Epidemiology, diagnosis, and management of esophageal perforations: systematic review

Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report

A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.

Endoluminal Therapies for Esophageal Perforations and Leaks

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Surgical management of early and late esophageal perforation

Introduction

Esophageal perforation is a rare and life-threating problem with a 10%–40% mortality rate. Early diagnosis and treatment are important for prevention of complications. Strategies for treatment of esophageal perforation have been controversial for many years, especially in cases of late presentation.

Methods

We prospectively studied 27 patients (12 male, 17 female, mean age 42.7 ± 17.8 years) who presented with esophageal perforation from 1996 to 2015, and evaluated the results of surgical treatment. The patients were divided into 3 groups according to time of presentation: early (<24 h), intermediate (24–72 h), and late (>72 h). We also considered the etiology and site of esophageal perforation, complications, and mortality.

Results

Surgery was performed in 5 patients in the early group, 7 in the moderate group, and 15 in the late group. Primary repair was carried out in 5 cases, primary repair and reinforcement with a flap in 10, esophageal resection and reconstruction in 8, and a T-tube stent was used in 4. Four patients developed a fistula postoperatively, and there was one death due to respiratory failure. No relationship was found between complications and the cause of perforation, time of presentation, or type of treatment.

Conclusion

In patients without sepsis, primary repair can be an option even in those presenting late after esophageal perforation, with an acceptable result.