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Suzuki K, Yoshida H, Esumi R, Ieki Y, Yamamoto A, Ohi M, Kaneko T, Imai H. Esophageal Perforation Accompanying Mediastinitis in Blunt Trauma in a Patient with Thoracic Osteophytes. Intern Med 2022; 61:2601-2605. [PMID: 35135923 PMCID: PMC9492484 DOI: 10.2169/internalmedicine.8930-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We herein report a 61-year-old man who sustained injury after a 2-m fall and developed mediastinitis. He presented to another hospital two days after the fall and was transferred to our hospital four days after the fall with a fever and dysphagia. Computed tomography revealed osteophytes on the second and third thoracic vertebrae and free air in the mediastinum, indicating esophageal perforation. Emergent surgery was performed. Intraoperatively, a longitudinal esophageal tear was identified. We stress the importance of being aware of the possibility of osteophyte-related esophageal perforation in patients with a history of a fall. A delayed diagnosis affects the prognosis.
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Affiliation(s)
- Kei Suzuki
- Emergency and Critical Care Center, Mie University Hospital, Japan
- Department of Infectious Diseases, Mie University Hospital, Japan
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Japan
| | - Haruna Yoshida
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Ryo Esumi
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Yohei Ieki
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Akira Yamamoto
- Department of Gastrointestinal and Pediatric Surgery, Mie University Hospital, Japan
| | - Masaki Ohi
- Department of Gastrointestinal and Pediatric Surgery, Mie University Hospital, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Japan
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital, Japan
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Gray KE, Sarode A, Jiang B, Alvarado CE, Sinopoli J, Linden PA, Worrell SG, Ho VP, Argote-Greene LM, Towe CW. Surgical Repair Versus Stent for Esophageal Perforation: A Multi-institutional Database Analysis. Ann Thorac Surg 2022; 115:1378-1384. [PMID: 35921860 DOI: 10.1016/j.athoracsur.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.
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Affiliation(s)
- Kelsey E Gray
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Anuja Sarode
- Department of Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Phillip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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García-Moreno V, Maiocchi K, Gómez-Quiles L, Villarin-Rodríguez A, Aliaga-Hilario E, Martínez-Hernández A, Abdelkader N, López E, Escrig-Sos J, Laguna-Sastre JM. Treatment of esophageal perforation: A review of our experience at a tertiary referral hospital spanning the past 19 years. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021; 87:405-410. [PMID: 34887217 DOI: 10.1016/j.rgmxen.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 02/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION AND AIMS Esophageal perforation is an uncommon event that is a medical/surgical emergency, with a 15-30% mortality rate. The aim of the present study was to communicate our experience in the management of esophageal perforation, evaluating the different strategies utilized, in an effort to establish measures to guide decision-making in selecting treatment. MATERIALS AND METHODS A retrospective descriptive study was conducted on patients diagnosed with esophageal perforation at our hospital center, within the time frame of 2000 and 2019. RESULTS Over the past 19 years, 15 patients were diagnosed with esophageal perforation. Surgical treatment was carried out in 80% of the cases. Primary closure, reinforced with plasty, was performed in 67% of the patients, of whom 62.5% had early diagnosis and a 100% survival rate. Diagnosis was late in 37.5% of the cases, with a 33.3% survival rate. Esophagectomy and gastric pull-up were performed on 25% of the patients, 66.6% of whom had early diagnosis and a 100% survival rate. In the 33.3% that had late diagnosis, the mortality rate was 100%. Esophagectomy, with cervical esophagostomy and feeding jejunostomy, was performed on one of the patients (8.3%) that had early diagnosis and a 100% survival rate. CONCLUSIONS The main survival predictor in esophageal perforation is the interval of time between the injury and its diagnosis, and in turn, the resulting treatment. Each patient with esophageal perforation should have individualized treatment to adequately manage the condition.
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Affiliation(s)
- V García-Moreno
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain.
| | - K Maiocchi
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - L Gómez-Quiles
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - A Villarin-Rodríguez
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - E Aliaga-Hilario
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - A Martínez-Hernández
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - N Abdelkader
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - E López
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - J Escrig-Sos
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - J M Laguna-Sastre
- Servicio de Cirugía General y del Aparato digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Issak A, Musleh M. Successful closure of chronic recurrent Enterocutaneous fistula with a concurrent over-the-scope closure and a stent placement. Clin Case Rep 2020; 8:239-242. [PMID: 32128164 PMCID: PMC7044360 DOI: 10.1002/ccr3.2652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 11/08/2022] Open
Abstract
Gastrointestinal ulcers and perforations can occur as a complication of nonsteroidal anti-inflammatory drugs (NSAID). Emerging endoscopic technologies can be utilized to successfully intervene perforations that fail surgical intervention. We report a case of perforated duodenal ulcer that failed surgical intervention and, however, was successfully closed with over-the-scope clip (OTSC) closure with concomitant placement of fully covered stent.
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Affiliation(s)
- Abdulfatah Issak
- Department of GastroenterologyWright State University Boonshoft School of MedicineDaytonOHUSA
| | - Mustafa Musleh
- Department of GastroenterologyWright State University Boonshoft School of MedicineDaytonOHUSA
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Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series. Ann Med Surg (Lond) 2019; 44:62-67. [PMID: 31316769 PMCID: PMC6611994 DOI: 10.1016/j.amsu.2019.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries. Materials and methods A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level. Results Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects. Conclusion Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome. Sixteen patients were treated for esophageal injuries at the PRTH. Two patients suffered blunt esophageal trauma and 14 patients had penetrating trauma to the esophagus. Most patients had a prompt diagnosis of traumatic esophageal perforation, while 3 patients had a delayed diagnosis. Regarding esophageal location, of the 16 patients, 9 presented cervical, 6 thoracic, and 1 abdominal esophageal injury. Only 2 deaths occurred among our 16 patients, including 1 in delayed diagnosed subjects.
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Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol 2018; 3:85. [PMID: 30505972 DOI: 10.21037/tgh.2018.10.09] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.
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Affiliation(s)
- Ritu Raj Singh
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy S Nussbaum
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil A Kumta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Novel Treatment for Anastomotic Leak After Ivor-Lewis Esophagectomy. Ann Thorac Surg 2018; 106:e107-e109. [DOI: 10.1016/j.athoracsur.2018.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 11/18/2022]
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9
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Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma: A single-center review of 86 cases. J Trauma Acute Care Surg 2018; 85:541-548. [PMID: 29787546 DOI: 10.1097/ta.0000000000001973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM). METHODS This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation. RESULTS Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19-8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13-6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks. CONCLUSION Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration. LEVEL OF EVIDENCE Clinical Management Study, Level V evidence.
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Grau Pérez M, Aguilar Mulet JM, Santiago Poveda C. Left hydropneumothorax in a patient with acute epigastric pain: an important clue! Intern Emerg Med 2018; 13:133-134. [PMID: 28779445 DOI: 10.1007/s11739-017-1727-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/29/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Mercè Grau Pérez
- Emergency Department, Hospital Universitario de La Princesa, Madrid, Spain.
- Dermatology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain.
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Ceppa DP, Rosati CM, Chabtini L, Stokes SM, Cook HC, Rieger KM, Birdas TJ, Lappas JC, Kessler WR, DeWitt JM, Maglinte DD, Kesler KA. Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies. Ann Thorac Surg 2017; 104:1054-1061. [PMID: 28619542 DOI: 10.1016/j.athoracsur.2017.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. METHODS After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. RESULTS Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). CONCLUSIONS Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.
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Affiliation(s)
- DuyKhanh P Ceppa
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Carlo Maria Rosati
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lola Chabtini
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Samantha M Stokes
- Center for Outcomes Research in Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Holly C Cook
- Indiana University Health, Indianapolis, Indiana
| | - Karen M Rieger
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas J Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - John C Lappas
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - William R Kessler
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - John M DeWitt
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dean D Maglinte
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kenneth A Kesler
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Katz-Agranov N, Nevah Rubin MI. Severe esophageal injury after radiofrequency ablation - a deadly complication. World J Gastroenterol 2017; 23:3374-3378. [PMID: 28566899 PMCID: PMC5434445 DOI: 10.3748/wjg.v23.i18.3374] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/18/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
Various degrees of esophageal injury have been described after radiofrequency ablation performed for treatment of atrial fibrillation. The main mechanism of injury is thermal and may lead to a range of esophageal mucosal changes, some clinically insignificant, however when deep ulceration occurs, this may be further complicated by perforation and mediastinitis, a rare but life threatening sequelae. We present a case of a severe esophageal injury leading to mediastinitis, with interesting endoscopic findings.
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Mirus M, Heller AR. [Diagnostic investigation in emergency medicine: Why case history is crucial]. Anaesthesist 2017; 66:256-264. [PMID: 28194478 DOI: 10.1007/s00101-017-0280-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 12/09/2016] [Accepted: 01/26/2017] [Indexed: 11/29/2022]
Abstract
We present the preclinical case of a patient reporting chest pain. Pain impeded physical examination. Reviewing the patient's detailed medical history after analgesia revealed a connection between the reported pain and vomiting. This led to a suspicion of organ perforation. Thus, the patient was admitted to a surgical emergency room (ER) and Boerhaave's Syndrome was diagnosed. After deterioration in the ER, cardiopulmonal reanimation (CPR), and successful surgical treatment, the patient was transferred to the intensive care unit (ICU) seven hours after first contact.
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Affiliation(s)
- M Mirus
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - A R Heller
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland
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Saxena P, Khashab MA. Endoscopic Management of Esophageal Perforations: Who, When, and How? ACTA ACUST UNITED AC 2017; 15:35-45. [PMID: 28116696 DOI: 10.1007/s11938-017-0117-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.
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Affiliation(s)
- Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA
| | - Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA.
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15
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Gupta A, Mody P, Bhushan S. An unusual cause of shortness of breath. Intern Emerg Med 2016; 11:1025-6. [PMID: 26715452 DOI: 10.1007/s11739-015-1373-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/10/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Centre, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA.
| | - Purav Mody
- Department of Internal Medicine, University of Texas Southwestern Medical Centre, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
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16
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Youn HC, Kwon SH. Endoscopic Vacuum-Assisted Closure (E-VAC) Treatment in a Patient with Delayed Anastomotic Perforation following a Perforated Gastric Conduit Repair after an Ivor-Lewis Esophagectomy. Ann Thorac Cardiovasc Surg 2016; 22:363-366. [PMID: 27075934 DOI: 10.5761/atcs.cr.15-00305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
It has been reported that intrathoracic esophageal leakages occur at a rate of 4%-17% after Ivor-Lewis esophagectomy. There has been no consensus on a specific treatment for the post-operative anastomotic leakage. Recently, endoscopic vacuum-assisted closure (E-VAC) has been introduced as a novel treatment for the post-operative anastomotic leakage. We herein report the case of a patient with early perforation of the gastric conduit followed by late esophagogastric anastomotic leakage who was successfully treated with early surgical repair and subsequent E-VAC. The patient had been previously diagnosed with achalasia and squamous cell carcinoma of the esophagus and undergone an Ivor-Lewis esophagectomy.
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Affiliation(s)
- Hyo Chul Youn
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital, Seoul, Korea
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17
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Mishra B, Singhal S, Aggarwal D, Kumar N, Kumar S. Non operative management of traumatic esophageal perforation leading to esophagocutaneous fistula in pediatric age group: review and case report. World J Emerg Surg 2015; 10:19. [PMID: 25866555 PMCID: PMC4393641 DOI: 10.1186/s13017-015-0012-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 02/25/2015] [Indexed: 01/21/2023] Open
Abstract
Management of delayed presenting esophageal perforations has long been a topic of debate. Most authors consider definitive surgery being the management of choice. Management, however, differs in pediatric patients in consideration with better healing of younger tissues. We extensively review the role of aggressive non-operative management in pediatric esophageal perforations, especially with delayed presentation and exemplify with case of a young boy with esophageal perforation and esophago-cutaneous fistula. We also lay down the protocol to manage such patients based on our institutional recommendations.
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Affiliation(s)
- Biplab Mishra
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | | | - Divya Aggarwal
- University College of Medical Sciences, New Delhi, India
| | - Nitesh Kumar
- All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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Stavropoulos SN, Modayil R, Friedel D. Closing perforations and postperforation management in endoscopy: esophagus and stomach. Gastrointest Endosc Clin N Am 2015; 25:29-45. [PMID: 25442956 DOI: 10.1016/j.giec.2014.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.
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Affiliation(s)
- Stavros N Stavropoulos
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA.
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
| | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
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Granel-Villach L, Fortea-Sanchis C, Martínez-Ramos D, Paiva-Coronel GA, Queralt-Martín R, Villarín-Rodríguez A, Salvador-Sanchis JL. [Boerhaave's syndrome: a review of our experience over the last 16 years]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:67-70. [PMID: 24656512 DOI: 10.1016/j.rgmx.2013.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/04/2013] [Accepted: 11/06/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Report our experience in the diagnosis and treatment of Boerhaave syndrome by retrospective study from 1997 to 2013. PATIENTS AND METHODS A retrospective study was conducted covering the time frame of 1997 to 2013. RESULTS There were a total of 5 men (71%) and 2 women (29%) and the mean age was 54 years (range: 33-80 years). Diagnosis was made through computed tomography scan in 5 cases (71%) and esophagogram in 2 cases (19%). Six patients (86%) had emergency surgery, whereas one case (14%) was managed conservatively. The surgical technique employed was primary suture and repair in 4 patients (67%) and esophageal resection and subsequent cervical esophagostomy in 2 patients (33%). CONCLUSIONS Boerhaave's syndrome is a clinically rare entity with an elevated mortality rate. Therefore, a high degree of suspicion is necessary for making the diagnosis and providing early treatment that can result in improved outcome.
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Affiliation(s)
- L Granel-Villach
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España.
| | - C Fortea-Sanchis
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
| | - D Martínez-Ramos
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
| | - G A Paiva-Coronel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
| | - R Queralt-Martín
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
| | - A Villarín-Rodríguez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
| | - J L Salvador-Sanchis
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Castellón, Castellón de la Plana, Castellón, España
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Granel-Villach L, Fortea-Sanchis C, Martínez-Ramos D, Paiva-Coronel G, Queralt-Martín R, Villarín-Rodríguez A, Salvador-Sanchis J. Boerhaave's syndrome: A review of our experience over the last 16 years. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014. [DOI: 10.1016/j.rgmxen.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Correia T, Amaro P, Sofia C. Tratamento de deiscência cirúrgica grave com sistema «Over-the-scope clip». ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.jpg.2013.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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22
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Hasimoto CN, Cataneo C, Eldib R, Thomazi R, Pereira RSDC, Minossi JG, Cataneo AJM. Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies. Acta Cir Bras 2013; 28:266-71. [PMID: 23568234 DOI: 10.1590/s0102-86502013000400006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 03/18/2013] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To evaluate the efficacy of surgical treatment for esophageal perforation. METHODS A systematic review of the literature was performed. We conducted a search strategy in the main electronic databases such as PubMed, Embase and Lilacs to identify all case series. RESULTS Thirty three case series met the inclusion criteria with a total of 1417 participants. The predominant etiology was iatrogenic (54.2%) followed by spontaneous cause (20.4%) and in 66.1% the localization was thoracic. In 65.4% and 33.4% surgical and conservative therapy, respectively, was considered the first choice. There was a statistically significance different with regards mortality rate favoring the surgical group (16.3%) versus conservative treatment (21.2%) (p<0.05). CONCLUSION Surgical treatment was more effective and safe than conservative treatment concerning mortality rates, although the possibility of bias due to clinical and methodological heterogeneity among the included studies and the level of evidence that cannot be ruled out.
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Biancari F, D'Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, Saarnio J, Lucenteforte E. Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013; 37:1051-9. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 Oulu, Finland.
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24
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Abstract
Esophageal leak is a life-threatening problem that can result from spontaneous rupture of the esophagus, cancer, anastomotic dehiscence after surgery, or as a complication of endoscopy. During the last decade, developments in the minimally invasive endoluminal approach to the management of esophageal leaks include utilization of endoscopy not only for diagnosis but also for closure of leaks with clips or sutures, bypass of the leaks with stents, and/or endoluminal drainage of mediastinal infection. The aim of this review is to summarize recent advances and the principles of endoscopic management of acute esophageal perforations.
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Affiliation(s)
- Rene Gomez-Esquivel
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
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Zhang XL, Sun G, Tang P, Zhang RG, Yang YS. Endoscopic closure of experimental iatrogenic gastric fundus perforation using over-the-scope clips in a surviving canine model. J Gastroenterol Hepatol 2013; 28:1502-6. [PMID: 23730967 DOI: 10.1111/jgh.12288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIM To evaluate the effectiveness and outcomes of endoscopic closure of a gastric fundus perforation using over-the-scope clips (OTSCs) system in a surviving canine model. METHODS Gastric fundus perforations (20-mm diameter) were created by an endoscopic needle-knife in six dogs. The perforations then were closed by the OTSC system. Gastroscopy was performed to evaluate the postoperative perforation healing every week. The animals were sacrificed 4 weeks later to examine the possible intraperitoneal complications, and the healing of the perforation was examined histopathologically. RESULTS The gastric fundus perforations could primarily be closed using one OTSC in each experimental dog, and the mean time of the procedure was 17.3 ± 7.6 min (9-26 min). All animals survived without postoperative complications. The OTSC retention was observed in one dog at the end of 4 weeks, and the apparent foreign-body reaction was examined pathologically. CONCLUSIONS Our surviving animal study demonstrated that the OTSC clip system could reliably close gastric fundus perforations without complications.
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Affiliation(s)
- Xiu Li Zhang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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26
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Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies. World J Surg 2013. [PMID: 23440483 DOI: 10.1007/s00268-013-1951-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. METHODS We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. RESULTS Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. CONCLUSIONS Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
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27
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Søreide JA, Konradsson A, Sandvik OM, Øvrebø K, Viste A. Esophageal perforation: clinical patterns and outcomes from a patient cohort of Western Norway. Dig Surg 2013; 29:494-502. [PMID: 23392348 DOI: 10.1159/000346479] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 12/10/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Esophageal perforation is a rare, often life-threatening condition, and management remains challenging. METHODS Retrospective review of consecutive patients with esophageal perforation treated at two university hospitals between 2000 and 2010. Pertinent data from hospital records were retrieved for statistical calculations and evaluation of perforation score. RESULTS Forty-seven patients [47% female, median age 62 years (range 15-88)] were included. The annual incidence was 4.7/1,000,000. Perforations were spontaneous in 14 patients (30%), iatrogenic in 25 (53%), and caused by trauma and foreign body impaction in 8 patients (17%). ASA score (p = 0.004), perforation localization (p = 0.001), diagnostic delay (p = 0.002), and perforation score (p < 0.001) differed significantly between patient groups with different etiology, but not between groups with different outcomes. Early diagnosis (≤24 h) was significantly associated with a low perforation score (p = 0.033). A non-operative approach was employed in 26 patients (55%) - more commonly for proximally localized perforations (p = 0.045). The non-operative group showed lower severe complication rates (p = 0.033), shorter ICU stays (p < 0.001) and durations of mechanical ventilation (p = 0.022). The overall 30-day mortality was 23.4%. CONCLUSION Careful clinical evaluation and appropriate, individualized treatment are important. The high mortality may be partly explained by the underlying disease and the complexity of the clinical condition in many patients.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastroenterologic Surgery, Stavanger University Hospital, Stavanger, Norway.
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Jabłoński S, Brocki M, Kordiak J, Misiak P, Terlecki A, Kozakiewicz M. Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients. ANZ J Surg 2012; 83:657-63. [DOI: 10.1111/j.1445-2197.2012.06252.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marian Brocki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Jacek Kordiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Piotr Misiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Artur Terlecki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marcin Kozakiewicz
- Department of Faciomaxillary Surgery; Medical University of Lodz; Łódź; Poland
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29
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Zhang XL, Qu JH, Sun G, Tang P, Yang YS. Feasibility study of secure closure of gastric fundus perforation using over-the-scope clips in a dog model. J Gastroenterol Hepatol 2012; 27:1200-4. [PMID: 22507171 DOI: 10.1111/j.1440-1746.2012.07156.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIM Gastric fundus perforation is a serious complication of endoscopic mucosal resection and endoscopic submucosal dissection performed for the removal of early gastric cancers or subepithelial tumors. The novel over-the-scope clip (OTSC) has recently been found to be effective for closing gastrointestinal-tract perforations and accesses for natural orifice transluminal endoscopic surgery. However, feasibility studies of OTSCs in gastric fundus perforation are still lacking. The aim of this study was therefore to demonstrate the feasibility of endoscopic closure of gastric fundus perforation using the OTSC system in a dog model. METHODS Gastric fundus perforations were created by needle-knife electrocautery in seven dogs. The perforations were then closed using the OTSC clipping system. Stomach distension was maintained by maximum insufflation with air and methylene blue solution (500 mL) was instilled to submerge the closed perforation. Leaks were detected laparoscopically. RESULTS Perforations were closed in all seven cases with a mean time of 18.5 ± 6.4 min (11-28 min). Twin Grasper assistance failed to release the OTSCs in two of the seven cases (2/7, 28.6%) because of difficulties associated with the J-maneuver (retroflexion of endoscope) required for the gastric fundus procedure, and OTCS were forced into place by suction. Minor leakage was observed in one case (1/7, 14.3%). No damages related to the clip system were found during postmortem examinations. CONCLUSIONS Despite difficulties associated with the J-maneuver of the endoscope, this small series demonstrated that sufficient closure of gastric fundus perforation could be achieved using the OTSC system.
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Affiliation(s)
- Xiu-Li Zhang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Lyman D. Spontaneous esophageal perforation in a patient with mixed connective tissue disease. Open Rheumatol J 2012; 5:138-43. [PMID: 22279514 PMCID: PMC3263470 DOI: 10.2174/1874312901105010138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/28/2011] [Accepted: 10/31/2011] [Indexed: 11/22/2022] Open
Abstract
Spontaneous esophageal perforation is a rare and life-threatening disorder. Failure to diagnosis within the first 24-48 hours of presentation portends a poor prognosis. A patient with mixed connective tissue disease (MCTD) on low-dose prednisone and methotrexate presented moribund with chest and shoulder pain, a left hydropneumothorax, progressive respiratory failure and shock. Initial management focussed on presumed community acquired pneumonia (CAP) in a patient on immunosuppressants. Bilateral yeast empyemas were treated and attributed to immunosuppression. On day 26, the patient developed mediastinitis, and the diagnosis of esophageal perforation was first considered. A review of the literature suggests that the diagnosis and management of spontaneous esophageal perforation could have been more timely and the outcome less catastrophic.
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Affiliation(s)
- David Lyman
- Cherry Street Health Services, 100 Cherry Street SE, Grand Rapids, Michigan, 49053, USA
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31
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Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg 2011; 92:209-15. [PMID: 21718846 DOI: 10.1016/j.athoracsur.2011.03.131] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 03/26/2011] [Accepted: 03/29/2011] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Pankaj Bhatia
- Division of Thoracic Surgery, The University of Western Ontario, London, Ontario, Canada
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van Boeckel PGA, Sijbring A, Vleggaar FP, Siersema PD. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther 2011; 33:1292-301. [PMID: 21517921 DOI: 10.1111/j.1365-2036.2011.04663.x] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred. AIM To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs. METHODS A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival. RESULTS Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68]. CONCLUSIONS Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).
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Affiliation(s)
- P G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, The Netherlands
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Hirdes MMC, Siersema PD, Houben MHMG, Weusten BLAM, Vleggaar FP. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol 2011; 106:286-93. [PMID: 20940709 DOI: 10.1038/ajg.2010.394] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Partially covered self-expanding metal stents (SEMSs) are regularly used for malignant and occasionally for benign esophageal disorders. Safe removal of these stents can be challenging due to embedding of the uncovered stent ends. Our aim is to report the results of removal of embedded, partially covered SEMSs by induction of pressure necrosis using the stent-in-stent technique. METHODS Consecutive patients referred to three endoscopy units in 2007-2009, treated by the stent-in-stent technique, were reviewed. The partially covered SEMSs were inserted for malignant (n=3) or benign (n=16) conditions and were left in situ for a median of 42 days (14-189). When SEMSs were found to be embedded, a fully covered self-expanding plastic stent (SEPS) or fully covered SEMS was placed inside the partially uncovered SEMS. Subsequent removal of both stents was planned after a period of 10-14 days. RESULTS In total, 23 stent-in-stent procedures were performed in 19 patients (10 males). Placement of a fully covered stent (SEPS: n=9 and SEMS: n=14) was technically successful in all patients. In 21 of 23 (91%) procedures, both stents were successfully removed in one procedure after a median of 12 days (5-18). In two patients, a repeat stent-in-stent procedure was needed for persistent embedding of the partially uncovered SEMSs. One (5%) procedure was complicated by severe bleeding, which could be treated endoscopically. In seven (36%) patients, the initial disorder had resolved after stent removal and no further endoscopic interventions were needed. Two (10%) patients were treated with chemoradiation or surgery for esophageal cancer after stent removal. In 10 (53%) patients, a repeat endoscopic intervention was required during follow-up because of progressive dysphagia or a persisting leak or fistula. CONCLUSIONS The stent-in-stent technique is safe and effective for the removal of partially covered SEMSs that are embedded in the esophageal wall.
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Affiliation(s)
- M M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
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.
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Affiliation(s)
- Paul D. Kiernan
- Section of Thoracic Surgery, Department of Surgery, Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
| | - Sandeep J. Khandhar
- Section of Thoracic Surgery, Department of Surgery, Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
| | - Daniel L.C. Fortes
- Section of Thoracic Surgery, Department of Surgery, Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
| | - Michael J. Sheridan
- Inova Research Center, Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
| | - Vivian Hetrick
- Section of Thoracic Operating Room Nursing, Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
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Immediate Placement of a Temporary Covered Stent for the Management of Iatrogenic Malignant Esophageal Perforation. Cardiovasc Intervent Radiol 2010; 34:886-8. [DOI: 10.1007/s00270-010-9995-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review current therapeutic strategies and outcomes in the management of esophageal perforation. The relative rarity and unpredictability of esophageal perforation has precluded a randomized or multiinstitutional study of this condition. Practice standards are based primarily on retrospective reviews and expert opinions. RECENT FINDINGS The last decade has observed a shift from an aggressive early operative intervention to a judicious, nonoperative management of esophageal perforation in selected patients. Encouraging outcomes for nonoperative management published in recent literature result from advancements in esophageal stent technology, imaging sciences, and critical care. SUMMARY Perforation of the esophagus, regardless of the cause, remains a major life-threatening event. Early recognition and aggressive care by a clinical team with experience in a variety of treatment modalities is increasingly important in achieving optimal outcomes in this difficult problem. Recently, encouraging results have been published utilizing esophageal stents and diligent nonoperative care in patients with esophageal perforation. The guiding principles in the treatment of this challenging condition remain early diagnosis, appropriate resuscitation, sepsis control, nutritional support, and re-establishment of esophageal continuity. Herein, we review the recent reports on the surgical, medical, and endoscopic treatment of esophageal perforation.
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Bailey C, Burke S. Boerhaave's syndrome complicating status epilepticus. Br J Hosp Med (Lond) 2010; 71:53. [PMID: 20081646 DOI: 10.12968/hmed.2010.71.1.45977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Boerhaave's syndrome, first described in 1724, is a spontaneous transmural perforation of the oesophagus, typically caused by forced emesis. It is classically associated with the 'Mackler triad' of vomiting, lower thoracic pain and subcutaneous emphysema. It is the most lethal perforation of the gastrointestinal tract with an estimated mortality of 20-40% (de Schipper et al, 2009).
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Affiliation(s)
- Cheron Bailey
- Department of Anaesthesia, St Georges Hospital, London SW17 0QT
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Fiscon V, Portale G, Frigo F, Migliorini G, Fania PL. Spontaneous rupture of middle thoracic esophagus: thoracoscopic treatment. Surg Endosc 2010; 24:2900-2. [PMID: 20464427 DOI: 10.1007/s00464-010-1056-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 03/19/2010] [Indexed: 11/29/2022]
Abstract
Spontaneous rupture of the esophagus (so-called Boerhaave's syndrome) is considered a medical emergency. It carries a significant mortality rate and requires prompt treatment. The treatment of choice involves surgical repair of the esophageal defect, usually accomplished via laparotomy, thoracotomy, or both to accomplish esophageal repair and mediastinal debridement. We have treated an elderly patient with severe comorbidities with a minimally invasive approach, achieving a successful complete repair. Long-term endoscopic and radiologic follow-up confirm the good results.
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Affiliation(s)
- Valentino Fiscon
- Department of General Surgery, Azienda ULSS 15 Alta Padovana, Via Riva Dell' Ospedale, 1, 35013, Cittadella, Padova, Italy.
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Iacopini F, Lorenzo ND, Altorio F, Schurr MO, Scozzarro A. Over-the-scope clip closure of two chronic fistulas after gastric band penetration. World J Gastroenterol 2010; 16:1665-9. [PMID: 20355247 PMCID: PMC2848377 DOI: 10.3748/wjg.v16.i13.1665] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal perforations are conservatively managed at endoscopy by through-the-scope endoclips and covered self expandable stents, according to the size and tissue features of the perforation. This is believed to be the first report of successful closure of two gastro-cutaneous fistulas with over-the-scope clips (OTSCs). After laparoscopic gastric banding, a 45-year old woman presented with band erosion and penetration. Despite surgical band removal and gastric wall suturing, external drainage of enteric material persisted for 2 wk, and esophagogastroduodenoscopy demonstrated two adjacent 10-mm and 15-mm fistulous orifices at the esophagogastric junction. After cauterization of the margins, the 10-mm fistulous tract was grasped by the OTSC anchor, invaginated into the applicator cap, and closed by a traumatic OTSC. The other 15-mm fistula was too large to be firmly grasped, and a fully-covered metal stent was temporarily placed. No leak occurred during the following 6 wk. At stent removal: the OTSC was completely embedded in hyperplastic overgrowth; the 15-mm fistula significantly reduced in diameter, and it was closed by another traumatic OTSC. After the procedure, no external fistula recurred and both OTSCs were lost spontaneously after 4 wk. The use of the anchor and the OTSC seem highly effective for successful closure of small chronic perforations.
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40
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Chuah SK, Wu KL, Hu TH, Tai WC, Changchien CS. Endoscope-guided pneumatic dilation for treatment of esophageal achalasia. World J Gastroenterol 2010; 16:411-7. [PMID: 20101764 PMCID: PMC2811791 DOI: 10.3748/wjg.v16.i4.411] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pneumatic dilation (PD) is considered to be the first line nonsurgical therapy for achalasia. The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force. The endoscope-guided procedure is done without fluoroscopic control. Clinicians usually use a low-compliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia. It has the advantage of determining mucosal injury during the dilation process, so that a repeat endoscopy is not needed to assess the mucosal tearing. Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities. Although the results may be promising, long-term follow-up is required in the near future.
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Abstract
Esophageal perforation is a difficult problem in thoracic surgery. Esophageal perforations can be spontaneous, iatrogenic, or malignant. We report two cases of esophageal perforations caused by thoracic osteophytes and different management strategies leading to successful outcomes. An 80-year-old male presented with chest pain and dysphagia following a fall. On endoscopy, an esophageal perforation and foreign body was noted which was confirmed as a thoracic osteophyte on computed tomography scan. He was managed conservatively as he declined surgery. A 63-year-old male was admitted with dysphagia following a food bolus obstruction. Following esophagoscopy and dilatation, there was clinical and radiological evidence of perforation. During surgery, a thoracic osteophyte was identified as the cause of perforation. The perforation was closed in layers and the osteophyte was trimmed. Both patients recovered well. Thoracic osteophytes are a rare cause of esophageal perforations and a high index of suspicion is required in patients with osteoarthritis who present with esophageal perforations.
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Affiliation(s)
- S Rathinam
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green, Birmingham, UK.
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Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Landreneau J, Luketich JD, Landreneau RJ. Contemporaneous management of esophageal perforation. Surgery 2009; 146:749-55; discussion 755-6. [PMID: 19789035 DOI: 10.1016/j.surg.2009.06.058] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 06/30/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal perforation is an important therapeutic challenge. We hypothesized that patients with minimal mediastinal contamination at the time of diagnosis could be managed successfully with nonoperative treatment modalities. METHODS We performed a retrospective review of 119 consecutive patients with esophageal perforation from 1998 to 2008. Demographics, cause of perforation, clinical presentation, diagnostic methods, and management results were evaluated. The decision to operate was based on the extent of mediastinal contamination and systemic sepsis rather than cause of perforation. RESULTS Median time to diagnosis among all patients was 12 hours (range, 1-120). Spontaneous (Boerhaave's) perforation occurred in 44 (37%) patients. Iatrogenic perforations constituted the remaining patients (n = 75). After instrumental perforation, 9 patients (13%) required esophagectomy, 48 patients were managed with repair and drainage, and the remaining 18 were managed nonoperatively. All 34 patients undergoing operative therapy for spontaneous perforations were treated with esophageal repair. Overall mortality was 14%, with intrathoracic perforations having 18% mortality, cervical 8%, and gastroesophageal junction 3%. Patients undergoing nonoperative therapy had a shorter hospitalizations (13 vs 24 days), fewer complications (36% vs 62%), and less mortality (4% vs 15%) compared with those undergoing operative intervention. CONCLUSION An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, nonoperative management may be successfully implemented in selected patients with a low morbidity and mortality if favorable radiographic and clinical characteristics are present.
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Affiliation(s)
- Ghulam Abbas
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Lin MT, Tai WC, Chiu KW, Chou YP, Tsai MC, Hu TH, Lee CM, Changchien CS, Chuah SK. Delayed presentation of intrathoracic esophageal perforation after pneumatic dilation for achalasia. World J Gastroenterol 2009; 15:4461-3. [PMID: 19764103 PMCID: PMC2747072 DOI: 10.3748/wjg.15.4461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pneumatic dilation (PD) is considered to be a safe and effective first line therapy for achalasia. The major adverse event caused by PD is esophageal perforation but an immediate gastrografin test may not always detect a perforation. It has been reported that delayed management of perforation for more than 24 h is associated with high mortality. Surgery is the treatment of choice within 24 h, but the management of delayed perforation remains controversial. Hereby, we report a delayed presentation of intrathoracic esophageal perforation following PD in a 48-year-old woman who suffered from achalasia. She completely recovered after intensive medical care. A review of the literature is also discussed.
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Udelnow A, Huber-Lang M, Juchems M, Träger K, Henne-Bruns D, Würl P. How to treat esophageal perforations when determinants and predictors of mortality are considered. World J Surg 2009; 33:787-96. [PMID: 19189177 DOI: 10.1007/s00268-008-9857-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Andrej Udelnow
- Department of Surgery, St. Franziskus Hospital Flensburg, Waldstr. 17, 24939, Flensburg, Germany.
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Mariani AW, Pêgo-Fernandes PM, Samano MN, de Albuquerque Cavalcanti EF, Cevasco JJ, Gattaz MD. Indolent form of mediastinitis caused by oesophageal perforation from fish bone ingestion. BMJ Case Rep 2009; 2009:bcr11.2008.1250. [PMID: 21686391 DOI: 10.1136/bcr.11.2008.1250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Mediastinitis caused by oesophageal perforation usually presents as a severe disease that can quickly progress to sepsis and death. We report a case with an indolent form of mediastinitis, caused by fish bone ingestion, which was successfully and exclusively treated with antibiotics. The patient had only one symptom, intense thoracic pain, with no signs of infection except for elevated C reactive protein. The diagnosis was difficult to obtain because of this atypical clinical presentation. The chest computed tomography scan combined with the thoracic pain and the history of fish bone ingestion allowed us to confirm the diagnosis and initiate treatment.
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Affiliation(s)
- Alessandro W Mariani
- Heart Institute, Thoracic Surgery Department, Av Dr Eneas Carvalho de Aguiar, 44, São Paulo, 05406000, Brazil
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Amrani L, Ménard C, Berdah S, Emungania O, Soune PA, Subtil C, Brunet C, Grimaud JC, Barthet M. From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of "stent-guided regeneration and re-epithelialization". Gastrointest Endosc 2009; 69:1282-7. [PMID: 19286179 DOI: 10.1016/j.gie.2008.09.043] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 09/18/2008] [Indexed: 01/30/2023]
Abstract
BACKGROUND Iatrogenic intestinal tract perforation and anastomotic disunion traditionally required surgical treatment. Complete anastomotic break was considered until now as an absolute contraindication for endoscopic management. OBJECTIVE The aim of this series was to show that endoscopic management is able to treat a spectrum of bowel wall breaks, from focal perforation to complete anastomotic disunion. SETTING A single-center prospective cohort study. PATIENTS Nine consecutive patients with nonmalignant gastrointestinal perforations were treated with endoscopic stenting between 2005 and 2008. Perforations were related to endoscopic perforations (4 cases: 2 esophageal and 2 colorectal), postoperative fistula or leakage (2 cases: 1 colorectal anastomosis and 1 esophageal), and complete anastomotic disunion (3 cases: 2 ileoanal anastomosis and 1 esophagogastric anastomosis). INTERVENTIONS All 9 patients underwent endoscopic installation of fully covered stents under endoscopic and radiologic guidance, sometimes associated with simultaneous endoscopic collection drainage. Oral feeding was resumed when radiologic contrast studies showed no residual leak. RESULTS The outcome in all 9 patients was favorable. Two migrated stents were replaced, and 2 stents were spontaneously expelled without consequence. All stents were withdrawn within an average of 5 weeks. LIMITATIONS Uncontrolled pilot study, small sample size. CONCLUSION The successful endoscopic management of bowel wall breaks ranging from perforation to complete postoperative disunion with fully covered stent could support a new concept of "stent-guided regeneration and re-epithelialization." Controlled trials are needed before this new endoscopic treatment can be proposed as a substitute for traditional treatments.
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Affiliation(s)
- Laila Amrani
- Department of Gastroenterology, Hôpital Nord, Marseille, France
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47
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Zhou JH, Gong TQ, Jiang YG, Wang RW, Zhao YP, Tan QY, Ma Z, Lin YD, Deng B. Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent. Dis Esophagus 2009; 22:434-8. [PMID: 19191858 DOI: 10.1111/j.1442-2050.2008.00927.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- J-H Zhou
- Department of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
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48
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Eroglu A, Turkyilmaz A, Aydin Y, Yekeler E, Karaoglanoglu N. Current management of esophageal perforation: 20 years experience. Dis Esophagus 2009; 22:374-80. [PMID: 19207557 DOI: 10.1111/j.1442-2050.2008.00918.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- A Eroglu
- Ataturk University, Medical Faculty, Department of Thoracic Surgery, Erzurum, Turkey.
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49
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Altorjay A. [Modern esophageal surgery and late functional results as equations with several unknowns--Hungarian Academy of Sciences Doctoral Thesis]. Magy Seb 2008; 61:285-96. [PMID: 19028662 DOI: 10.1556/maseb.61.2008.5.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Using the same surgical method and anatomically ideal primary healing, the functional results could even be different later. Trying to identify various factors being responsible for the above differences, 637 patient's data, who underwent previous oesophago-gastric surgery between 1985-2005, were analyzed. Biochemical, histological and electrophysiological examinations had been evaluated. Developing hypertrophy-like metabolic changes and enteric ganglionitis as morphological alternations of LES muscles induced by GERD may be reasons for complaints after antireflux surgery. The marking of Z-line with endoscopic clips followed by an immediately upright contrast study and substractional evaluation is appropriate for detecting true short esophagus. Open surgical procedures are justified even in the new millennium in cases when the patient already underwent previous upper abdominal operations - due to an increased risk of injury because of adhesions - in cases of primarily recurrent paraesophageal hernias after an unsuccessful open and/or laparoscopic reconstruction, as well as in cases of reflux with complications. When adenocarcinomas of the gastro-oesophageal junction are examined preoperatively, the ratio of the performed catabolic - AMAN, CB, and DPP I - enzymatic activity of the tissue sample from the tumour and adjacent intact mucosa within 2 cm of the tumour may have a prognostic value even in the preoperative examination period, and neo-adjuvant treatment should be considered in these group of patients. 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 "Akiyama stomach". Tachygastria seems to be the major pathogenetic factor involved in the contractile dysfunction. Gastro-jejuno-duodenal interposition represents an adequate 'second-best' method of choice if technical difficulties emerge with jejunal or colon interposition following limited resection of the oesophagus performed due to early Barrett's carcinoma or non-dilatable peptic stricture.
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Affiliation(s)
- Aron Altorjay
- Fejér Megyei Szent György Kórház Sebészeti Osztály, 8000 Székesfehérvár, Seregélyesi út 3.
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Abstract
Several options–but choose wisely
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Affiliation(s)
- J Kiss
- State Health Centre, Róbert Károly krt. 44, H-1134 Budapest, Hungary
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