Emergent Esophagectomy for Esophageal Perforations: A Safe Option

Emergent Esophagectomy in Patients with Esophageal Malignancy Is Associated with Higher Rates of Perioperative Complications but No Independent Impact on Short-Term Mortality

Background

Data on perioperative outcomes of emergent versus elective resection in esophageal cancer patients requiring esophagectomy are lacking. We investigated whether emergent resection was associated with increased risks of morbidity and mortality.

Methods

Data on patients with esophageal malignancy who underwent esophagectomy from 2005 to 2020 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day complication and mortality rates were compared between emergent esophagectomy (EE) and non-emergent esophagectomy. Logistic regression assessed factors associated with complications and mortality.

Results

Of 10,067 patients with malignancy who underwent esophagectomy, 181 (1.8%) had EE, 64% had preoperative systemic inflammatory response syndrome, sepsis, or septic shock, and 44% had bleeding requiring transfusion. The EE group had higher American Society of Anesthesiologists (ASA) class and functional dependency. More transhiatal esophagectomies and diversions were performed in the EE group. After EE, the rates of 30-day mortality (6.1% vs. 2.8%), overall complications (65.2% vs. 44.2%), bleeding, pneumonia, prolonged intubation, and positive margin (17.7% vs. 7.4%) were higher, while that of anastomotic leak was similar. On adjusted logistic regression, older age, lower albumin, higher ASA class, and fragility were associated with increased complications and mortality. McKeown esophagectomy and esophageal diversion were associated with a higher risk of postoperative complications. EE was associated with 30-day postoperative complications (odds ratio, 2.39; 95% confidence interval, 1.66-3.43; p<0.0001).

Conclusion

EE was associated with a more than 2-fold increase in complications compared to elective procedures, but no independent increase in short-term mortality. These findings may help guide data-driven critical decision-making for surgery in select cases of complicated esophageal malignancy.

Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus

OBJECTIVES

The aim of this study was to determine differences in esophageal perforation populations undergoing different advanced interventions for perforated esophagus and identify predictors of treatment outcomes.

SUMMARY BACKGROUND DATA

Contained esophageal perforation can often be managed expectantly, but uncontained perforation is uniformly fatal without invasive intervention. Treatment options for the latter range from simple endoscopic control through advanced intervention. Clinical presentation varies greatly and directs which intervention is most appropriate.

METHODS

From 1996 to 2017, 335 patients were treated for esophageal perforation, and 166 for advanced interventions: 74 primary repair with tissue flap (repair), 26 esophagectomy and gastric pull-up (resection), and 66 esophagectomy and immediate diversion with planned delayed reconstruction (resection-diversion). Patient characteristics, clinical presentation, operative outcomes, and survival were abstracted. Pittsburgh Severity Scores (PSS) were retrospectively calculated. Random survival forest analysis was performed for 90-day mortality and competing risks for reconstruction after resection-diversion.

RESULTS

Repair and resection patients had lower PSS than resection-diversion patients (3 vs 3 vs 6, respectively). Ninety-day mortality for repair, resection, and resection-diversion was 11% vs 7.7% vs 23%, and 5-year survival was 71% vs 63% vs 47%. Risk of death after resection-diversion was highest within 1 year, but 52% of patients had reconstruction of the upper alimentary tract within 2 years.

CONCLUSIONS

Several advanced interventions exist for critically ill patients with uncontained esophageal perforation. Repair and organ preservation are always preferred; however, patients at extremes of illness might best be treated with resection-diversion, with the understanding that the competing risk of death may preclude eventual reconstruction.

Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database

BACKGROUND

Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions.

STUDY DESIGN

We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM).

RESULTS

Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort.

CONCLUSION

J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.

The decrease of BMI and albumin levels influences the rate of anastomotic leaks in patients following reconstruction after emergency diverting esophagectomy

OBJECTIVES

Diverting esophagectomies in cases of benign esophageal perforations remain rare but potentially life saving procedures. Usually, an esophagostoma and a feeding jejunostomy or gastrostomy are created, and patients are given time to recover from the emergency situation. However, little is known about morbidity and mortality as well as the optimal timing for a staged reconstruction.

METHODS

Patients with benign esophageal perforations were selected from our retrospective database. Perforations in esophageal malignancies were excluded to avoid bias on patients' general outcome. Clinical parameters and especially, the influence of the nutritional status indicated by the BMI (Body Mass Index) as well as serum albumin levels (g/l) were analyzed.

RESULTS

A total of 24 patients with diverting esophagectomies were identified. Of these, 13 (54.2%) patients received a staged reconstruction after a median of 143.0 days. Patients presenting for their staged reconstruction demonstrated a significantly decreased level of their BMI (p = 0.026) as compared to their prior hospitalization. Interestingly, the relative decrease of BMI (8.5 kg/m² vs. 4.3 kg/m²) and albumin levels (6.5 g/l vs. 0.0 g/l) was significantly different in patients with or without anastomotic leaks between both surgeries (p = 0.021; p = 0.034, respectively). In addition, higher rates of overall complications were associated with an increased rate of malnutrition.

CONCLUSIONS

The relative amount of malnutrition indicated by BMI or serum albumin levels influences the rate of anastomotic leaks and general complications in patients with staged reconstruction after diverting esophagectomy for non-malignant esophageal perforations. Hence, reconstruction should be done as fast as possible to reduce the amount of malnutrition and a frequent assessment of the nutritional status must be done during recovery from the emergency surgery.

Salvage Esophagectomy After Atrioesophageal Repair

Atrioesophageal fistula is a rare but highly morbid complication after endovascular ablation for atrial fibrillation. We report the case of a 63-year-old man with an atrioesophageal fistula after ablation who presented with neurologic symptoms and underwent emergent repair. He subsequently sustained a leak from the esophageal repair requiring emergent esophagectomy with end-esophagostomy. After several months, the patient underwent re-establishment of gastrointestinal continuity via retrosternal gastric conduit reconstruction.

Surgical management and prognostic factors in esophageal perforation caused by foreign body

OBJECTIVES

Esophageal perforation is associated with multiple serious complications and high mortality. Herein, we identify some predictors for postoperative outcomes, compare the outcomes of various surgical approaches, and summarize our experience with esophageal perforation over the past 13 years.

METHODS

We retrospectively analyzed 38 patients diagnosed with esophageal perforation caused by foreign body between November 2004 and May 2018. Univariate analysis and multivariate logistic regression analysis were performed to identify potential risk factors related to prognosis. Effects of different surgery were compared based on postoperative outcomes.

RESULTS

Of the 38 patients, the number of females was equal to males with a mean age of 55.6 ± 14.9 (range 23-93) years; 22 had thoracic perforations and 16 had cervical perforations. The overall mortality rate was 5.3%. Univariate analysis revealed that sex (p = 0.049), type of foreign body (p = 0.042), abscess (p = 0.049), and site of perforation (p = 0.031) were associated with prognosis. The interval between perforation and surgery did not significantly influence prognosis (p = 0.929). No significant difference was found in postoperative outcomes among various surgeries.

CONCLUSIONS

The interval between perforation and treatment was not as important as previously reported. Surgical management should be performed early when feasible, even if the interval between perforation and surgery is 24 h or longer.

Surgical management of early and late esophageal perforation

Introduction

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

Methods

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

Results

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

Conclusion

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

Esophagectomy with gastric conduit reconstruction for benign disease: extreme but important

Esophagectomy is usually performed to resect esophageal cancer. However, there are numerous other indications for esophagectomy, including Barrett's esophagus with high-grade dysplasia (HGD) and some benign diseases such as obstruction, end-stage achalasia, esophagus perforation or disruption, benign neoplasm, and severe caustic injury. For these patients, esophagectomy could relieve their symptom obviously. However, esophagectomy causes huge trauma, induces quite high morbidity and mortality, and may decreases patients' quality of life obviously due to postoperative reflux, dumping, anastomotic stricture and other complications. Accordingly, the considerations of a surgery must be carefully deliberated, including the underlying disorder, lesions localization, extent of disease, and options for esophageal replacement. For patients received esophagectomy and alimentary tract reconstruction, gastric conduit is the most common used replacement organ, then colon and jejunum. This review demonstrated the importance and technical experience of esophagectomy with gastric conduit reconstruction for benign diseases.

Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

Internal Drainage of an Esophageal Perforation in a Patient with a High Surgical Risk

A 71-year-old man presented with a productive cough and fever, and he was diagnosed as having an esophageal perforation and a mediastinal abscess. He had a history of traumatic hemothorax and pleural drainage for empyema in the right chest and was considered unable to tolerate thoracic surgery because of sepsis and progressive aspiration pneumonia. In order to aggressively drain the mediastinal contamination, we performed internal drainage by placing a Levin tube into the mediastinum through the perforation site. This procedure, in conjunction with controlling sepsis and providing sufficient postpyloric nutrition, allowed the esophageal injury to completely heal.

Video-thoracoscopic approach, without suture, of late thoracic esophageal perforations

OBJECTIVES

to evaluate the use of video-thoracoscopy, in the treatment of late perforations of the thoracic esophagus, without suture or organ resection.

METHODS

retrospective analysis of patients with late diagnosis (> 12 hours) of thoracic esophageal perforation treated by video-thoracoscopy, without suture or organ resection, over a 15-year period.

RESULTS

sixteen patients were operated on, ten men and six women, aged between 48 and 66 years, with time between the diagnosis of the perforation and the surgery ranging from 16 to 26 hours. All patients underwent video-thoracoscopy, with pulmonary decortication, pleural loculations approach, opening of the mediastinal pleura near the perforation site and debridement of the devitalized tissues, followed by double drainage of the pleural cavity. No esophageal suture or resection was performed, and the patients evolved with complete closure of the lesions, without deaths.

CONCLUSION

the video-thoracoscopic surgical approach was able to control pleural infection, pulmonary expansion and enable complete regeneration of the esophagus with late-diagnosed perforation.

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

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Successful primary repair of late diagnosed spontaneous esophageal rupture: A case report

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Diagnosis of spontaneous rupture of the esophagus is often delayed.

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Significant contamination of the mediastinum and pleural space is not uncommon.

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Debridement and drainage of the mediastinum and pleural space are necessary to control sepsis.

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Debridement of necrotic tissue is necessary.

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Primary repair in layers of the esophagus is possible in majority of the cases regardless of the time lapsed from rupture.

Introduction

Spontaneous esophageal rupture is rare, roughly 300 cases reported annually. Diagnosis is often delayed or missed. Overall mortality is about 20%. This feared high mortality rate has led to the misconception that primary esophageal repair should be avoided in late diagnosed patients. We report a successful primary repair of spontaneous esophageal rupture which was delayed for more than two weeks.

Methods

A 53 year-old male presented to our medical service after falsely having been treated for pneumonia at an outside hospital. He was subsequently diagnosed with spontaneous esophageal rupture and treated with over the scope clips followed by stenting. Persistent leak into mediastinum made surgical exploration necessary. At exploration a primary repair could be performed successfully.

Results

Unsuccessful endoscopic management of esophageal perforation that was delayed for two weeks underwent primary surgical repair without complications.

Conclusion

Primary closure of late diagnosed spontaneous esophageal rupture can be successful, even when it is complicated by a prolonged delay in treatment and failed endoscopic procedures. We conclude that primary surgical repair should be attempted in patients with spontaneous esophageal rupture if tissues are viable.

Successful surgical treatment of a complicated esophageal perforation, by use of primary closure and lung parenchyma reinforcement

Esophageal perforation (EP) is a medical condition which demands urgent confrontation with significant complications. The cause of the perforation may be common, spontaneous or iatrogenic, with conservative or surgical therapeutic strategy, which is needed in the majority of incidents, depending on the characteristics of the lesion. We report a case of a 68-year-old man, with the existence of an ulcerative lesion 31 cm approximately from the dental barrier, and a coexistent stenosis, diagnosed through esophagogastroduodenoscopy, which evolved to an extensive purulent necrotic mediastinitis, diagnosed through a thorax CT scan after the patient began to complain of asphyxiation during eating. A right posterolateral thoracotomy was performed along with intensive wide spectrum antibiotic therapy. Primary closure of the perforation as well as pulmonary tenting was used with satisfactory results. There was no evidence of leakage after a 12-month "follow-up" period. The early diagnosis of an EP combined with immediate surgical procedure and frequent "follow-up" of the patient, eliminate the risks for the patient's life and ensure a satisfactory outcome.

Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

BACKGROUND

With the introduction of new treatment paradigms for esophageal perforation, the management of this highly morbid condition is evolving. We reviewed our experience to investigate the modern management and outcomes of esophageal perforations with a focus on operatively repaired patients.

METHODS

A retrospective review of all esophageal perforations was conducted between August 2003 and January 2016.

RESULTS

A total of 48 patients were identified, with iatrogenic injury in 19 (40%), spontaneous perforation in 18 (38%), and traumatic/foreign body causes in 11 (23%). The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was <24 hours in 60%. Nonoperative management was employed in 18 (38%) and operative repair in 30 (primary operative repair = 20, drainage = 4, esophagectomy = 6). Iatrogenic and traumatic perforations were more likely to be treated nonoperatively (68%), while all spontaneous perforations were treated by operative intervention. There were no complications or mortalities in the nonoperative group and only a 5% reintervention rate. In the operative group, complications occurred in 10 (33%), reinterventions in 13 (43%), and mortality in 2 (7%) patients.

CONCLUSION

Our study highlights the importance of considering the etiology of a perforation when planning management and the success of nonoperative treatment with careful patient selection. In addition, operative repair in septic patients yielded excellent outcomes and should be the standard for comparison in future studies exploring endoscopic approaches.