Esophageal perforation: the importance of early diagnosis and primary repair

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

The use of the LigaSure Vessel Sealing System in esophageal cancer surgery

PURPOSE

In this clinical study we investigated the use and results of the LigaSure Vessel Sealing Sytem (LVSS) (Valleylab, Boulder, CO) compared with conventional surgery in esophageal cancer resection.

DESCRIPTION

The LVSS (Valleylab) is a device with a hemostatic design frequently used in abdominal surgery. Sixty patients (n = 30 in each group) with esophageal cancer from a single center were evaluated to undergo esophagectomy using either the LVSS or conventional clamping methods. The main outcome measures (ie, operating time, intraoperative blood loss, and postoperative course) were then compared.

EVALUATION

In resections performed using the LVSS, operation duration (307 +/- 35 minutes vs 260 +/- 35 minutes; p = 0.000), intraoperative blood loss (average 533 +/- 211 mL vs 390 +/- 256 mL; p = 0.022), and postoperative drainage volumes (abdomen, 70 +/- 86 mL vs 40 +/- 61 mL; p = 0.122; thorax, 690 +/- 646 mL vs 540 +/- 359 mL; p = 0.271) all decreased.

CONCLUSIONS

The LVSS is easy to use and a reliable method in esophageal cancer surgery. Compared with conventional hemostatic techniques a reduction in intraoperative and postoperative blood loss, and a shortening of operation duration were determined. We believe that the use of the LVSS in esophageal surgery will become even more widespread in the future.

Pulmonary agenesis associated with dextrocardia, sternal defects, and ectopic kidney

Pulmonary agenesis is a rare embryological defect, usually unilateral, and is associated with skeletal, cardiovascular, and other anomalies. A 22-month-old girl was admitted to our clinic with recurrent pulmonary infections. A chest X-ray and multidetector computed tomography (MDCT) revealed pulmonary agenesis with dextrocardia, sternal defects, and a right pelvic ectopic kidney. We report on the first known case of right-sided pulmonary agenesis combined with isolated dextrocardia, sternal defects, and an ectopic kidney. The importance of MDCT for the diagnosis of pulmonary agenesis and associated other anomalies is demonstrated.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Follicular thyroid carcinoma: metastasis to the sternum, 13 years after total thyroidectomy

Primary and metastatic malignancies of the sternum are uncommon. Secondary lesions to the sternum occur more commonly in patients with lung and breast cancer, and only a few cases of sternal metastasis arising from a follicular thyroid carcinoma have been reported in the literature. Rarely, metastases to the sternum present in the guise of primary sternal tumours may be treated surgically with that diagnosis in mind. We describe a case of a sternal mass treated by radical surgery, which ultimately proved to be a solitary metastasis from a follicular carcinoma of the thyroid, appearing 13 years after total thyroidectomy and radioactive iodine therapy. Late metastatic thyroid carcinoma to the sternum should be kept in mind in the differential diagnosis of sternal lesions. For patients with thyroid carcinoma and sternal metastasis, we recommend surgical resection of the metastasis, not only as a curative or palliative measure but also to maximise the effect of subsequent radioiodine treatment.

Solitary eosinophilic granuloma of sternum

Primary bone tumors of the chest wall are uncommon, although a wide variety of both benign and malignant tumors arise within the chest wall. Among those tumors, sternal tumors are rare and usually malignant. We report an extremely rare case of eosinophilic granuloma developed in the sternum in a 30-year-old woman. She presented anterior chest pain and somewhat tender mass over the sternum. Chest roentgenogram, computed tomography scanning of the thorax, and total body bone scintigraphy revealed an isolated lytic lesion in the corpus sterni. A tru-cut biopsy of the mass exhibited the typical histologic appearance of eosinophilic granuloma. The solitary lesion was removed completely surgically. This rare condition should be kept in mind in differential diagnosis of sternal lesions.

Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

CT Imaging Findings of Pulmonary Alveolar Echinococcosis

Alveolar echinococcosis is a parasitic infection caused by Echinococcus multilocularis in the metacestode stage. The disease involves the liver in almost all cases, and additionally, lung involvement is accompanied in approximately 13% of the cases. Due to the low incidence of pulmonary alveolar echinococci, there are few case reports of lung involvement in the literature. In this study, computed tomography (CT) findings related to pulmonary involvement in alveolar echinococcosis cases, which have increased worldwide in recent years, were evaluated.

Simultaneous Esophageal and Tracheal Fistulization Resulting From Pott's Abscess

We describe a case of a 30-year-old woman who presented with a complaint of coughing while drinking water, which began 2 months earlier and was treated with surgical repair of esophageal and tracheal fistulization that resulted from a Pott's abscess. The patient had been diagnosed with pulmonary tuberculosis 4 years previously and had been treated for 6 months. Esophageal and tracheal fistulization of the abscess cavity was observed both radiologically and intraoperatively. The fistulas were closed through separate operations for the trachea and the esophagus. Simultaneous esophageal and tracheal fistulization of a Pott's abscess is a serious complication of spinal tuberculosis that has not been previously reported in the literature.

Minimally Invasive and Endoscopic Approach to Esophageal Perforation

Although esophageal perforation is rare, it is a life-threatening condition. The esophagus is very sensitive to rupture and perforation due to the absence of a serosal layer. More than half of the esophageal perforations are iatrogenic and most occur during endoscopy. Around 55% of esophageal injuries occur in the intrathoracic region, 25% in the cervical region, and 20% in the abdominal region. Clinical manifestations and mortality are related to various components such as the etiology, localization, type of injury, severity of contamination, injury to adjacent mediastinal structures, and time from perforation to treatment. When perforation occurs in the esophagus, saliva, stomach contents, bile fluid, and other secretions may pass into the mediastinum causing mediastinal emphysema, inflammation followed by mediastinal necrosis, and chemical mediastinitis. Early clinical suspicion and imaging are essential for successful treatment. Despite advances in technology and treatment, the morbidity and mortality rate due to esophageal perforation is still higher than 20% according to the reported studies. Until now, the main treatment of esophageal perforation was the surgical approach. Nowadays, endoluminal procedures such as endoscopic vacuum therapy, endoscopic stent placement, endoscopic clip closure, endoscopic suturing, and tissue adhesives have started to be applied more. In this review, the minimally invasive and endoscopic approach methods suitable for esophageal perforation according to the characteristics of the patients and the structure of the perforation were examined.

Primary Endoscopic Repair of a Large Tracheal Rupture Through Tracheal Stoma

We describe the case of an 83-year-old man who presented with a large trauma to the membranous wall of the trachea and was treated with endoscopic primary repair of the tracheal wall through a preexisting tracheal stoma. Assessment with an optical telescope through the tracheal stoma revealed a 5-cm laceration in the membranous wall of the trachea starting immediately above the carina. The laceration was closed using continuous 4-0 monofilament polydioxanone sutures with direct visualization of tissues through a fiberoptic telescope. This approach is particularly effective in cases of traumatic rupture of the membranous trachea.