Oesophageal perforation: primary suture repair reinforced with absorbable mesh and fibrin glue

Conservative surgical management of Boerhaave's syndrome: experience of two tertiary referral centers

BACKGROUND

Surgery is generally proposed for Boerhaave's syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers.

METHODS

From June 1985 to November 2010, among 53 patients presenting with Boerhaave's syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S).

RESULTS

Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021).

CONCLUSIONS

These findings from the largest reported cohort of Boerhaave's syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.

Surgical treatment of esophageal perforations: the importance of a primary repair

PURPOSE

The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis.

METHODS

All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients.

RESULTS

The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19).

CONCLUSIONS

Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.

Successful surgical treatment of a spontaneous rupture of the esophagus diagnosed two days after onset

Esophageal perforation is a relatively uncommon disease with a high rate of mortality and morbidity. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40–60%. Primary repair is generally considered the gold standard for patients who present within the first 24 h following perforation of the esophagus. In this paper, we present a case of successful surgical treatment of spontaneous rupture of the esophagus that was diagnosed 2 days after onset. The patient was a 42-year-old man admitted to internal medicine with a diagnosis of pleuritis and complaining of chest and back pain. The next day, computed tomography revealed left-sided pleural effusion and mediastinal emphysema. An esophagogram revealed extravasation of the contrast medium from the lower left esophagus to the mediastinal cavity. These results confirmed a rupture of the esophagus, and an emergency left thoracotomy was performed. The perforation was repaired with a single-layered closure and was covered with elevated great omentum obtained by laparotomy. The patient was discharged 23 days after the first surgery. In conclusion, primary repair surgery must be selected as the best treatment beyond 24 h if the patient's general state was stable and there was no evidence of clinical sepsis.

A successful strategy for surgical treatment of Boerhaave's syndrome

BACKGROUND

This retrospective single-institution study presents a successful treatment strategy for Boerhaave's syndrome.

METHODS

During 1995-2008, 15 patients with spontaneous esophageal perforation were treated. Patients were grouped according to time from symptoms to referral (early, <24 h; late, >24 h). In group I (early, n = 8 patients) treatment comprised primary surgical esophageal repair in seven cases and endoscopic clipping in one case. In group II (late, n = 7 patients) treatment comprised esophagectomy without primary reconstruction (4 cases) or controlled esophagocutaneous fistula (3 cases). Measures of outcome included age (years), delay to diagnosis (h), severe sepsis on admission, mortality, and hospital and intensive care unit (ICU) stay.

RESULTS

The overall hospital mortality rate was 6.6% (1/15), being 0% (0/8) in group I and 14.2% (1/7) in group II. Patient age (49.6 vs. 68.6 years, P < 0.0001), delay to diagnosis (17.75 vs. 69 h, P < 0.0001), severe sepsis on admission (0 vs. 4, P = 0.0256), and ICU stay (4 vs. 14 days, P = 0.006) were all greater in group II.

CONCLUSIONS

Early diagnosis and carefully selected therapeutic tactics can reduce the mortality rate of Boerhaave's syndrome to an acceptably low level. Methods of organ preservation and minimally invasive techniques can be applied successfully in the treatment.

A successful strategy for surgical treatment of Boerhaave's syndrome

BACKGROUND

This retrospective single-institution study presents a successful treatment strategy for Boerhaave's syndrome.

METHODS

During 1995-2008, 15 patients with spontaneous esophageal perforation were treated. Patients were grouped according to time from symptoms to referral (early, <24 h; late, >24 h). In group I (early, n = 8 patients) treatment comprised primary surgical esophageal repair in seven cases and endoscopic clipping in one case. In group II (late, n = 7 patients) treatment comprised esophagectomy without primary reconstruction (4 cases) or controlled esophagocutaneous fistula (3 cases). Measures of outcome included age (years), delay to diagnosis (h), severe sepsis on admission, mortality, and hospital and intensive care unit (ICU) stay.

RESULTS

The overall hospital mortality rate was 6.6% (1/15), being 0% (0/8) in group I and 14.2% (1/7) in group II. Patient age (49.6 vs. 68.6 years, P < 0.0001), delay to diagnosis (17.75 vs. 69 h, P < 0.0001), severe sepsis on admission (0 vs. 4, P = 0.0256), and ICU stay (4 vs. 14 days, P = 0.006) were all greater in group II.

CONCLUSIONS

Early diagnosis and carefully selected therapeutic tactics can reduce the mortality rate of Boerhaave's syndrome to an acceptably low level. Methods of organ preservation and minimally invasive techniques can be applied successfully in the treatment.

Successful treatment of a spontaneous esophageal rupture in an elderly patient: a case report

An 80-year-old woman was admitted to our hospital with severe chest and back pains after vomiting. Computed tomography (CT) of the chest revealed left-sided pneumothorax and pleural effusion. Some food was drained from an inserted chest tube, and we diagnosed spontaneous esophageal rupture (Boerhaave's syndrome). A left thoracotomy was performed 7 hours after the onset of symptoms. A 3-cm perforation was discovered in the lateral wall of the distal esophagus. The perforation was repaired with a primary two-layered closure and covered with pericardial fat. The patient had a good postoperative course and was discharged 1 month after surgery. This case suggests the importance of early surgical treatment, even in elderly patients with spontaneous esophageal rupture.

Effects of different kinds of meshes on postoperative adhesion formation in the New Zealand White rabbit

The aim of this study was to compare the effect of different kinds of surgical meshes on postoperative adhesion formation. Forty-two New Zealand White rabbits were studied. The rabbits were grouped into six groups, according to the type of surgical meshes (Prolene, Mersilene, Vypro, polytetraflouroethylene (PTFE), Proceed and control group) implanted into the peritoneum cavity. Thirty days after the operation, the relaparotomies were carried out, and any adhesions observed between the implanted mesh and tissues were evaluated and graded. The mean adhesion degree was 9.2 in the Mersilene mesh group, 9.5 in the Prolene mesh group, 9.7 and in the Vypro mesh group (P > 0.05). The mean adhesion degree was 1 in the control group, 2.75 in the Proceed mesh group and 2.25 in the PTFE mesh group. There was a significant difference in adhesion degree between the control, Proceed and PTFE groups and the Prolene, Mersilene and Vypro mesh groups. The adhesion degree was significantly lower in the Proceed and PTFE mesh groups when comparing them with the Prolene, Mersilene and Vypro meshes.

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.

An experimental study of the adhesive potential of different meshes

OBJECTIVE

To assess the adhesive potential and incidence of incisional hernia with three meshes.

DESIGN

Open experimental study.

SETTING

Surgical Research Laboratory, Turkey.

ANIMALS

75 Wistar albino rats

INTERVENTIONS

Abdominal walls were excised, and defects closed primarily or with polyglactin 910, polypropylene, or dura mater. Adhesions were graded and hydroxyproline concentrations measured on days 14 and 180. On day 180, the incidence of incisional hernia, and the grades of inflammation and fibrosis were also recorded.

RESULTS

The polyglactin 910 group had a higher adhesion grading than the control and dura mater groups on day 14, whereas the polypropylene group had higher adhesion grading than controls. Both polypropylene and polyglactin 910 groups had significantly higher concentration of hydroxyproline than the control and dura mater groups. On day 180, the polypropylene group had a higher adhesion grading than the controls. There were no differences in hydroxyproline concentrations, incidence of hernias, or grading of fibrosis levels among the groups.

CONCLUSION

Polyglactin 910 induced more fibrotic adhesions in the early postoperative period whereas polypropylene did in both the early and late postoperative periods.