Esophageal perforation: the importance of early diagnosis and primary repair

Surgical repair of long-segment cervical esophageal injury with a sternocleidomastoid myocutaneous flap

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.

[Emergency interventions for perforation and bleeding in esophageal cancer patients]

Bleeding and perforation in esophageal cancer patients are rare but associated with a high morbidity and mortality. Because of disappointing results after primary surgical exploration and resection endoscopic intervention was introduced as the primary treatment option with an improved outcome. Aortoesophageal and esophagobronchial fistulas may occur spontaneously or secondary to stenting of the esophagus. They are uncommon but fatal if untreated. The first option is prompt placement of a stent graft as a bridging solution followed by surgical treatment.

Endoscopic management for delayed diagnosis of a foreign body penetrating the esophagus into the lung

A 31-year-old male presented with chest pain started after eating chicken about 2 weeks earlier. Upper endoscopy and Computed tomography scan of the chest revealed a sharp chicken bone penetrating the esophageal wall into the right lung. The foreign body was removed endoscopically using a rat-tooth forceps, followed by prophylactic placement of a metal stent across the esophageal perforation site. Foreign body-induced perforation is one of the common etiologies of benign esophageal perforations. Although the primary treatment is surgery, endoscopic therapy may be appropriate in individualized cases like our patient.

Treatment of cervical esophageal perforation caused by foreign bodies

In this article, we reviewed our experience of treatment of cervical esophageal perforation caused by foreign bodies. Between 1980 and 2010, 42 patients were included in this study. There were 18 women and 24 men with a median age of 54 years. We divided the patients into three groups: the patients whose foreign bodies could not be extracted by otolaryngologists using endoscope (n= 7), the patients who had some signs of abscess formation but the foreign bodies had been extracted using endoscope (n= 25), and the patients who had no signs of abscess formation and the foreign bodies had been extracted (n= 10). We treated the patients of the three groups with surgical treatment, drainage alone, and conservative treatment, respectively. The outcome of the current series was favorable. Our experience suggested that most of the cases can be treated conservatively or by drainage alone. If the foreign bodies of the esophagus could not be extracted using endoscope, surgical treatment including the removal of the foreign bodies, primary repair, and drainage should be performed.

Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience

BACKGROUND

Perforation of the esophagus remains a challenging clinical problem.

METHODS

A retrospective review was performed of patients diagnosed with an esophageal perforation admitted to the London Health Sciences Centre from 1981 to 2007. Univariate and multivariate logistic regression was used to determine which factors had a statistically significant effect on mortality.

RESULTS

There were 119 patients; 15 with cervical, 95 with thoracic, and 9 with abdominal perforations. Fifty-one percent of all the perforations were iatrogenic and 33% were spontaneous. Multivariate logistic regression analysis revealed that patients with preoperative respiratory failure requiring mechanical ventilation had a mortality odds ratio of 32.4 (95% confidence interval [CI] 3.1 to 272.0), followed by malignant perforations with 20.2 (95% CI 5.4 to 115.6), a Charlson comorbidity index of 7.1 or greater with 19.6 (95% CI 4.8 to 84.9), the presence of a pulmonary comorbidity with 13.9 (95% CI 2.9 to 97.4), and sepsis with 3.1 (95% CI 1.0 to 10.1). A wait time of greater than 24 hours was not associated with an increased risk of mortality (p=0.52).

CONCLUSIONS

Malignant perforations, sepsis, mechanical ventilation at presentation, a higher overall burden of comorbidity, and a pulmonary comorbidity have a significant impact on the overall survival. Time to treatment is not as important. Restoration of intestinal continuity, either by primary repair or by excision and reanastomosis can be attempted even in patients with a greater time from perforation to treatment with respectable morbidity and mortality rates.

Treatment of Boerhaave's Syndrome

Boerhaave's syndrome is the spontaneous transmural rupture of the esophagus. A high degree of clinical suspicion is a prerequisite for its prompt diagnosis, and early therapeutic intervention reduces its associated morbidity and mortality. Factors that influence the outcome are location and extent of perforation and the timing of medical or surgical treatment. Boerhaave's syndrome is the most lethal perforation of the gastrointestinal tract. Delay in intervention relates directly to increased mortality. Despite advances in surgical techniques and endoscopic therapies, this disorder still has high morbidity and mortality rates. The outcome of patients with this disorder is dependent upon the prompt and accurate diagnosis. Initial stabilization of the patient with intravenous fluids and antibiotics is of key importance, with subsequent decisive therapy initiated using either a conservative medical or endoscopic or surgical approach. Boerhaave's syndrome often occurs in otherwise-relatively healthy patients. This postemetic perforation of the esophagus can result in a devastating injury that usually is exacerbated by delayed diagnosis. This article will focus on its clinical presentations and review its potentially applicable therapies.

Thoracic Esophageal Perforations

The authors review their experience with thoracic esophageal perforation at Inova Fairfax Hospital, June 1, 1988, to March 1, 2009. With the exception of 6 patients with occult perforation, all of whom survived with nonoperative therapy, aggressive surgical intervention was the standard approach. Among patients treated aggressively with surgery within 24 hours of perforation, hospital survival was 97 per cent versus 89 per cent for patients treated aggressively surgically after 24 hours. In the absence of phlegmon, implacable obstruction, or delay, primary repair resulted in 100 per cent survival. Where phlegmon or resolute obstruction existed, resection and reconstruction resulted in 96 per cent survival. Even when patients were deemed too ill to undergo surgery, cervical diversion was 100 per cent effective in eradicating continuing leak and achieved 89 per cent survival. Endoesophageal stenting was applied as primary treatment or secondarily such as where leak complicated primary repair. When stenting was used as the initial and primary treatment modality, survival was 88 per cent. Targeted drainage was helpful on occasion as an adjunct to initial therapies. Comfort measures alone were appropriate when clinical circumstances merited no effort at resuscitation. Finally, survivors were asked to self-categorize their ability to swallow; 95 per cent responded good to excellent.

Management of esophageal perforations

BACKGROUND

Esophageal perforations remain a life-threatening event requiring rapid diagnosis and treatment. Surgical repair and interventional endoscopic or conservative treatment are the common treatment methods.

METHODS

From 1998 to 2006, the authors retrospectively analyzed 62 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, therapeutic regimen, complications, and mortality.

RESULTS

The causes of perforation were iatrogenic or suicidal (n = 33) or spontaneous (n = 29). In the first group, the causes were dilation of stenosis (n = 16), endoscopy (n = 7), transesophageal echography (n = 4), ingestion of acid or leach (n = 2), intubation (n = 2), ingestion of a foreign body (n = 1), and migration of a screw after osteosynthesis (n = 1). The spontaneous perforations were caused by tumors (n = 19), Boerhaave syndrome (n = 6), unknown origin (n = 3), and Barrett's ulcer (n = 1). The most frequent symptoms were dysphagia (n = 50), pain (n = 35), fever (n = 24), and vomiting (n = 18). At the time of perforation, 28 patients presented with cancer. Of these 28 patients, 18 had esophageal cancer. The treatment included surgery (n = 32), which consisted of double-layer suture (n = 26) or esophageal resection (n = 6). A total of 30 patients were treated interventionally with a stent (n = 21), clips (n = 1), or without further measures (n = 8). The patients in the surgery group presented with severe primary and postoperative general conditions including renal failure (25%), respiratory insufficiency (65.5%), and need for catecholamines (62.5%). This multiorgan involvement was found only occasionally in the conservative group. The overall hospital mortality rate was 14.5%, involving 9 patients (5 in the surgery group and 4 in the conservative group). Early treatment led to better survival than late treatment with a delay exceeding 24 h.

CONCLUSION

The treatment method still must be chosen on an individual basis. It appears that surgical treatment is necessary in cases of severe general conditions. The data from this study show that surgical repair and conservative treatment may be used successfully. The best outcome was obtained after immediate treatment.

Options in the management of esophageal perforation: analysis over a 12-year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

High-risk chief complaints I: chest pain--the big three

Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

Unique case of esophageal rupture after a fall from height

Background

Traumatic ruptures of the esophagus are relatively rare. This condition is associated with high morbidity and mortality. Most traumatic ruptures occur after motor vehicle accidents.

Case Presentation

We describe a unique case of a 23 year old woman that presented at our trauma resuscitation room after a fall from 8 meters. During physical examination there were no clinical signs of life-threatening injuries. She did however have a massive amount of subcutaneous emphysema of the chest and neck and pneumomediastinum. Flexible laryngoscopy revealed a lesion in the upper esophagus just below the level of the upper esophageal sphincter. Despite preventive administration of intravenous antibiotics and nutrition via a nasogastric tube, the patient developed a cervical abscess, which drained spontaneously. Normal diet was gradually resumed after 2.5 weeks and the patient was discharged in a reasonable condition 3 weeks after the accident.

Conclusions

This case report presents a high cervical esophageal rupture without associated local injuries after a fall from height.

PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis

OBJECTIVES

PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening.

METHODS

Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model.

RESULTS

Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results.

CONCLUSIONS

PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.

Do foreign bodies migrate through the body towards the heart?

Fixation of foreign bodies (FB), in the mucosa, can favor its migration, giving origin to the popular saying: “FB walk to the heart”.

Aim

describe the mechanisms involved in FB migration and how to diagnose them.

Methodology

From a sample of 3,000 foreign bodies, during 40 years, we analyzed four which had extra-lumen migration. We analyzed clinical, radiologic, endoscopic and ultrasound data collected at the medical documentation service.

Results

three clinical histories are presented, describing two fish bones and one piece of fish cartilage. FB shifting was analyzed in all of them. Migration started in the esophagus in two, one going to the aorta and the other to the neck area. In the other two, migration started in the pharynx, and the FB moved towards the prevertebral fascia and the other externalized in the submandibular region. The mechanisms and the risks posed to the patient, by FB migration, and the way to diagnose them are hereby discussed.

Conclusions

the study allows us to determine that FB can move through the body but not towards the heart. The study also serves as a warning sign: in cases of prolonged histories of FB ingestion, imaging studies are mandatory before endoscopic examination.

How to treat esophageal perforations when determinants and predictors of mortality are considered

BACKGROUND

Published lethality rates of esophageal perforation (EP) vary depending on patient- and disease-related factors. This study was designed to evaluate how these factors impact death. Furthermore, we calculated the predictive accuracy of the Mortality Prediction Model (MPM II) and the Simplified Acute Physiology Score (SAPS II) for in-hospital death. Conclusions about treatment decisions were drawn based on our data and analysis of recent literature.

METHODS

Every patient who was treated for EP at our department from December 2001 to July 2008 is included in this study. Logistic regression analyses of various risk factors, such as etiology, time interval, size, comorbidities, localization, type of treatment, and preexisting pathologies of the esophagus on death, were performed.

RESULTS

Of the 41 patients diagnosed with EP, nine died (21%). The most important risk factor concerning death was cirrhosis of the liver (0 vs. 89% mortality; odds ratio, 208; P<0.001). Accuracy for lethality risk prediction was calculated with MPM II and SAPS II on admission, and afterward the characteristic increase that occurred was evaluated by using receiver operator characteristic curves. Optimal results were achieved by using a characteristic SAPS II increase (AUC 0.86; P: 0.009) after the patient was admitted to the intensive care unit.

CONCLUSIONS

Our study was the first to demonstrate that a rapid or continuous increase more than 40 of the daily SAPS II clearly indicates that a high risk of death is imminent. This should be used as a reevaluation factor when choosing a treatment strategy.

Imaging presentations of esophageal perforation

AIM: To illustrate imaging presentations related to esophageal perforation and their significance for therapeutic decisions.

METHODS: We studied 21 patients with suspected esophageal injury from June 2002 to October 2008 at our hospital. Ten patients underwent standard chest radiography and 2 patients were submitted to cervical plain film, while 11 patients with suspected esophageal perforation were submitted to gastrografin swallow study (7 with iodine and 4 with barium). Nine patients underwent row spiral CT examination (2 with enhancement). Imaging presentations were compared and analyzed.

RESULTS: Chest radiography (n = 10) revealed hydropneumothorax in 4/10 and pleural effusions in 4/10, and pulmonary infection were observed in 3/10; Changes of mediastinum were seen in 7/10 patients, pneumomediastinum in 3 cases, mediastinum widen in 3 cases, and air-fluid level in 1 case. Subcutaneous emphysema in the neck, chest was noted in 4/10. Esophagography (n = 11) demonstrated contrast medium extravasation in 9/11, indicating a submucosal contrast medium collection in 4/11, except for 2 cases with negative finding. Enhanced CT scans (n = 9) revealed periesophageal air and fluid collections with irregular soft tissue masses in 5/11 patients, thicken wall with typical localization in 4/11, abscess formation in mediastinum or under diaphragm in 4/11. Contrast-enhanced CT (n = 2) demonstrated abscess formation with contrast enhancement of the margins.

CONCLUSION: Esophagography and CT examination are the main diagnosis methods for suspected esophageal perforation. CT findings of inflammatory reaction for esophageal perforation are especially important for surgical treatment.

Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent

In this article, we reviewed our experience of treatment of the delayed intrathoracic nonmalignant esophageal perforation employing modified intraluminal esophageal stent. Between February 1990 and August 2006, eight patients were included in this study. Five patients experienced sepsis. The interval time between perforation and stent placement ranged from 36 h to 27 days (average, 8.6 days). Esophageal stenting and throracotomy for foreign body removal were performed in four patients. The remaining four patients underwent stent placement and thoracostomy. Nutrition was initiated through gastrostomy after 7 to 10 days after the stenting. The stent was removed after the patients resumed oral intake of food and the esophagogram showed that perforation was closed. There was no death in this group. Signs of sepsis remitted 1 week after stent placement. Complications included stress ulcer, stimulative cough, and pneumonia each. Stent removal ranged 32 to 120 days (average 66.7) after its placement. The stent was kept in place for 4 months to prevent formation of esophageal stricture in one patient with caustic esophageal burns. The follow-up was completed in all the patients. The mean follow-up period was 59 months (range 12-180). One patient with caustic esophageal burn underwent cicatricial esophagectomy and gastric transposition 3 years later due to the esophageal stricture. Barium swallow demonstrated that there was a diverticulum-like outpouching in one patient and slight esophageal stricture at T2 and T3 level in another. One patient developed reflux esophagitis 5 years after stent removal. All the patients finally had a normal intake of food. Modified esophageal stenting is an effective method to manage the delayed intrathoracic esophageal perforation. Prevention of stent migration and its convenient adjustment might be the major advantages of this method.

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.

Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations

BACKGROUND

Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center.

METHODS

Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured.

RESULTS

Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%).

CONCLUSIONS

Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.

Primary esophageal repair in Boerhaave's syndrome

Boerhaave's syndrome is the most severe disease in the esophageal perforation. The purpose of this report is to evaluate the outcome in patients who were treated with primary repair for Boerhaave's syndrome regardless of the time interval. From 1997 to July 2007, 10 patients with Boerhaave's syndrome were treated with primary repair regardless of the time interval. The interval between rupture and initial treatment was less than 24 hours in five patients (50.0%) and more than 24 hours in the other five patients (50.0%). There was no operative mortality and five postoperative leaks. Of these five patients with postoperative leaks, one received primary repair for less than 24 hours (20%) and four received operation for more than 24 hours (80%). However, postoperative leaks were managed by non-operative methods and resolved within 2 weeks. The time interval between perforation and operative intervention should not prejudice the surgeon against primary repair of Boerhaave's syndrome. Although a high incidence of postoperative leak occurred in patients who were operated on for more than 24 hours, its management is not hard to perform and its prognosis was not poor.

Risk factors for surgical site infection after surgery for esophageal perforation

Esophageal perforations carry a high potential for morbidity and mortality. The prognosis depends on rapid and precise diagnosis and management. Surgical site infections (SSIs) are very common following the surgical treatment of esophageal lesions. We aimed identify significant risk factors for SSI after surgery for esophageal perforation via an historical cohort study including patients who underwent surgical management of esophageal perforation. The predictive variables were analyzed by bivariate analysis and multiple logistic regression. Eighty-one patients were studied during a 10-year period ending in 2004. The mean age was 42.6 years. In 44% of the patients the time interval between the perforation and surgery was up to 6 h and in 30% it was > 24 h. Associated lesions occurred in other cavities; 17% in the chest, 5% in the abdomen, 5% in the extremities, 4% in the spinal column and bone marrow and 2% in the face. There were grade I lesions in eight cases (10%), grade II in 64 cases (79%) and grade III in nine cases (11%). The mean time of surgery procedure was 117.2 min. The mean SSI was 7.99. SSIs occurred in 33 patients (41%). The risk factors for SSI following surgical management of esophageal perforation were: age > or = 50 years, time delay to treatment > 24 h, associated lesion in another cavity and Injury Severity Score > or = 15.

Treatment of perforation in the healthy esophagus: analysis of 12 cases

BACKGROUND

Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice.

MATERIALS AND METHODS

We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out.

RESULTS

Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045).

CONCLUSIONS

The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

The Sealing Effect of a Fibrin Tissue Patch on the Esophageal Perforation Area in Primary Repair

BACKGROUND

The aim of this study was to investigate the efficacy of the fibrin tissue patch and to analyze its use in patients with esophageal perforation.

METHODS

We studied 28 patients who were diagnosed with esophageal perforation between January 1990 and January 2006 at Akdeniz University Hospital. Sixteen (57.14%) were male. The average age was 59 +/- 9 years. We performed surgery and primary repair reinforcement even if the diagnosis of esophageal perforation was late.

RESULTS

Twenty-three (82.14%) perforations were the result of endoscopic instruments; spontaneous perforations occurred in three (10.71%) patients. Postoperative complication (Heller myotomy) caused perforation in one patient (3.57%) and blunt trauma in one patient (3.57%). Three (10.71%) patients had cervical perforation, and 25 (89.29%) patients had thoracic esophageal perforation. Twelve (42.86%) patients underwent emergency surgery (within the first 24 h). Ten (35.71%) patients underwent surgery within 48 h, and the remaining 6 (21.43%) underwent surgery after 48 h. Nine (32.14%) patients had primary repair, 7 (25%) had reinforcement of the primary repair with fibrin tissue patch, 7 (25%) had esophagectomy and gastric pull-up, and 2 (7.14%) had drainage and placement of metallic stents. In four patients of the nine who had primary repair, fistula complication was detected, whereas in only one of the seven who had reinforcement of the primary repair with fibrin tissue patch was a fistula detected. Three patients (10.71%), two of whom had Boerhaave's syndrome, died.

CONCLUSIONS

Surgical primary repair with fibrin tissue patch is the most successful treatment option in the management of esophageal perforation.

Boerhaave syndrome--unusual cause of chest pain

Spontaneous esophageal rupture (Boerhaave syndrome) is uncommon in children. Delayed or missed diagnosis can lead to poor outcomes in terms of morbidity and mortality. To highlight the importance of early recognition and management of spontaneous esophageal rupture in children, we report a case of a 16-year-old boy who presented in the emergency department with acute chest pain after episodes of vomiting.

Recurrent Subcutaneous Emphysema of the Face

In the neck or face, there are different causes for subcutaneous emphysema such as injury to the sinuses, the hypopharynx, the laryngotracheal complex, the pulmonary parenchyma, the esophagus or the presence of gas-forming organisms. However, factitious subcutaneous emphysema, a rare cause, must be considered in the differential diagnosis. In this clinical report, we discuss a 20-year-old girl who was under follow-up because of recurrent subcutaneous emphysema of the face and periorbital area. After 2 years of work-ups, including a period of close observation in the intensive care unit, self air injection by syringe was found as the cause of recurrent subcutaneous emphysema of the face, and the patient was labeled as having factitious recurrent subcutaneous emphysema. Therefore, when a patient presents with unexplained recurrent subcutaneous emphysema, one should suspect self-infliction and examine for puncture marks.

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.

Identifying Chest Pain Emergencies in the Primary Care Setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.

Repairing Esophageal Perforations With a Transverse Cervical Musculofascial Flap

OBJECTIVES/HYPOTHESIS

Although rare, perforations of the esophagus following spinal surgery via an anterior approach are serious life-threatening problems. Complications include abscess formation, mediastinitis, sepsis, and fistula that can carry a mortality rate of 20%-50%. Early diagnosis and treatment are imperative. A common method of repair is isolation and primary repair of the defect in the esophagus, with interpositional muscle coverage. A transverse cervical myofascial artery flap is described here as a potential reconstructive option.

STUDY DESIGN/METHODS

Retrospective review was performed on 3 patients who had repair of esophageal perforations following spinal surgery with an anterior approach.

RESULTS

In all 3 cases, hardware was found to be eroding through the esophagus. The hardware was removed at the time of repair and flap coverage in 2 patients, and each went on to an oral diet within 10 days without complication, with follow-up exceeding 6 months. A third patient with recurrent erosions could not have the hardware removed and subsequently suffered with another erosion through the muscle flap. A secondary surgery with pectoralis flap coverage was successful but required revision surgeries for flap debulking. No patients had limitation of shoulder movement after flap reconstruction, and all went on to a normal diet without dysphagia.

CONCLUSIONS

The transverse cervical artery musculofascial flap can be an ideal method for repair of small cervical esophageal perforations, although spinal hardware should be removed if felt to be the etiology of the perforation.

Nonvascular Mediastinal Trauma

This article discusses the radiologic and clinical features of nonvascular mediastinal trauma, and focuses on the tracheobronchial tree, the esophagus, and the thoracic duct. Blunt chest and penetrating trauma account for most of the causes of such nonvascular injuries, but iatrogenic and inhalation injuries are other well-known causes. The injury distribution and clinical manifestations are different for each structure. In our combined experience at a level 1 trauma center, the overall prevalence of injury in each organ is low compared with vascular injuries. As such, and given the frequent nonspecific nature of clinical signs and symptoms of nonvascular mediastinal injuries, the diagnosis often is delayed and results in poor treatment outcome.

Thoracic esophageal perforation: one surgeon's experience

Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.

[Emergency management of thoracic trauma]

Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.

Spontaneous perforation in the ringed esophagus

A 54-year-old man presented to the ER with chest pain. He underwent an upper endoscopy revealing a large linear esophageal tear and a CT chest showed free air in the mediastinum. He was managed conservatively and was discharged 2 days later. An UGI series revealed a distal esophageal stricture. He was commenced on esomeprazole for gastroesophageal reflux symptoms and his dysphagia improved significantly. Upper endoscopy revealed multiple rings throughout the esophagus. Biopsies from the distal and mid-esophagus were normal. The underlying pathophysiology, in patients with dysphagia and a ringed esophagus has evoked debate in the literature. Opinions range from underlying gastroesophageal reflux disease (GERD) to eosinophilic esophagitis (EE). Our patient's symptoms of GERD and dysphagia resolved with proton pump inhibitor therapy. Normal histology excluded underlying EE. There have been a few case reports of esophageal perforation in patients with a ringed esophagus, and underlying EE, but none with spontaneous perforation occurring in a 'ringed esophagus'. Perforations in the upper and mid-esophagus can usually be managed conservatively, while those in the distal esophagus often need surgery due to the high risk of developing mediastinitis. However, our patient, despite sustaining a large tear in the distal esophagus, did well with conservative management. This case demonstrates that spontaneous perforation in the ringed esophagus, with normal underlying histology can occur in the distal esophagus and may not require surgery.

Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations

Esophageal perforations are surgical emergencies with high mortality rates. A variety of treatment strategies have been advocated. No single strategy has however, been fully applicable to deal with most situations. The aim of this study was to investigate if treatment with covered expandable metallic stents could offer a feasible option for the management of a leaking esophagus regardless of cause. Twenty-two consecutive patients with perforation or leakage from the intrathoracic esophagus were endoscopically treated with placement of a covered expandable metallic stent. Nine patients had esophageal cancer and 13 had benign underlying disease of whom two had a leakage from a surgical anastomosis. The leakage could be sealed in all but one patient. This patient died after an open esophageal diversion procedure. Twelve patients had an uneventful recovery, whereas three patients needed percutaneous drainage of abscesses and one drainage of the pleural cavity through a small thoracotomy. One patient required a conventional thoracotomy to drain the mediastinum. In total five (23%) patients died from the perforation within 30 days. Two of the deaths were unrelated and three (14%) related to the perforation. In patients with benign disease stents were removed or replaced after 3 weeks. In total 17 stents were successfully removed. Leakage from a damage esophagus can be effectively covered by expandable metallic stents seemingly regardless of the underlying cause and is likely to offer a good chance of survival even in severely ill patients.