The role of esophagectomy in the management of esophageal perforations

Management of spontaneous rupture of the oesophagus (Boerhaave’s syndrome): Single centre experience of 18 cases

BACKGROUND

Spontaneous oesophageal rupture (Boerhaave's syndrome) is rare, and carries a high attendant risk of mortality.

METHODS

A retrospective eight-year review from a tertiary unit.

RESULTS

Eighteen patients were managed, with a mean age of 57 (39 - 88 years). Eight patients presented early and underwent surgery, seven with primary closure and one with exclusion and diversion. There was one death in this group. Ten patients were managed conservatively. In this group, two underwent an oesophagectomy because of failed conservative measures, and four had an endoprosthesis inserted. One patient died in this group on the first admission, but two patients with stents in situ died from massive bleeding relating to an aorto-oesophageal fistula at 39 days and 189 days respectively following presentation.

CONCLUSIONS

Surgical intervention remains the gold standard when the diagnosis is made early. For late diagnoses, this series suggests caution in the use of endoprostheses.

Esophageal perforation: principles of diagnosis and surgical management

PURPOSE

Esophageal perforation (EP) is still associated with a high mortality rate, even after surgical repair. We reviewed 17 cases of EP to evaluate the management of this major surgical problem.

METHODS

We reviewed the medical records of all patients treated for EP in our department between November 2001 and November 2004. Therapy was based on various patient-related factors.

RESULTS

Seventeen patients, with a mean age of 63 years, presented with EP mostly caused by iatrogenic incidents (11/17). In nine patients, the perforation was located in the thoracic segment, with a mean size of 2.5 +/- 0.6 cm. Thoracic computed tomography (CT) was performed in all patients to assess the periesophageal inflammation precisely. More than 50% showed signs of systemic inflammation indicative of sepsis, reflected by a dramatic increase in serum C-reactive protein and leukocytosis. Treatment consisted of debridement and drainage (n = 3), primary repair (n = 3), reinforced repair (n = 4), esophageal resection (n = 5), and conservative measures (n = 2). All patients, except for three with pre-existing liver dysfunction and other comorbidities, survived, representing a mortality rate of 17.6% (14/17). An analysis of the literature (2000-2005) revealed an overall mortality rate of 19.7% (101/521), ranging from 3% to 67%.

CONCLUSION

Our data support the individualized surgical management of EP, based on careful evaluation of various patient-related factors, including CT findings.

Treatment of esophageal perforation in a referral center in taiwan

PURPOSE

The high mortality associated with esophageal perforation can be reduced by aggressive surgery and good critical care. We report our experience of treating esophageal perforation in a clinic in Taiwan.

METHODS

The subjects were 28 patients who underwent surgery for a benign esophageal perforation.

RESULTS

The esophageal perforation was iatrogenic in 11 patients, spontaneous in 8, and caused by foreign body injury in 9. Most (22/28) of the patients were seen longer than 24 h after perforation, and 77% had empyema preoperatively. The perforation was located in the cervical area in 5 patients and in the thoracic esophagus in 23. We performed primary repair in 24 patients, esophagectomy in 3, and drainage in 1. Leakage occurred after primary repair in ten (41%) patients, resulting in one death, and two patients died of other diseases. Postoperative leakage prolonged the hospital stay but had no impact on mortality. Overall survival was 90%. Univariate analysis revealed that age, timing of treatment, and cause and location of the perforation influenced outcome, but multivariate analysis failed to identify a predictor of mortality.

CONCLUSIONS

Early diagnosis and intervention are crucial to prevent morbidity and mortality in patients with esophageal perforation. Primary repair is feasible even if the diagnosis is delayed.

Management of esophageal perforations: the value of aggressive surgical treatment

BACKGROUND

The treatment of esophageal perforation remains controversial, particularly in terms of the type of operative therapy. This report analyzed results of an aggressive treatment protocol.

METHODS

Patients with esophageal perforations in a normal esophagus or those with a motor disorder were treated by operative closure. All defects were buttressed or closed by either muscle or pleura. Sternocleidomastoid muscle was used to buttress or primarily close the defects in the neck, and a flap of diaphragm was often used for thoracic perforation. Patients with perforated cancer or severe underlying disease had an esophagectomy.

RESULTS

Sixty-four patients had operation: 50 underwent preservation of the esophagus after closure of the perforation and 14 underwent resection. The leak rate was 17%, but all healed. One patient treated with primary closure died (1.5% mortality); only 1 patient required subsequent esophagectomy. Thirteen of 14 patients treated with esophagectomy had an excellent result.

CONCLUSION

The aggressive approach to esophageal perforations with attempt at uniform closure or resection of severe disease produced excellent results with reduced morbidity and low mortality.

Boerhaave's syndrome: diagnosis and treatment

Boerhaave's syndrome, or postemetic rupture of the esophagus,represents one of several etiologies of esophageal perforation. Early diagnosis, which requires both a high index of suspicion and contrast esophagography, is essential for optimal outcome. Primary repair is often possible, although other techniques, such as esophageal exclusion or diversion, may be appropriate in certain circumstances.

Synchronous spontaneous perforation of the esophagus and a duodenal ulcer

Although 41% of patients with spontaneous rupture of the esophagus also suffer from gastro duodenal ulcer disease, cases of synchronous spontaneous esophageal and duodenal ulcer perforation have thus far not been reported in the literature. We report on the case of a 61-year-old man who presented with a 72-hour history of esophageal rupture and duodenal ulcer perforation. Following appropriate circulatory resuscitation we performed double resection; involving the esophagus, cardia and the distal part of the stomach, followed by substitution by means of gastro-jejunal transposition as a one-stage procedure. With reference to this case with a favorable outcome, we are presenting an analysis of indications for resectional surgery in advanced spontaneous esophageal perforation.

Tratamiento de las perforaciones del esófago torácico

OBJECTIVE

To evaluate the results of the treatment of patients with thoracic esophageal perforation in order to determine the most appropriate management of this entity.

PATIENTS AND METHOD

We performed a retrospective study of 21 patients (mean age 59 years; 24-82) who presented with thoracic esophageal perforation to our hospital between 1991 and 2004.

RESULTS

In 13 patients (62%) treatment was performed within 24 hours. In the remaining 8 patients the mean delay was 7.2 (2-12) days. In 4 patients (26%) the perforation was confined to the mediastinum and conservative treatment was provided. Of these patients, 1 developed empyema and underwent esophageal resection. Extramediastinal involvement was confirmed in 17 patients (73%) and was treated by a variety of surgical procedures: esophagectomy (n=2), drainage alone (n=2), primary closure (n=2) and reinforced primary repair (n=11). Two patients with simple closure and 1 with reinforced primary closure developed leakage of the suture line resulting in death. The 3 patients who underwent esophagectomy survived. In patients with perforation confined to the mediastinum mortality was 0%, whereas in those with extramediastinal involvement mortality was 23%.

CONCLUSIONS

Thoracic esophageal perforation leads to high mortality rates and requires early diagnosis and immediate treatment. Conservative management is appropriate in only a few selected patients. When surgical treatment is indicated, we advocate reinforced primary repair regardless of the interval between injury and operation, except when the esophagus is in such poor condition that esophagectomy is the only option.

Synchronous electrogastrographic and manometric study of the stomach as an esophageal substitute

AIM: To investigate the electric and contractile mechanisms involved in the deranged function of the transposed stomach in relation to the course of the symptoms and the changes in contractile and electrical parameters over time.

METHODS: Twenty-one patients after subtotal esoph-agectomy and 18 healthy volunteers were studied. Complaints were compiled by using a questionnaire, and a symptom score was formed. Synchronous electrogas-trography and gastric manometry were performed in the fasting state and postprandially.

RESULTS: Eight of the operated patients were symptom-free and 13 had symptoms. The durations of the postoperative periods for the symptomatic (9.1±6.5 mo) and the asymptomatic (28.3±8.8 mo) patients were significantly different. The symptom score correlated negatively with the time that had elapsed since the operation. The percentages of the dominant frequency in the normogastric, bradygastric and tachygastric ranges differed significantly between the controls and the patients. A significant difference was detected between the power ratio of the controls and that of the patients. The occurrence of tachygastria in the symptomatic and the symptom-free patients correlated negatively both with the time that had elapsed and with the symptom score. There was a significant increase in motility index after feeding in the controls, but not in the patients. The contractile activity of the stomach increased both in the controls and in the symptom-free patients. In contrast, in the group of symptomatic patients, the contractile activity decreased postprandially as compared with the fasting state.

CONCLUSION: The patients’ post-operative complaints and symptoms change during the post-operative period and correlate with the parameters of the myoelectric and contractile activities of the stomach. Tachygastria seems to be the major pathogenetic factor involved in the contractile dysfunction.

Evolving options in the management of esophageal perforation

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

Selective approach in the treatment of esophageal perforations

BACKGROUND

Treatment of esophageal perforation remains controversial and recommendations vary from initially non-operative to aggressive surgical management. Several factors are responsible for this life-threatening event, which has led to more individualized treatment ensuring adequate pleuromediastinal drainage with sufficient irrigation. We analyzed our data, evaluating morbidity and mortality in this selective approach.

METHODS

During 1985 to 2001, 17 of the 38 patients with esophageal perforation treated in our hospital underwent primarily a thoracotomy, wide drainage and debridement of chest/ mediastinum and enteral hyperalimentation. Twenty-one patients (55%) initially were treated non-operatively (NPO, nasogastric tube, hyperalimentation, antibiotics and chest tube), but surgery was required in 9 patients (43%).

RESULTS

Most perforations were iatrogenic (45%; 17/38) followed by spontaneous perforations (32%; 12/38). Cervical perforations were managed earlier (< 24 h) than thoracic tears, 8/10 (80%) and 17/28 (61%) respectively. Initial conservative treatment failed in all spontaneous ruptures and more in thoracic lesions (62%) than in cervical lesions (13%). Most patients with thoracic perforations and 'free' intrathoracic contamination underwent primary surgery. Surgery with adequate drainage (n = 23) was based on signs of sepsis, empyema and progression of pneumomediastinum/thorax. Mortality occurred in one patient (3%), initially treated conservatively. Median intensive care and duration of hospitalization were not different between the conservative (5 and 7 days, respectively) and the primary surgical approach (21 and 27 days, respectively), but were higher after secondary surgery (13 and 50 days, respectively).

CONCLUSIONS

Spontaneous esophageal perforations require early surgical exploration with drainage and irrigation of mediastinum and pleural cavity, while most iatrogenic lesions can be managed conservatively. Cervical perforations can be treated adequately non-operatively, but thoracic perforations often require surgical intervention.

Ruptures spontanées de l’œsophage

INTRODUCTION

Spontaneous rupture of the oesophagus, also called Boerhaave's syndrome, is rare. Since its clinical manifestations are non specific, it must be evoked when confronted the sudden onset of chest or upper abdominal pain.

OBSERVATIONS

Two patients were admitted to the emergency department with severe chest pain associated with vomiting. The CT scan obtained rapidly, revealed the perforation of the oesophagus. Despite early surgical treatment, only one patient survived, the second died of infectious complications.

COMMENTS

Boerhaave's syndrome is fatal unless promptly recognized and adequately treated. A CT scan of the chest is the procedure of choice demonstrating the rupture.

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery]

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

Delayed Esophageal Injury Without Instrumentation Failure

The authors describe a case of a 67-year-old man who presented with a delayed esophageal perforation 4 years after anterior cervical spine surgery for spondylotic myelopathy. Diagnosis was made with esophagoscopic visualization of the lesion and repair performed with hardware removal and esophageal closure utilizing a sternocleidomastoid muscle flap. The pertinent literature is reviewed and the therapeutic implications discussed.

Boerhaave's syndrome: 10 years experience and review of the literature

BACKGROUND

Spontaneous oesophageal rupture, also known as Boerhaave's syndrome, is a rare condition. It has a high mortality and its management is clouded with controversy.

METHODS

A retrospective review of cases presenting to Middlemore Hospital over a period of 10 years was performed.

RESULTS

A total of eight patients were found to have spontaneous oesophageal perforation. Six were managed operatively and two were managed non-operatively. There were seven men and one woman, whose ages ranged from 37 to 80 years (median: 64 years) at presentation. Six patients underwent thoracotomy. Five patients had primary closure of oesophageal perforation, two of these with tissue reinforcement. One patient underwent lavage alone without primary closure because there was widespread inflammation from the perforation. Two of the patients were managed non-operatively. Both subsequently died. The median postoperative stay was 36 days (range: 12-60 days). There was no postoperative mortality.

CONCLUSION

Boerhaave's syndrome is rare and its management is not uniform. A review of the literature demonstrates wide disparity in management due to the rarity of the condition. Primary repair is appropriate for ruptures diagnosed early. Many are diagnosed late and T-tube drainage may be the simplest way to manage this difficult condition in this situation.

Thoracic esophageal perforations: a decade of experience

BACKGROUND

Perforation of the thoracic esophagus is a formidable challenge. Treatment and outcome are largely determined by the time to presentation. We reviewed our experience with esophageal perforations to determine the overall mortality and whether the time to presentation should influence management strategy.

METHODS

A retrospective chart review was performed on all patients treated for perforation of the thoracic esophagus from 1990 to 2001. There were 26 patients (14 men and 12 women; median age, 62 years; range, 36 to 89 years). Fourteen patients presented within 24 hours (early), and 12 patients presented after 24 hours (delayed). Nine of the 12 patients in the delayed group presented after 72 hours. The causes of the perforations were as follows: instrumentation (19 patients), Boerhaave's syndrome (2 patients), intraoperative injury (1 patient), and other (4 patients). In the early group, 3 patients were treated conservatively, 10 patients underwent primary repair, and 1 patient required esophagectomy for carcinoma. In the delayed group, 3 patients were treated conservatively, 6 underwent successful repair of the perforation, 1 had a T-tube placement through the perforation and eventually required an esophagectomy, and 2 had an esophagectomy as primary surgical treatment.

RESULTS

Hospital mortality was 3.8% (1 of 26) and morbidity was 38% (10 of 26). Persistent leaks occurred in 3 patients, 2 after primary repair and 1 after T-tube drainage. All patients selected for conservative management successfully healed their perforation.

CONCLUSIONS

Primary repair can be carried out in most cases of thoracic esophageal perforation regardless of time to presentation, with a low mortality rate. A small but carefully selected group of patients may be treated successfully without operation. Esophagectomy should be reserved for patients with carcinoma or extensive necrosis of the esophagus.

Surgery in thoracic esophageal perforation: primary repair is feasible

Prompt diagnosis and effective treatment are important for thoracic esophageal perforations. The decision for proper management is difficult especially when diagnosed late. However, there is an increasing consensus that primary repair provides good results for repair of thoracic esophageal perforations, which are not diagnosed on time. Primary repair for thoracic esophageal perforations was applied in 20 out of 25 consecutive patients. The time interval between perforation and repair was less than 24 h in six patients (group I), and more than 24 h in 14 patients (group II). The remaining five patients underwent esophagectomy with simultaneous or staged reconstruction because of incorrectable underlying esophageal pathology. Group I had much more iatrogenic causes (P < 0.05). Preoperative sepsis occurred only in group II (P=0.05) and was highly associated with Boerhaave syndrome (P=0.001). Regional viable tissue was used to reinforce the sites of primary repair (n=15, 75%). All of the postoperative morbidity (n=9, 45%) including esophageal leaks (n=6, 30%) and operative death (n=1, 5%) occurred in group II. In patients with postoperative leaks, five eventually healed, but one became a fistula that required reoperation. Primary healing with preservation of the native esophagus was achieved in all 19 patients except one operative death. In addition, the increased incidence of leak and morbidity did not lead to an increase in mortality. In the esophagectomy group, there was no mortality, but one minor suture leak. Regardless of the time interval between the injury and the operation, primary repair is recommended for non-malignant, thoracic, esophageal perforations, but not for anastomotic leaks. Reinforcement that may change the nature of a possible leak is also useful. For incorrectable underlying esophageal pathology, esophagectomy with simultaneous or staged reconstruction is indicated.

Simultaneous surgical management of iatrogenic pharyngeal perforation and distal esophageal malignancy

Instrumental perforation of the pharynx with distal obstruction is a complex problem. A fistula is not likely to close in the presence of distal obstruction. The stenotic lesion needs to be treated in addition to the perforation. We report a 83-year-old female patient who underwent three-stage total esophagectomy and right cervical pharyngo-gastric anastomosis for iatrogenic pharyngeal perforation and distal esophageal malignancy. The radical surgical approach has the advantage of treating the immediate crisis due to perforation and also treating the stricture for which the esophagoscopy was originally performed.

Successful primary reinforced repair of esophageal perforation using a pedicled omental graft through a transhiatal approach

Esophageal perforation is potentially lethal if untreated. We report a case of distal esophageal perforation probably caused by swallowing a fish bone. The patient initially received conservative treatment 4 days after the esophageal injury. The treatment was promptly changed from conservative to operative treatment owing to rapid manifestation of suppurative mediastinitis followed by peritonitis. The patient successfully underwent primary repair of the perforation buttressed with a pedicled omental graft pulled up through the esophageal hiatus following a laparotomy. We discuss the validity of this method of transhiatal approach without thoracotomy for primary repair of distal esophageal perforation.

Treatment of chronic contained spontaneous esophageal perforations

Spontaneous esophageal perforations are associated with a high mortality and morbidity without surgery. The treatment mortality for early (<24) and late (>24 h) spontaneous esophageal perforations is reviewed as well as all recent cases of chronic spontaneous esophageal perforations. Chronic esophageal perforations with mediastinal cavities may be best treated by internal drainage of the cavity into the esophagus in order to convert the transmural perforation into an intramural esophageal dissection.

Esophagectomy and staged reconstruction

OBJECTIVE

Esophageal resection with diversion and staged reconstruction of the upper gastrointestinal (GI) tract is an option in the management of complex problems. This study characterizes circumstances, indications, outcomes and their predictors for staged reconstruction, and estimates the optimal timing for reconstruction.

METHODS

Between October 1981 and March 1999, 43 patients were identified with planned staged reconstruction. Twenty-six had esophageal cancer, and 17 had complications of benign disease. Primary diversion with esophageal resection was needed in 16 patients, and secondary diversion with takedown of previous esophageal reconstruction was needed in 27. Common indications were failed esophageal anastomosis and esophageal perforation. Death before and death after reconstruction were considered as competing risks. Multivariable analyses were used to estimate the optimal timing of reconstruction.

RESULTS

The survival was 75, 21 and 9% at 3 months, 5 and 10 years, with survival only somewhat better (P=0. 06) among patients having benign versus malignant disease. A similar proportion of patients died before reconstruction as underwent reconstruction, resulting in only 17 reconstructions, typically 9 months after diversion. The risk factors for death included cancer and primary diversion. The survival was best for benign disease when reconstruction was early. The survival was poor after reconstruction in the few patients with malignant disease.

CONCLUSIONS

Patients requiring staged esophageal reconstruction are heterogeneous, with malignant or benign disease, and primary or secondary diversion. The outcome is poor, and is influenced by the pathology and timing of diversion. Patients with benign disease should be reconstructed as early as feasible; reconstruction is rarely indicated for patients with cancer.