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.

Curative Criteria After Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinomas

BACKGROUND

According to the Japanese Esophageal Society (JES) guidelines, risk factors for lymph node (LN) metastasis in the muscularis mucosa (MM)/submucosa to a depth of up to 200 μm (SM1) in cases of esophageal squamous cell carcinomas (ESCCs) include the presence of lymphatic invasion (ly), venous invasion (v), infiltration pattern (INF)c, and SM1. The long-term prognoses of these patients are unclear, and there are very few reports on the validation of the curative criteria for MM/SM1 ESCCs.

AIMS

To examine the long-term prognoses of these patients and the risk factors for LN metastasis of MM/SM1 ESCCs after endoscopic resection (ER).

METHODS

This study included patients with MM/SM1 ESCCs who underwent ER at Hiroshima University Hospital from December 1990 to November 2016. We evaluated the clinicopathological characteristics of 98 patients and overall survival, disease-specific survival, recurrence-free survival, and recurrence rates in the e-curative and non-e-curative groups.

RESULTS

The mean observation period was 75 months. There was no significant difference in disease-specific survival rate between the e-curative and non-e-curative groups (100 vs. 98%). There was no significant difference in disease-specific survival rates between the groups (100 vs. 98%). In contrast, the LN recurrence-free survival rate in patients with INFa, ly(-), and v(-) was significantly higher than that in patients with INFb/c, ly(+), or v(+) (100 and 87%, P < 0.05).

CONCLUSION

Contrary to the JES guidelines, our findings suggest that new criteria (MM/SM1, INFa, negative vertical margin (VM0), ly[-], and v[-]) may be associated with curative ER without additional treatment.

Ten-year experience of esophageal endoscopic submucosal dissection of superficial esophageal neoplasms in a single center

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) of a superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ESD to determine its feasibility and effectiveness for the treatment of SEN.

METHODS

Patients who underwent ESD for SEN between August 2005 and June 2014 were eligible for this study. The clinical features of patients and tumors, histopathologic characteristics, adverse events, results of endoscopic resection, and survival were investigated.

RESULTS

ESD was performed in 225 patients with 261 lesions, including 70 cases (26.8%) of dysplasias and 191 cases (73.2%) of squamous cell carcinomas. The median age was 65 years (range, 44 to 86), and the male to female ratio was 21.5:1. Median tumor size was 37 mm (range, 5 to 85) and median procedure time was 45 minutes (range, 9 to 160). En bloc resection was performed in 245 of 261 lesions (93.9%), with complete resection in 234 lesions (89.7%) and curative resection in 201 lesions (77.0%). Adverse events occurred in 33 cases (12.6%), including bleeding (1.5%), perforation (4.6%), and stricture (6.5%). During a median follow-up period of 35.0 months (interquartile range, 18 to 62), none of the patients showed local recurrence. The 5-year overall and disease-specific survival rates were 89.7% and 100%, respectively.

CONCLUSIONS

ESD is a feasible and effective procedure for the treatment of SEN based on our 10-year experience, which showed favorable outcomes.

Risk factors for complications associated with upper gastrointestinal foreign bodies

AIM: To investigate predictive risk factors associated with complications in the endoscopic removal of foreign bodies from the upper gastrointestinal tract.

METHODS: We retrospectively reviewed the medical records of 194 patients with a diagnosis of foreign body impaction in the upper gastrointestinal tract, confirmed by endoscopy, at two university hospital in South Korea. Patient demographic data, including age, gender, intention to ingestion, symptoms at admission, and comorbidities, were collected. Clinical features of the foreign bodies, such as type, size, sharpness of edges, number, and location, were analyzed. Endoscopic data those were analyzed included duration of foreign body impaction, duration of endoscopic performance, endoscopic device, days of hospitalization, complication rate, 30-d mortality rate, and the number of operations related to foreign body removal.

RESULTS: The types of upper gastrointestinal foreign bodies included fish bones, drugs, shells, meat, metal, and animal bones. The locations of impacted foreign bodies were the upper esophagus (57.2%), mid esophagus (28.4%), stomach (10.8%), and lower esophagus (3.6%). The median size of the foreign bodies was 26.2 ± 16.7 mm. Among 194 patients, endoscopic removal was achieved in 189, and complications developed in 51 patients (26.9%). Significant complications associated with foreign body impaction and removal included deep lacerations with minor bleeding (n = 31, 16%), ulcer (n = 11, 5.7%), perforation (n = 3, 1.5%), and abscess (n = 1, 0.5%). Four patients underwent operations because of incomplete endoscopic foreign body extraction. In multivariate analyses, risk factors for endoscopic complications and failure were sharpness (HR = 2.48, 95%CI: 1.07-5.72; P = 0.034) and a greater than 12-h duration of impaction (HR = 2.42, 95%CI: 1.12-5.25, P = 0.025).

CONCLUSION: In cases of longer than 12 h since foreign body ingestion or sharp-pointed objects, rapid endoscopic intervention should be provided in patients with ingested foreign bodies.

[Mechanical damage and spontaneous esophageal perforation]

The article presents the results of treatment of 95 patients with iatrogenic damages and perforations caused by other reasons and spontaneous rupture of the esophagus. A defect of the esophagus was formed in thoracic part in 67.4% cases. Combined suppurative complications such as a neck phlegmon, mediastinitis, pleural empyema, pericarditis, pneumonia and lung abscess occurred in prevalent majority of patients. Surgical interventions were performed through cervical, thoracotomical and laparoscopical accesses. Different plastic methods of covering sutures of the esophagus were used in conditions of suppurative inflammation in 33 patients. An inconsistency of sutures was noted in 6 (18.2%) cases. Postoperative lethality consisted of 34.6% in spontaneous rupture of the esophagus and it was 11.9% in case of other damages.

The clinical research of the endoscopic sequential treatment for patients with intermediate-advanced esophageal cancer: a randomized clinical trial

We tried to find an ideal therapeutic regimen for patients with advanced esophageal cancer. Totally 240 patients with advanced esophageal cancer were randomly divided into experimental group (endoscopic sequential treatment, 126 cases) and control group (traditional treatment, 114 cases) with a 2-year follow-up period. The experimental group was randomly divided into three subgroups: group A: local chemotherapeutic drug injection with ordinary metal stent implantation; group B: local chemotherapeutic drug injection with iodine-125 particle implantation; and group C: radiofrequency (RF) therapy with ordinary metal stent group. The control group was also randomly divided into three subgroups: group D: local chemotherapeutic drug injection group; group E: RF therapy group; and group F: common metal stent implantation group. The survival rate, survival quality, adverse reactions, and complications were compared among these groups. A significant improvement of curative effect was found in the experimental group. Group A and B had higher survival rate and survival quality, and lower esophagotracheal fistula incidence and metastasis rate, compared with group C. There was no significant difference in survival rate between group A and group B, while the quality of life was higher in group B than in group A. While patients in group B had lower esophagotracheal fistula incidence and metastasis rate comparing with group A. Local chemotherapeutic drug injection combined with iodine-125 particle stent might be an effective sequential treatment to improve the life quality of advanced esophageal cancer patients.

Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

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.

Management of esophageal foreign bodies: experience in a developing country

BACKGROUND

The outcome of esophagoscopy for removal of suspected esophageal foreign bodies (EFBs) is dependent on the FB characteristics and the surgeon's experience. This study was conducted to review our experience and highlight challenges in the management of EFBs in a developing country. The value of radiologic signs in FB detection was also evaluated.

METHODS

We conducted a retrospective chart review of 131 patients: 58.8% males and 41.9% females aged 8 months to 64 years, treated for suspected EFBs in our institution over a 13-year period. Statistics were derived by univariate analysis

RESULTS

Foreign bodies were found and retrieved in 118 cases. Coins were the predominant FB in children (35%), and bones (25%) and dentures (17%) were predominant in adults. Plain radiography was highly useful in detecting FBs in children (coins/metals 100%) but less so in adults (bones 25%, dentures 11%). Repeated esophagoscopy attempts were encountered more in patients with impacted sharp objects (85%) and were recorded significantly among trainee surgeons (p = 0.004). Open esophagotomy was carried out in 13 (10%) difficult cases. Major complications including two iatrogenic esophageal perforations and one death occurred following esophagoscopy by trainee surgeons.

CONCLUSIONS

Rigid esophagoscopy is relatively safe and useful procedure in trained hands for removal of EFBs. Management of long-standing EFBs, dentures, and other sharp objects requires the skills of the most experienced members of the surgical team for a successful outcome. Open surgical treatment is unavoidable in cases of irretrievable esophageal FBs or in the presence of esophageal perforation.

Outpatient experience with oesophageal endoscopic dilation

Between March 1990 and August 1997, outpatient endoscopic balloon dilation was performed for oesophageal strictures which developed secondary to malignancies, peptic strictures, post surgical narrowing, achalasia cardia, corrosive ingestion and other causes. A total of 169 dilations were performed in the 92 cases with an average of 1.8 dilation/case (Range 1 to 8). Dilation was possible in all 92 cases without the need for fluoroscopic monitoring. Twenty three (13.6%) of the dilations were performed using pneumatic balloon while in 146(86.4%) cases wire guided metal olives were used. There were nine minor complications which were treated with medication on an outpatient basis and four major complications which required inpatient care. Three of these had perforation of the oesophagus and one died. One other patient developed aspiration pneumonia and subsequently died.

Endoscopic treatment of malignant dysphagia

Palliative endoscopic treatment of dysphagia in patients with inoperable oesophageal cancer includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. Such procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1988, 476 patients (401 males, 75 females) were treated at the Endoscopy division of the National Cancer Institute of Milan for inoperable primary or recurrent malignancies of the oesophagus or cardia or for extra-oesophageal neoplasms causing dysphagia. Dilation was used in 172 cases, Nd:YAG laser photocoagulation in 90, prosthesis insertion in 72, dilation and laser in 97, and prosthesis and laser in 45. Functional improvement was reported in 75% of patients after dilation, in 89% after laser treatment, in 80% after intubation, in 80% after dilation and photocoagulation, and in 89% after laser and intubation. The median duration of dysphagia-free interval was 4 weeks in dilated patients, 6-8 weeks in photocoagulated patients and 20 weeks intubate patients. Overall median survival was 6.2 months. The complication rate was: 1.4% in dilation treatment, 1.4% in laser photocoagulation, and 8.8% in prosthesis intubation. Mortality related to endoscopic treatment was 2.1% (10/476 patients). Relief of dysphagia is one of the most important goals of palliative treatment in patients with inoperable oesophageal neoplasms. Moreover, endoscopic palliation improves the quality of life in the patients, with a low complication rate.