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Harrich F, Knoefel WT, Bölke E, Schauer M. Classification of the oesophageal perforation. Eur J Med Res 2024; 29:352. [PMID: 38951825 PMCID: PMC11218290 DOI: 10.1186/s40001-024-01910-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2024] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES Esophageal perforations are a complex clinical scenario that have been poorly studied. To date, there is no grading of esophageal perforations, the reason being that the outcome is very heterogeneous, because the perforation is very heterogeneous. A grading of the severity of the perforation may guide treatment, and could ultimately affect morbidity and mortality. METHODS The observation period of the study was four years. All patients with a perforation of the esophagus aged 18 to 90 years were included. All anastomotic insufficiencies or fistulas after surgery of the esophagus were excluded. The cause of the injury and the time interval between the event and the start of therapy were analyzed. The severity of each perforation was classified based on the results of a diagnostic CT scan, gastroscopy as well as clinical and laboratory findings. Therapy and signs of infection were evaluated. Endpoints of the study were patient recovery or death. The study was conducted as a retrospective single-center study at a university hospital of Düsseldorf. The study has been approved by the review board. Patients gave their informed consent before data collection. All data were analyzed using SPSS 29 (IBM SPSS Statistics software). RESULTS Age, gender and cause of the esophageal perforation did not impact significantly on overall survival. The duration of injury > 24 h (p = 0.01), presence of mediastinitis (p = 0.01) and necrosis of the esophagus (p = 0.02) were associated with an unfavorable outcome. The correlation of the clinical grading of the severity of the perforation based on the endoscopic, radiological and clinical findings with the overall survival of patients was significant. Patients categorized into the four grades of severity (I-IV) had an overall survival of 100%, 100%, 70% and 50%, respectively. CONCLUSION The severity of esophageal perforations can be systematically rated grades I to IV based on the radiological, endoscopic and clinical findings at diagnosis. Due to the grading and its correlation to the overall survival, a comparison of patients, their treatment and outcome becomes possible. In future, the grade of a perforation may guide treatment, and therefore affect morbidity and mortality.
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Affiliation(s)
- Friederike Harrich
- Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | | | - Edwin Bölke
- Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Matthias Schauer
- Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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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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Kumar A, Singla V, Pulle MV, Asaf BB, Puri HV, Bishnoi S. Multidisciplinary, minimally invasive approach for oesophageal perforations with delayed presentation. J Minim Access Surg 2022; 18:353-359. [PMID: 35708379 PMCID: PMC9306118 DOI: 10.4103/jmas.jmas_28_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The present study aims to report the outcomes of a multidisciplinary, minimally invasive approach to treating patients with delayed presentation of oesophageal perforation. Patients and Methods The present study is a retrospective analysis of prospectively maintained data at a tertiary care centre. All patients with oesophageal perforation presenting over 48 h after the onset of symptoms and without oesophageal obstruction were included in the study. Self-expanding Metallic Stent (SEMS) or endoscopic clip placement was performed in all the patients, followed by video-assisted thoracoscopic surgery (VATS) debridement and decortication of pleural cavity collection. 'Success' was defined as, discharge without the need of oesophageal diversion and complete healing of leak site at 8 weeks with successful removal of the stent. Results Between March 2012 and December 2019, 12 patients (10 males, median age of 55 years- range of 39-71 years) with oesophageal perforation and delayed presentation underwent treatment with this approach. Ten patients had spontaneous perforation (83.3%) and one patient each had upper gastrointestinal endoscopy-induced and post-traumatic perforation. The median duration of symptoms was 8 days (range 3-31 days). SEMS was placed in ten patients and, in two patients, an over-the-scope clip was used. VATS decortication was done in ten patients (83.3%) and the remaining two (16.7%) underwent VATS debridement. One patient required oesophageal diversion and another patient expired due to sepsis. The overall success with this approach was 83.3%. Conclusion This multidisciplinary, minimally invasive approach is feasible in patients with thoracic oesophageal perforation and delayed presentation, with a high success rate.
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Affiliation(s)
- Arvind Kumar
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Vikas Singla
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | - Mohan Venkatesh Pulle
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Belal Bin Asaf
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Harsh Vardhan Puri
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sukhram Bishnoi
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
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Ge PS, Raju GS. Rupture and Perforation of the Esophagus. THE ESOPHAGUS 2021:769-788. [DOI: 10.1002/9781119599692.ch45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Boerhaave syndrome: A rare postoperative complication. JAAPA 2019; 32:1-3. [PMID: 31348107 DOI: 10.1097/01.jaa.0000558372.31728.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Spontaneous esophageal perforation, also called Boerhaave syndrome, is a relatively rare condition that can result in significant morbidity or mortality. The tear commonly involves all three layers of the esophagus. It results from increased intraluminal pressure, most commonly from violent retching and vomiting. This article describes a patient with esophageal perforation in the immediate postoperative period following elective hip arthroplasty.
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Matsui R, Takayama S, Hattori T, Imagami T, Sakamoto M, Kani H. Iatrogenic esophageal perforation that could be treated indirectly by cervical esophagostomy and laparoscopic surgery. Int J Surg Case Rep 2019; 60:4-7. [PMID: 31185454 PMCID: PMC6556829 DOI: 10.1016/j.ijscr.2019.05.053] [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: 04/07/2019] [Revised: 05/08/2019] [Accepted: 05/27/2019] [Indexed: 11/24/2022] Open
Abstract
It is very rare case that each esophageal stump become connected and patent spontaneously. Two-stage surgery is useful for esophageal perforation if radical operation is difficult. Esophageal perforation can be resolved without direct closure if appropriate drainage is performed. Introduction Successful nonoperative management has been reported for esophageal perforation; however, some cases require surgery. Case presentation We presented the case of an 85-year-old woman with iatrogenic thoracic esophageal perforation in whom primary repair or resection of the perforated esophagus was difficult because she was elderly and had severe aortic valve stenosis. Therefore, we selected a two-stage surgery; laparoscopic gastrostomy, jejunostomy, posterior mediastinal drainage, and cervical esophagostomy were performed. We planned reconstruction after the perforation was closed, but endoscopic examination revealed spontaneous patency of each esophageal stump. Endoscopic balloon dilation was necessary because of esophageal stenosis; however, anastomotic surgery was unnecessary. Conclusion This case report suggests that esophageal perforation is resolved without direct closure if appropriate drainage is performed.
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Affiliation(s)
- Ryohei Matsui
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan.
| | - Satoru Takayama
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Taku Hattori
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Toru Imagami
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Masaki Sakamoto
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Hisanori Kani
- Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai, Japan
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Vermeulen BD, Siersema PD. Diagnosis and endoscopic treatment of esophageal leakage: a systematic review. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Yu LL, He ZF, Liu QF, Dai N, Si JM, Ye B, Zhou JC. Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection. J Int Med Res 2018; 46:1528-1536. [PMID: 29376459 PMCID: PMC6091846 DOI: 10.1177/0300060517752995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional “three-tube” method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new “two-tube” method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture. Methods From January 2007 to June 2016, patients with SER and managed with the “two-tube” method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications. Results The average procedure time for the “two-tube” method was 22.1 ± 5.5 minutes. In comparison with the control method, the “two-tube” method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the “two-tube” method occurred. Conclusion The “two-tube” method is an effective and safe approach for patients with SER.
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Affiliation(s)
- Liang-Liang Yu
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zheng-Fu He
- 2 Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi-Fang Liu
- 3 Department of Endoscopy Center, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Dai
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Min Si
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bei Ye
- 4 Taizhou Vocational College of Science and Technology, Taizhou, Zhejiang, China
| | - Jian-Cang Zhou
- 5 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Aloreidi K, Patel B, Ridgway T, Yeager T, Atiq M. Non-surgical management of Boerhaave's syndrome: a case series study and review of the literature. Endosc Int Open 2018; 6:E92-E97. [PMID: 29344568 PMCID: PMC5770272 DOI: 10.1055/s-0043-124075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/31/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Boerhaave's syndrome (BS) is a life-threatening condition with morbidity and mortality rates as high as 50 % in some reports. Until recently, surgical intervention has been the mainstay of management plans. With advances in therapeutic endoscopy, however, there has been increasing interest in non-surgical options including endoscopic esophageal stenting. PATIENTS AND METHODS We reviewed the medical records of all patients diagnosed with BS and managed with endoscopic interventions between November 2011 and November 2016. The following variables were collected: patient demographics, clinical presentations, locations of esophageal perforation, primary interventions, complications, and outcomes. RESULTS Six patients were found to be diagnosed with BS during the study period. The median age at presentation was 55. There were 4 males and 2 females. The most common site of perforation was in the distal esophagus. The most common presenting symptom was chest pain (67 %) following an episode of vomiting or retching. Four patients (66.7 %) developed septic shock. Endoscopic treatment with a fully covered esophageal stent was the primary intervention in all patients (100 %). Interventional radiology was consulted in all cases for fluid drainage and chest tube placements. Clinical resolution of the BS was achieved in all patients (100 %) without any subsequent surgical interventions. There were no deaths within the study group, and the average follow-up duration was 2 years. CONCLUSION Endoscopic treatment seems to be an effective management strategy in patients with BS. We also noted satisfactory results in patients presenting with sepsis, presumably due to urgent, interventional radiology-guided fluid drainage.
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Affiliation(s)
- Khalil Aloreidi
- Department of Internal Medicine, University of South Dakota – Sanford School of Medicine, Sioux Falls, South Dakota, United States,Corresponding author Khalil Aloreidi Internal Medicine Residency programUniversity of South Dakota – Sanford School of Medicine1400 West 22nd Street Sioux Falls, SD 57105+1-605-357-1365
| | - Bhavesh Patel
- Department of Gastroenterology, University of South Dakota – Sanford School of Medicine, Sioux Falls, South Dakota, United States
| | - Tim Ridgway
- Department of Gastroenterology, University of South Dakota – Sanford School of Medicine, Sioux Falls, South Dakota, United States
| | - Terry Yeager
- Department of Interventional Radiology, University of South Dakota – Sanford School of Medicine, Sioux Falls, South Dakota, United States
| | - Muslim Atiq
- Department of Gastroenterology, University of South Dakota – Sanford School of Medicine, Sioux Falls, South Dakota, United States
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Sdralis EIK, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Dis Esophagus 2017; 30:1-6. [PMID: 28575240 DOI: 10.1093/dote/dox013] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 12/11/2022]
Abstract
We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.
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Affiliation(s)
- E Ilias K Sdralis
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK.,Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - S Petousis
- Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - F Rashid
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - B Lorenzi
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - A Charalabopoulos
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
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12
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Treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement. J Trauma Acute Care Surg 2017; 82:141-149. [PMID: 27805991 DOI: 10.1097/ta.0000000000001272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Spontaneous rupture of the esophagus is a rare but life-threatening thoracic emergency, with high rates of clinical misdiagnosis and mortality. This article summarizes our experience in the treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement. METHODS We retrospectively assessed the medical records of 19 patients with spontaneous esophageal rupture treated using our intervention protocol. Patients received local anesthesia and sedation prior to undergoing transnasal drainage catheter placement into the thoracic abscess cavity, followed by temporary esophageal stent and jejunal feeding tube placement. After the operation, abscess lavage, nutritional support, and anti-inflammatory treatment were given. The transnasal thoracic drainage catheter, esophageal stent, and feeding tube were removed after the healing of the abscess cavity. RESULTS In all, 19 covered esophageal stents were placed in 19 patients with spontaneous esophageal rupture. All operations were technically successful. After an average of 84.06 days, the stents were successfully removed from 17 patients. No cases of massive hemorrhage, esophageal rupture, or other complications occurred during stent removal. An 82-year-old patient died of heart failure 2 months after the operation. One patient died of sudden massive hematemesis and hematochezia 55 days after the operation. In one patient, the esophageal injury failed to heal completely. CONCLUSION Our treatment protocol is simple, minimally invasive, and efficacious and may be an alternative for patients who are not candidates for surgery, have a high risk of postoperative complications, or wish to undergo minimally invasive surgery. LEVEL OF EVIDENCE Therapeutic study, level V.
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Outcome of stent grafting for esophageal perforations: single-center experience. Surg Endosc 2017; 31:3696-3702. [PMID: 28078464 DOI: 10.1007/s00464-016-5408-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recent studies showed that stent grafting is a promising technique for treatment of esophageal perforation. However, the evidence of its benefits is still scarce. METHODS Forty-three consecutive patients underwent stent grafting for esophageal perforation at the Oulu University Hospital, Finland. The main endpoints of this study were early and mid-term mortality. Secondary outcome endpoints were the need of esophagectomy and additional surgical procedures on the esophagus and extraesophageal structures. RESULTS Patients' mean age was 64.6 ± 13.4 years. The mean delay to primary treatment was 23 ± 27 h. The most frequent cause of perforation was Boerhaave's syndrome (46.5%). The thoraco-abdominal segment of the esophagus was affected in 58.1% of cases. Minor primary procedures were performed in 25 patients (58.1%) and repeat surgical procedures in 23 patients (53.5%). Forty-nine repeat stent graftings were performed in 22 patients (50%). Two patients (4.7%) underwent esophagectomy, one for unrelenting preprocedural stricture of the esophagus and another for persistent leakage of a perforated esophageal carcinoma. The mean length of stay in the intensive care unit was 6.0 ± 7.5 days and the in-hospital stay was 24.3 ± 19.6 days. In-hospital mortality was 4.6%. Three-year survival was 67.2%. CONCLUSIONS Stent grafting seems to be an effective less invasive technique for the treatment of esophageal perforation. Repeat stent grafting and procedures on the pleural spaces are often needed to control the site of perforation and for debridement of surrounding infected structures. Stent grafting allows the preservation of the esophagus in most of patients. The mid-term survival of these patients is suboptimal and requires further investigation.
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Zimmermann M, Hoffmann M, Jungbluth T, Bruch HP, Keck T, Schloericke E. Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients. Scand J Surg 2016; 106:126-132. [DOI: 10.1177/1457496916654097] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation. Patients and Methods: This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig–Holstein, Luebeck Campus, from January 1986 through December 2011. Results: Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance. Conclusion: Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.
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Affiliation(s)
- M. Zimmermann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - M. Hoffmann
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Jungbluth
- Department of Surgery, Klinikum Wolfsburg, Wolfsburg, Germany
| | - H. P. Bruch
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - T. Keck
- Department of Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - E. Schloericke
- Department of Surgery, Westküstenklinikum Heide, Heide, Germany
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Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries. J Trauma Acute Care Surg 2016; 79:1089-95. [PMID: 26680145 DOI: 10.1097/ta.0000000000000772] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.
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Leoncini G, Novello L, Denegri A, Morelli L, Ratto GB. Successful primary staple-repair of thoracic oesophagus after delayed presentation of a spontaneous perforation. Int J Surg Case Rep 2015; 14:167-71. [PMID: 26279260 PMCID: PMC4573848 DOI: 10.1016/j.ijscr.2015.07.032] [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: 07/15/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Spontaneous perforation of the oesophagus is diagnosed late in over 50% of cases. Misdiagnosis may be due to atypical presentations. Primary repair is technically demanding in this setting and the risk of failure is high. PRESENTATION OF CASE An 85 year-old lady presented with an atypical cohort of mild nonspecific symptoms in spite of a pleuro-mediastinal purulent collection secondary to an undiagnosed spontaneous perforation of the oesophagus occurred seven days before. Despite the extent of perforation (3cm in length), the late diagnosis and the necrosis of the muscular wall, the oesophagus was successfully repaired by means of a stapler. DISCUSSION The mechanism of the atypical presentation is discussed and possible modalities of treatment of delayed oesophageal perforations are reviewed, with particular reference to primary repair and to the possible use of staplers within this setting. CONCLUSION Even large spontaneous perforations of the oesophagus can result in a contained abscess, with no frank sepsis. Diagnosis can be missed for days in these cases. The attempt at primary repair of the oesophagus is still indicated. The use of a stapler is preferable in such cases as a perfect mucosal approximation is provided with minimal manipulation and with the use of inert, well tolerated material, which does not tend to become infected.
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Affiliation(s)
- Giacomo Leoncini
- IRCCS San Martino University Hospital-IST National Institute for Cancer Research Unit of Thoracic Surgery, Genoa, Italy.
| | - Luca Novello
- IRCCS San Martino University Hospital-IST National Institute for Cancer Research Unit of Thoracic Surgery, Genoa, Italy.
| | - Andrea Denegri
- IRCCS San Martino University Hospital-IST National Institute for Cancer Research Unit of Thoracic Surgery, Genoa, Italy.
| | - Lucia Morelli
- IRCCS San Martino University Hospital-IST National Institute for Cancer Research Unit of Thoracic Surgery, Genoa, Italy.
| | - Giovanni B Ratto
- IRCCS San Martino University Hospital-IST National Institute for Cancer Research Unit of Thoracic Surgery, Genoa, Italy.
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17
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Biancari F, Saarnio J, Mennander A, Hypén L, Salminen P, Kuttila K, Victorzon M, Böckelman C, Tarantino E, Tiffet O, Koivukangas V, Søreide JA, Viste A, Bonavina L, Vidarsdóttir H, Gudbjartsson T. Outcome of patients with esophageal perforations: a multicenter study. World J Surg 2014; 38:902-9. [PMID: 24174169 DOI: 10.1007/s00268-013-2312-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent studies have suggested that stent-grafting may improve the treatment outcome of patients with esophageal perforation, but evidence on this is still lacking. METHODS Data on 194 patients who underwent conservative (43 patients), endoclip (4 patients) stent-grafting (63 patients) or surgical treatment (84 patients) for esophageal perforation were retrieved from nine medical centers. RESULTS In-hospital/30-day mortality was 17.5 %. Three-year survival was 67.1 %. Age, coronary artery disease, and esophageal malignancy were independent predictors of early mortality. Chi squared automatic interaction detection analysis showed that patients without coronary artery disease, without esophageal malignancy and younger than 70 years had the lowest early mortality (4.1 %). Surgery was associated with slightly lower early mortality (conservative 23.3, endoclips 25.0 %, stent-grafting 19.0 %, surgery 13.1 %; p = 0.499). One center reported a series of more than 20 patients treated with stent-grafting which achieved an early mortality of 7.7 % (2/26 patients). Stent-grafting was associated with better survival with salvaged esophagus (conservative 76.7 %, endoclips 75.0 %, stent-grafting 77.8 %, surgery 56.0 %; p = 0.019). Propensity score adjusted analysis showed that stent-grafting achieved similar early mortality (p = 0.946), but significantly higher survival with salvaged esophagus than with surgical treatment (p = 0.001, OR 0.253, 95 % CI 0.110-0.585). Primary surgical repair was associated with somewhat lower early mortality (14.6 vs. 19.0 %; p = 0.561) and better survival with salvaged esophagus (85.4 vs. 77.8 %; p = 0.337) than stent-grafting. CONCLUSIONS Esophageal perforation was associated with a rather high mortality rate in this all-comers population. Stent-grafting failed to decrease operative mortality, but it improved survival with salvaged esophagus. The results of one of the centers indicate that increasing experience with this less invasive procedure may possibly improve the outcome of these patients.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, PL 21, 90029, Oulu, Finland,
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18
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Persson S, Elbe P, Rouvelas I, Lindblad M, Kumagai K, Lundell L, Nilsson M, Tsai JA. Predictors for failure of stent treatment for benign esophageal perforations - a single center 10-year experience. World J Gastroenterol 2014; 20:10613-10619. [PMID: 25132783 PMCID: PMC4130874 DOI: 10.3748/wjg.v20.i30.10613] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 11/21/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Ivatury RR, Moore FA, Biffl W, Leppeniemi A, Ansaloni L, Catena F, Peitzman A, Moore EE. Oesophageal injuries: Position paper, WSES, 2013. World J Emerg Surg 2014; 9:9. [PMID: 24447730 PMCID: PMC3899941 DOI: 10.1186/1749-7922-9-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 12/30/2013] [Indexed: 01/04/2023] Open
Abstract
The oesophagus is a difficult challenge for the surgeon because of its lack of serosal covering, the tenuous, segmental blood supply and the common delay in the diagnosis of injury. Early diagnosis is the key to successful management. Recent introduction of newer, minimally invasive techniques have provided management alternatives for both the normal and the diseased organ that is injured with both early and delayed diagnosis.
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Affiliation(s)
- Rao R Ivatury
- Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA.
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20
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Wahed S, Dent B, Jones R, Griffin SM. Spectrum of oesophageal perforations and their influence on management. Br J Surg 2013; 101:e156-62. [DOI: 10.1002/bjs.9338] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 01/23/2023]
Abstract
Abstract
Background
Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.
Methods
All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.
Results
There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days.
Conclusion
The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.
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Affiliation(s)
- S Wahed
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - B Dent
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - R Jones
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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21
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Biancari F, D'Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, Saarnio J, Lucenteforte E. Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013; 37:1051-9. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 Oulu, Finland.
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22
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Biancari F, Gudbjartsson T, Mennander A, Hypén L, Salminen P, Kuttila K, Viktorzon M, Böckelman C, Tarantino E, Tiffet O, Koivukangas V, Søreide JA, Viste A, Bonavina L, Vidarsdottir HH, Saarnio J. Treatment of esophageal perforation in octogenarians: a multicenter study. Dis Esophagus 2013; 27:715-8. [PMID: 24118339 DOI: 10.1111/dote.12148] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforation is associated with significant mortality, and this may markedly increase with advanced age. This multicenter study investigates this issue in patients older than 80 years. Data on 33 patients >80 years old who underwent conservative (10 patients), endoclip (one patient), stent grafting (11 patients), or surgical treatment (11 patients) for esophageal perforation were collected from nine centers. Surgical repair consisted of repair on drain in one patient, primary repair in seven patients, and esophagectomy in two patients. Among patients who underwent stent grafting, one required repeat stenting and another stent graft repositioning. One patient was converted to surgical repair after stent grafting. Thirteen patients (39.4%) died during the 30-day and/or in-hospital stay. Their mortality was significantly higher than in a series of patients<80 years old (13.0%, 21/161 patients, P=0.001). Three patients (30.0%) died after conservative treatment, one (100%) after treatment with endoclips, five (45.5%) after stent grafting, and four (36.4%) after surgical repair (P=0.548). Early survival with salvaged esophagus was 42.4% (conservative treatment: 70.0% endoclips 0%, stent grafting: 54.5%, and surgical repair: 54.5%, respectively, P=0.558). Estimated glomerular filtration rate<60 mL/minute/1.73 m2 (70.0% vs. 25.0%, P=0.043) and sepsis (100% vs. 32.1%, P=0.049) at presentation were associated with increased risk of early mortality in univariate analysis. Esophageal perforation in octogenarians is associated with very high early and intermediate high mortality irrespective of the treatment method used.
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Affiliation(s)
- F Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
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Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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Conservative management of esophageal perforation after a fall. Int J Surg Case Rep 2013; 4:550-3. [PMID: 23624199 DOI: 10.1016/j.ijscr.2013.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/02/2013] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Esophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury. PRESENTATION OF CASE We present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4-C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation. DISCUSSION Early diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively. CONCLUSION In the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.
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