-37.4, P = 0.016). The predominant site of perforation was the left wall [6/9 (67%)]. Six of nine perforation sites were successfully closed by clips during the procedures. Two of nine cases required drainage for pleural effusions; however, all nine cases recovered with conservative treatment and without surgical intervention. At the median follow up of 42 mo after ESD, no cases of local recurrence or distant organ metastasis had been observed.

CONCLUSION

This study suggests that mucosal deficiency larger than 75% of the luminal circumference is a risk factor for intraoperative perforation during ESD for ESCC.

Removable self-expanding metal stents insertion for the treatment of perforations and postoperative leaks of the esophagus

BACKGROUND

Esophageal rupture, spontaneous or iatrogenic, is associated with significant morbidity and mortality. The current study aims at highlighting the various clinical scenarios, where esophageal fully covered self-expanding removable metal stents (FCSEMS) can be used in esophageal rupture.

METHODS

In patients who underwent insertion of FCSEMS between January 2013 and June 2014, all data regarding demographics, indications, insertion, removal, and outcomes were studied retrospectively.

RESULTS

Seven patients underwent the placement of esophageal covered SEMS. Two patients had Boerhaave syndrome, two had leak following the repair of aortic aneurysm, one had extensive esophageal injury following transesophageal echocardiography, one had carcinoma esophagus with tracheaesophageal fistula, and one had dehiscence of esophagogastric anastomosis. Stent insertion was successful in all the patients; one had stent migration which was managed endoscopically. Two patients died due to underlying illness; the rest had successful removal of stents after 8-10 weeks and good outcomes.

CONCLUSION

Esophageal FCSEMS placement is safe and effective modality in management of patients with esophageal rupture.

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system

OBJECTIVE

The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population.

METHODS

In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups.

RESULTS

Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS.

CONCLUSIONS

The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Iatrogenic Esophageal Perforation

Iatrogenic esophageal perforation is the most common cause of esophageal perforation associated with high mortality rate of 19%. Acute sudden onset of pain after endoscopic intervention is the most common presenting symptom. Water soluble contrast study, CT scan, and endoscopy provide a high sensitivity for diagnosis of iatrogenic perforation. Non-operative management is safe and effective treatment for early perforation (< 24 hours) without clinical signs of sepsis. However, surgical management such as primary repair esophageal exclusion and diversion, and esophagectomy is warranted in the patients who did not meet the criteria for non-operative management. Endoscopic management (clip, esophageal stent) is an alternative treatment option with 80 to 90% of esophageal healing rate. Early recognition of suspicious symptoms within 24 hours, the use of the appropriate investigation, selection of the optimal treatment options, and multidisciplinary critical care are the best way to improve outcomes.

[Early diagnosis and treatment of Boerhaave's syndrome is pivotal for the prognosis]

Hydropneumothorax following oesophageal rupture is very rare and often lethal. We report case of a 78-year-old man with known Barret's oesophagus with increasing shortness of breath and right chest pain followed by increasing emesis. Further investigations showed a right side hydropneumothorax and pleural effusion. Thorax and abdominal CT showed middle oesophageal perforation and pneumomediastinum. Oesophageal perforation can lead to pneumothorax and pleural fluid. Early diagnosis is pivotal to reduce mortality.

Esophageal Perforation and Acute Bacterial Mediastinitis: Other Causes of Chest Pain That Can Be Easily Missed

Esophageal perforation is a rare condition that is commonly missed. Male gender and alcohol use are predisposing risk factors. Most of the cases are iatrogenic or traumatic; nonetheless, spontaneous cases are not uncommon. It typically occurs after vomiting or straining as the increased intra-abdominal pressure transmits into the esophagus and results in the tear. One of the main complications is acute bacterial mediastinitis from contamination with esophageal flora. This condition can be life-threatening because it is very frequently misdiagnosed and appropriate management is often delayed.A 49-year-old man presented with worsening sudden-onset interscapular back pain that then changed to chest pain with odynophagia and was found to have fever and leukocytosis.Chest computed tomography revealed signs of mediastinitis with possible esophageal perforation. He reported symptoms started 2 days ago after lifting of heavy objects. Empiric antimicrobial was begun with conservative management and avoidance of oral intake. Barium esophagram and esophagogastroduodenoscopy revealed no signs of perforation or inflammation. His symptoms resolved and he gradually resumed oral intake. Blood cultures grew Methicillin-sensitive Staphylococcus aureus and he was discharged on appropriate antibiotics for 4 weeks. He did well on follow-up 3 months after hospitalization.The case highlights the importance of considering esophageal etiologies of chest pain.

Boerhaave's syndrome: Experience with patients presenting later than 24 hours

Boerhaave's syndrome is the most sinister cause of esophageal perforation. Clinical presentation is vague. Diagnostic delays are frequent. As condition is rare therefore no consensus exists on management. A wide variety of management options are described in literature, each with its advantages and disadvantages. We present our experience of managing these cases which presented after 24 hr. Of onset of symptoms with emphasis on primary reinforced repair as first line surgical option.

[DIAGNOSTICS AND TREATMENT OF BOERHAAVE'S SYNDROME]

The article presents the results of diagnostics and treatment of 12 patients with Boerhaave's syndrome (men--9, women-- 3). The age of the patients was 19-68 years old. The prescription of spontaneous rupture of the oesophagus was 7 h-2 days from moment of the rupture to hospital admission. General aspects of disease were noted in 10 patients, though only 5 patients were directed to the hospital with suspicion on Boerhaave's syndrome. Emergency surgeries were performed on all patients. At first the opening was carried out, than drainage of posterior lower mediastinum were performed by Savinykh-Rozanov method with wound closure of the oesophagus walls. The complications were noted in 2 patients (the first case-pleural empyema, the second case-pulmonary embolism). Late complications, such as esophagostenosis in the place of wound closure were followed up in 3 patients in terms more than one month after operation.

False esophageal hiatus hernia caused by a foreign body: A fatal event

Foreign body ingestion is a common complaint in gastrointestinal clinics. It is usually not difficult to diagnose because most of the patients report a definitive history of accidental foreign body ingestion. However, in rare cases, patients do not have a clear history. Thus, the actual condition of the patient is difficult to diagnosis or is misdiagnosed; consequently, treatment is delayed or the wrong treatment is administered, respectively. This report describes a fatal case of esophageal perforation caused by an unknowingly ingested fishbone, which resulted in lower esophageal necrosis, chest cavity infection, posterior mediastinum fester, and significant upper gastrointestinal accumulation of blood. However, his clinical symptoms and imaging data are very similar with esophageal hiatal hernia. Unfortunately, because the patient was too late in consulting a physician, he finally died of chest infection and hemorrhage caused by thoracic aortic rupture. First, this case report underlines the importance of immediate consultation with a physician as soon as symptoms are experienced so as not to delay diagnosis and treatment, and thus avoid a fatal outcome. Second, diagnostic imaging should be performed in the early stage, without interference by clinical judgment. Third, when computed tomography reveals esophageal hiatus hernia with stomach incarceration, posterior mediastinal hematoma, and pneumatosis caused by esophageal, a foreign body should be suspected. Finally, medical professionals are responsible for making people aware of the danger of foreign body ingestion, especially among children, those who abuse alcohol, and those who wear dentures, particularly among the elderly, whose discriminability of foreign bodies is decreased, to avoid dire consequences.

Predictors for failure of stent treatment for benign esophageal perforations - a single center 10-year experience

AIM: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).

METHODS: All patients between 2003-2013 treated for EPR at the Karolinska University Hospital, a tertiary referral center, were studied with regard to initial management with SEMS. Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded. Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible. Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis, which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis. Patient and lesion characteristics were analyzed and are presented as median and interquartile range. Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression, while variables with P < 0.2 were further analyzed with multi-variate logistic regression.

RESULTS: Of the total number of 48 patients presenting with EPR, 40 patients (83.3%) were treated with SEMS at the time of admission, with an intention to heal the perforation. Twenty-three patients had Boerhaave’s syndrome (58%), 16 had an iatrogenic perforation (40%) and 1 had external trauma to the esophagus (3%). The total in-hospital mortality, including the cases that had other initial treatments (n = 8), was 10.4% and 7.5% among those who were subjected to the SEMS-based strategy. In 33 of the 40 patients (82.5%) who were treated with stent, the EPR healed without further change in treatment strategy. Patients classified as treatment success received a SEMS at a median time of 1 (1-1) d after the actual EPR, compared to 3 (1-10) d among those where the initial treatment failed, P = 0.039 in uni-variate analysis and P = 0.052 in multi-variate analysis. No other significant factors emerged, indicating an increased risk for failure. Six of 7 patients, where stent treatment of the defect failed, underwent an emergency esophagectomy with end esophagostomy and one patient died.

CONCLUSION: SEMS as an upfront therapeutic strategy seems to be a successful concept, when applied to an unselected group of patients with EPR.

Externally removable stents in the treatment of benign recalcitrant strictures and esophageal perforations in pediatric patients with esophageal atresia

BACKGROUND

We investigated whether removable stents, such as self-expandable plastic stents (SEPSs) and fully covered self-expandable metal stents (FCSEMSs) could provide an alternative treatment for recalcitrant strictures and esophageal perforations after esophageal atresia (EA) repair.

OBJECTIVE

The primary aim of our study was to evaluate technical feasibility. Secondary aims were to evaluate safety and procedural success.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

A total of 24 children with EA.

INTERVENTIONS

Retrospective review of all children with EA who underwent dilation and esophageal stent placement from January 2010 to February 2013 at our institution.

MAIN OUTCOME MEASUREMENTS

Healing of perforation and stricture resolution at 30 and 90 days.

RESULTS

A total of 41 stents (SEPSs 14, FCSEMSs 27) were placed in 24 patients with EA during the study period, including 14 who had developed esophageal leaks. Procedural success of esophageal stent placement in the treatment of refractory strictures was 39% at 30 days and 26% at 90 days. The success rate was 80% for closure of esophageal perforations with stent therapy after dilation and 25% for perforations associated with surgical repair. Adverse events of stent placement included migration (21% of SEPSs and 7% of FCSEMSs), granulation tissue (37% of FCSEMSs), and deep ulcerations (22% of FCSEMSs).

LIMITATIONS

Retrospective study with small sample size.

CONCLUSION

SEPSs and FCSEMSs can be placed successfully in small infants and children with a history of EA repair. The stents appear to be safe and beneficial in closing esophageal perforations, especially post-dilation. However, a high stricture recurrence rate after stent removal may limit their usefulness in treating recalcitrant esophageal anastomotic strictures.

[Conservative treatment of oesophageal perforation in a child caused by a toothbrush]

Traumatic perforation of the oesophagus is a condition with high morbidity and mortality. We report a case of a one-year-old girl with traumatic oesophageal perforation caused by a fall with a toothbrush. She underwent a conservative regimen consisting of drainage of the mediastinum by a naso-cavitary drain, antibiotics and a feeding tube. No sign of mediastinitis was found on a follow-up computed tomography 19 days later, and she was discharged in good condition.

Perforation during esophageal dilatation: a 10-year experience

BACKGROUND & AIM

Esophageal stenosis can be caused by malignant, postsurgical, benign diseases etc. Endoscopic treatment options consist primarily of balloon dilatation and bougination. Both interventions carry a certain risk of further complications such as perforations. We aimed to evaluate this risk in our patients.

METHODS

Frequency, perforation rates, further diagnostics, therapy, outcome and underlying diseases in 368 patients who underwent endoscopic dilatation or bougination in a 10 year period were evaluated.

RESULTS

Overall, 1497 endoscopic interventions were performed for treatment of esophageal stricture, causing 8 perforations (0.53% per intervention, 2.17% per patient) and one lethal outcome (0.05% per intervention, 0.27% per patient). In 1286 bouginations, 8 perforations (0.62%) and one death occurred (0.08%), whilst no perforation was noted during 211 balloon dilatations. Outcome of the 8 perforations was greatly influenced by co-morbidities, causing a prolonged hospitalization and the death of one patient.

CONCLUSION

Although complication rates are fairly small, patients should be under supervision or in contact for 24-72 hours after each intervention. In cases where perforation is suspected, radiological examinations should be conducted early. The perforation rate and mortality per patient may be used for patient information. Therapy and prognosis depend on the cause of perforation, localization and size of the perforation site as well as concomitant diseases.

Esophageal stents in malignant and benign disorders

Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.

Self-expanding stents in treatment of esophageal leaks post bariatric surgery

The Alimaxx self-expanding metal stents were used in two morbidly obese patients with esophageal leaks complicating reoperative bariatric surgery. Although the patients could be maintained on oral intake with their sepsis controlled, surgery was ultimately required for non-healing after 3 weeks of conservative management. Self-expanding metal stent should be considered the preferred treatment in small esophageal leaks less than 1 cm in morbidly obese patients who generally pose a higher operative risk due to concomitant co-morbidities. Stents are also useful adjuncts in patients with larger leaks that are either inoperable or need further stabilization at presentation and those preferring an initial 2-3 weeks trial of conservative management before contemplating surgery.

Hematemesis from esophageal varices associated with esophageal perforation: sclerotherapy and endoscopic clipping

A 46-year-old man was referred to our Unit for hematemesis. The medical history of the patient revealed an HCV-related cirrhosis, a human immunodeficiency virus (HIV) infection and recent and persistent episodes of emesis. An urgent gastroscopy disclosed evidence of active bleeding from varices of the lower third of the esophagus and a concomitant laceration of the esophageal wall due to the emesis. These two conditions have been endoscopically diagnosed and successfully treated by sclerotherapy and endoscopic clipping.

[Diagnosis and treatment of esophagus perforation caused by esophageal foreign bodies]

OBJECTIVE

Summarize the treatment skills of esophagus perforation caused by esophageal foreign bodies.

METHOD

Retrospectively analyze the seven cases of esophagus foreign body perforation with various complications in our department.

RESULT

Six cases recovered in 3 to 18 days after operation, on average 14.2 day, while one case recovered in 49 days by conservative method.

CONCLUSION

Foreign bodies removing, fistulae repairing, abscess incising, effusion rinsing, effective antibiotics administrating and support treatment are effective to treat esophagus perforation caused by esophageal foreign bodies. It will take a relative long time to be treated only by conservative way.

Not just another sore throat

Case study A man, 26 years of age, presented to a hospital emergency department complaining of a sudden onset of a sore throat 6 hours previously while consuming a carbonated drink at work. The pain commenced about lunchtime, after he had been mixing concrete powder, and since then had been intermittent and was becoming more severe.

[Diagnosis and treatment of oesophageal perforations]

The treatment of oesophageal perforations (EP) has primarily been a surgical issue and despite significant advances in surgery and intensive care medicine EP is continuously associated with high morbidity and mortality. Implementation of an effective treatment algorithm which steps away from the traditional surgical approach is essential for achieving a better clinical outcome. A modern treatment algorithm includes contrast computed tomography and endoscopy diagnostics and use of non- or semi-invasive procedures like selfexpanding metal stents, selective digestive decontamination and the establishment of a controlled fistula.

Aetiology, treatment and mortality after oesophageal perforation in Denmark

INTRODUCTION

Perforation of the oesophagus into the thoracic cavity is a potentially life-threatening condition. The causes are numerous. Treatment for oesophageal perforation targets mediastinal and pleural contamination. Present knowledge about the causes of perforation and the types of treatment is poor.

MATERIAL AND METHODS

A retrospective review was made between 1997 and 2005 based on extracts from the National Patient Registry.

RESULTS

A total of 286 patients were diagnosed with perforation of the oesophagus (131 women and 155 men). Their average age was 60 years. A wide spectrum of causes was reported, e.g. instrumentation of the oesophagus 136 (47.6%), spontaneous rupture 89 (31.1%) or procedures otherwise related to surgical intervention 9 (3.1%). One third of the patients started conservative treatment 91 (31.9%). The majority of the patients were transferred to a thoracic surgery department for further treatment: about 25% of patients underwent surgery. The average hospitalization time was 18 days. The mortality rate was 21%.

CONCLUSION

Oesophageal perforation remains a diagnostic and therapeutic challenge and the condition requires aggressive treatment. Recent consensus in early treatment with thoracotomy, debridement, irrigation and subsequent parenteral nutrition has improved survival. In this material, most perforations were iatrogenic in nature. In the 2002-2005 period, the study showed that 29% of the iatrogenic perforations were caused by the use of a rigid endoscope which is risky and whose use should therefore be restricted. It is advisable to set up national guidelines for treatment of oesophageal perforation and to centralise treatment.