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Jung DH, Huh CW, Min YW, Park JC. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022; 95:281-290. [PMID: 34555386 DOI: 10.1016/j.gie.2021.09.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates. METHODS Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract. RESULTS Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself. CONCLUSIONS EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.
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Affiliation(s)
- Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Cheal Wung Huh
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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2
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Zhu C, Castrodad A, Santos AP. Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting. BMJ Case Rep 2021; 14:14/7/e244122. [PMID: 34257131 DOI: 10.1136/bcr-2021-244122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Boerhaave's syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%-50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave's syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.
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Affiliation(s)
- Christina Zhu
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Adan Castrodad
- Department of Surgery, Texas Tech University Health Sciences Center, Covenant Medical Center, Lubbock, TX, USA
| | - Ariel P Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Covenant Medical Center, Lubbock, TX, USA
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3
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Abstract
Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.
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Affiliation(s)
- Thomas Fabian
- Section of Thoracic Surgery, Albany Medical College, Third Floor, 50 New Scotland Avenue, Albany, NY 12159, USA.
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4
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Min YW, Kim T, Lee H, Min BH, Kim HK, Choi YS, Lee JH, Rhee PL, Kim JJ, Zo JI, Shim YM. Endoscopic vacuum therapy for postoperative esophageal leak. BMC Surg 2019; 19:37. [PMID: 30975210 PMCID: PMC6458610 DOI: 10.1186/s12893-019-0497-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023] Open
Abstract
Background Anastomotic leak is the most common and serious complication following esophagectomy. Endoscopic vacuum-assisted closure (EVAC) is a promising method for treating anastomotic leak. We aimed to evaluate the efficacy of EVAC and to identify factors associated with longer treatment duration for esophageal anastomotic leak following esophagectomy for cancer. Methods We retrospectively analyzed 20 esophageal cancer patients who had undergone EVAC for anastomotic leak after esophagectomy. The efficacy and success rates were evaluated and factors associated with longer treatment duration (≥ 21 days) were identified. Results All 20 patients were male. Of these, 10 (50.0%) received neoadjuvant treatment and 6 (30.0%) had one or more comorbidities. The median size of fistula opening was 1.75 cm. During a median of 14.5 days of EVAC treatment, a median of 5 interventions were performed. Treatment success was achieved in 19 patients (95.0%). Neoadjuvant treatment was significantly associated with longer EVAC treatment. There was a non-significant trend toward the need for longer treatment duration for a larger fistula opening size. Conclusions EVAC treatment is a good non-surgical option for anastomotic leak following esophagectomy. Long duration of treatment is associated with neoadjuvant treatment and a large leakage opening.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taewan Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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Yu D, Zhou Z, Zhang X. Surgical treatment of the severe thoracic gastrocutaneous fistula by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma: A case report. Int J Surg Case Rep 2019; 55:76-79. [PMID: 30711886 PMCID: PMC6360347 DOI: 10.1016/j.ijscr.2019.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic anastomotic fistula (TAF) is a severe postoperative complication of oesophagectomy, and its occurrence coupled with a thoracic gastrocutaneous fistula (TGCF) and tracheostenosis is very unusual and may lead to a fatal consequence. CASE PRESENTATION We describe a case of an old female diagnosed with mid-oesophageal carcinoma, who presented with a TAF after oesophagectomy, which was healed by an effective treatment, while a severe TGCF and tracheostenosis appeared one month postoperation. The complications were detected by gastroscopy, barium oesophagogram and thoracic computed tomography (CT). Through surgical treatments, including pedicled muscle flap filling and thoracoplasty, and a correlated corrective procedure, the patient completely recovered and was discharged six months after the admission. CONCLUSION Treatment by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma can be a curative alternative for the severe thoracic gastrocutaneous fistula.
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Affiliation(s)
- Dongmin Yu
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zizi Zhou
- Department of Cardio-Thoracic Surgery, Shenzhen University General Hospital, Shenzhen, China; Department of Plastic and Reconstructive Surgery, BG Unfallklinik Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Xiaoming Zhang
- Department of Cardio-Thoracic Surgery, Shenzhen University General Hospital, Shenzhen, China.
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6
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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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7
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Zhang Y, Yao L, Xu M, Berzin TM, Li Q, Chen W, Hu J, Wang Y, Cai M, Qin W, Xu J, Huang Y, Zhou P. Treatment of leakage via metallic stents placements after endoscopic full-thickness resection for esophageal and gastroesophageal junction submucosal tumors. Scand J Gastroenterol 2017; 52:76-80. [PMID: 27632665 DOI: 10.1080/00365521.2016.1228121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the feasibility and efficacy of endoscopic full-thickness resection (EFTR) and fully covered retrievable self-expandable metal stents (SEMSs) placement for this kind of tumors. METHODS A total of six consecutive patients, presenting with esophageal and GE junction SMTs, received EFTR and SEMSs placement at the our endoscopic center between January 2015 and June 2015. Their medical records were thoroughly investigated. RESULTS EFTR was performed successfully in all cases. The en bloc resection rate was 100%. The final pathological diagnoses were leiomyomas in all six cases. No patients developed delayed bleeding. SEMSs were placed immediately after EFTR during the same endoscopic session except patient #1. Complete healing of esophageal leakage after stent placement was achieved for 6/6 patients (100%) without the need for surgical interventions. Stent migration occurred in one patient. No residual tumor or tumor recurrence was observed during the follow-up period. CONCLUSIONS EFTR combined with fully covered retrievable self-expandable metallic stents placement is a feasible and effective new method for providing radical treatments for SMTs from the deep MP layer of esophagus and GE junction. Standardization of the procedure should be studied further.
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Affiliation(s)
- Yiqun Zhang
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Liqing Yao
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Meidong Xu
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Tyler M Berzin
- b The Center for Advanced Endoscopy , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , MA , USA
| | - Quanlin Li
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Weifeng Chen
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Jianwei Hu
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Yan Wang
- c Department of Gastrointestinal Endoscopy , The First Affiliated Hospital of Nanjing Medical University , Nanjing , Jiangsu , PR China
| | - Mingyan Cai
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Wenzheng Qin
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Jiaxin Xu
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Yuan Huang
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
| | - Pinghong Zhou
- a Endoscopy Center and Endoscopy Research Institute , Zhongshan Hospital, Fudan University , Shanghai , China
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Recent improvements in the management of esophageal anastomotic leak after surgery for cancer. Eur J Surg Oncol 2016; 43:258-269. [PMID: 27396305 DOI: 10.1016/j.ejso.2016.06.394] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/05/2016] [Accepted: 06/18/2016] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.
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Gonzalez JM, Servajean C, Aider B, Gasmi M, D'Journo XB, Leone M, Grimaud JC, Barthet M. Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series. Surg Endosc 2016; 30:4895-4903. [PMID: 26944730 DOI: 10.1007/s00464-016-4828-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery. METHODS Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success. RESULTS There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified. CONCLUSIONS The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %.
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Affiliation(s)
- Jean-Michel Gonzalez
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France.
| | - C Servajean
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - B Aider
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Gasmi
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - X B D'Journo
- Department of Thoracic Surgery, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - M Leone
- Intensive Care Unit, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - J C Grimaud
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Barthet
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
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Harustiak T, Pazdro A, Snajdauf M, Stolz A, Lischke R. Anastomotic leak and stricture after hand-sewn versus linear-stapled intrathoracic oesophagogastric anastomosis: single-centre analysis of 415 oesophagectomies. Eur J Cardiothorac Surg 2015; 49:1650-9. [PMID: 26574497 DOI: 10.1093/ejcts/ezv395] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/06/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES There seems to be a decreased anastomotic leak rate and a late stricture formation after linear-stapled (LS) cervical oesophagogastric anastomosis compared with hand-sewn (HS) technique. The aim of our study was to compare the surgical outcomes of intrathoracic side-to-side LS and end-to-end HS anastomosis after transthoracic oesophagectomy. METHODS We conducted a retrospective review of all patients undergoing Ivor Lewis oesophagectomy with LS or HS anastomosis for neoplasia at our institution from 2005 to 2012. Anastomotic leak was radiologically and clinically graded as minor or major. End-points included overall and major leak rate, morbidity, mortality, length of hospital stay and endoscopically identified late anastomotic stricture. A propensity score-matched analysis was done to compensate for the differences in baseline characteristics between HS and LS groups. Multivariable analyses of the associations of anastomotic technique and other preoperative and pathological variables with anastomotic leak and stricture were performed. RESULTS There were 415 patients, 134 with HS and 281 with LS anastomoses. Anastomotic leak occurred in 56 patients (13.5%), significantly more after HS than LS technique (20.9 vs 10.0%; P = 0.002). Major leak rate was not significantly different (9.0 vs 5.7%; P = 0.216, respectively). Overall morbidity (54.7%), in-hospital mortality (3.9%) and length of hospital stay (median 12 days) were not affected by the anastomotic technique. A follow-up endoscopic evaluation was available in 248 patients (59.8%). An anastomotic stricture was detected in 24 patients (9.7%), significantly more after HS than LS technique (20.3 vs 6.3%; P = 0.002). The propensity score-matched analysis of 105 patient pairs confirmed a significantly decreased overall leak rate (11.4 vs 22.9%; P = 0.045) and stricture formation (7.5 vs 18.2%; P = 0.041) in LS technique compared with HS technique. The multivariable analyses found obesity and HS anastomotic technique associated with an increased overall leak rate, chronic hepatopathy and diabetes associated with major leak and HS technique, female sex and the absence of arterial hypertension associated with increased stricture formation. CONCLUSIONS Our non-randomized study showed that side-to-side LS technique is the preferred method of intrathoracic oesophagogastric anastomosis due to a decreased overall anastomotic leak rate and anastomotic stricture formation compared with HS technique.
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Affiliation(s)
- Tomas Harustiak
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alexandr Pazdro
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Martin Snajdauf
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alan Stolz
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Robert Lischke
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014; 208:536-43. [PMID: 25151186 DOI: 10.1016/j.amjsurg.2014.05.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/10/2014] [Accepted: 05/20/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. DATA SOURCES We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. CONCLUSIONS Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.
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Affiliation(s)
- Lara Schaheen
- Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Katie S Nason
- Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Cervical esophageal perforation: a 10-year clinical experience in north of iran. Indian J Otolaryngol Head Neck Surg 2014; 67:34-9. [PMID: 25621251 DOI: 10.1007/s12070-014-0737-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022] Open
Abstract
Perforations of the cervical esophagus are infrequent severe conditions associated with a high rate of morbidity and mortality if misdiagnosed. The diagnosis and management of cervical esophageal perforation remains a challenging clinical problem. We aimed to present our experience of the etiology, presentation, management and outcome of cervical esophageal perforation in a 10 years period. In this cross-sectional study, we reviewed the records of all patients with a diagnosis of cervical esophageal perforation admitted at the teaching Razi Hospital of Rasht, north of Iran, between 2001 and 2011. 26 patients (15 male) were studied with mean age of 47.6 ± 13.78 years, a range from 10 to 68 years. Only 16 (61.5 %) of patients were referred within 24 h of injury. The etiology was iatrogenic in 15 cases (57.69 %), foreign body ingestion in 7 cases (26.9 %), and penetrating traumatic injury in 4 cases (15.4 %). The common clinical manifestations of perforation were neck pain in 22 cases (84.6 %), fever in 19 cases (73.1 %), and subcutaneous emphysema in 12 cases (46.2 %). Barium and gastrografin swallow were performed in 57.7 and 23.1 % of patients, respectively and flexible esophagoscopy was used in 23.06 %. Most of patients (65.4 %) were managed by primary repair. Overall, mortality rate was 7.7 %. Our study demonstrates that the most common cause of cervical esophageal perforation is iatrogenic injury. Clinical suspicion is most important problem. Furthermore, Diagnosis is mainly made by Barium and gastrografin swallow. For a successful outcome, primary repair is a preferred treatment for most perforation patients.
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13
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Anwuzia-Iwegbu C, Al Omran Y, Heaford A. Against all odds. Conservative management of Boerhaave's syndrome. BMJ Case Rep 2014; 2014:bcr-2013-200485. [PMID: 24850546 DOI: 10.1136/bcr-2013-200485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Spontaneous oesophageal perforation or Boerhaave's syndrome is a life-threatening condition that usually requires early diagnosis and early surgical management. A 79-year-old man presented to the accident and emergency department with an ischaemic left big toe. He reported a 2-week history of worsening symptoms and a claudication distance in his left leg of 20-30 m. Three days post-revascularisation of the leg, the patient reported chest pain radiating to the back. CT angiography of the aorta indicated Boerhaave's syndrome. Following 35 days of conservative management in the intensive care unit and high dependency unit, the patient was stepped down to a surgical ward. A water-soluble contrast study demonstrated minimal leak through the perforated oesophagus. The patient was started on oral intake, which was well tolerated. This case highlights that conservative management may be appropriate.
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Affiliation(s)
| | - Yasser Al Omran
- Barts and The London School of Medicine & Dentistry, London, UK
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Schweigert M, Solymosi N, Dubecz A, Stadlhuber RJ, Muschweck H, Ofner D, Stein HJ. Endoscopic stent insertion for anastomotic leakage following oesophagectomy. Ann R Coll Surg Engl 2013; 95:43-7. [PMID: 23317727 PMCID: PMC3964637 DOI: 10.1308/003588413x13511609956255] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2012] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls. METHODS Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed. RESULTS A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06-12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases. CONCLUSIONS Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.
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Affiliation(s)
- M Schweigert
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Nürnberg Nord, Prof-Ernst-Nathan-Str. 1, 90419 Nürnberg, Germany.
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15
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Elbe P, Lindblad M, Tsai J, Juto JE, Henriksson G, Agustsson T, Lundell L, Nilsson M. Non-malignant respiratory tract fistula from the oesophagus. A lethal condition for which novel therapeutic options are emerging. Interact Cardiovasc Thorac Surg 2012. [PMID: 23184563 DOI: 10.1093/icvts/ivs478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Fistulas between the oesophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after oesophageal resection, without any signs of local residual tumour growth. Other causes that are, by definition, benign may rarely prevail. The traditional therapeutic approach is to divert the proximal portion of the oesophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. We have evaluated our stent-based strategy for managing these life-threatening situations. METHODS At Karolinska University Hospital, all patients admitted with an oesophago-respiratory fistula during the period 2003-2011 followed a stent-based strategy. On clinical suspicion, a prompt computed tomography scan was performed with contrast ingestion, to visualize the status of the anastomosis and the potential communications. Often an endoscopy was done to assess the oesophagus and the conduit. The respiratory tree was inspected through a concomitant bronchoscopy. The double-stent strategy presently applied meant that covered self-expandable metal stents (SEMS) were applied on the alimentary and airway sides to adequately cover the fistula orifice on both sides. The subsequent clinical course determined the ensuing therapeutic strategy. RESULTS During the study period, 17 cases with oesophago-respiratory fistulas were treated at our unit, of which 13 exhibited fistulation following an oesophageal resection due to cancer and 4 cases had a benign underlying disease. The cancer patients did not show any obvious demographic profile when it came to the cancer sub-location, histological type of cancer, or treatment with neoadjuvant chemo- and radiochemotherapy. There was an equal distribution between hand-sutured and stapled anastomoses. In 10 of the cases, the anastomoses were located in the upper right chest; the remainder in the neck, and all reconstructions were carried out by a tubulized stomach. The diagnosis of the fistula tract between the anastomotic area and the respiratory tract was attained on the 15th postoperative day (median), with a range from 5 to 24 days. CONCLUSIONS When an oesophago-respiratory fistula is diagnosed, even in a situation where no neoplastic tissue is prevailing, attempts should be made to close the fistula tract by SEMS from both directions, i.e. from the oesophageal as well as the respiratory side. By this means, a majority of these patients can be initially managed conservatively with prospects of a successful outcome, although virtually all will eventually require a single-stage resection and reconstruction.
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Affiliation(s)
- Peter Elbe
- Division of Surgery, CLINTEC, Karolinska Institute, Sweden.
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16
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Nwiloh JO. Self-expanding stents in treatment of esophageal leaks post bariatric surgery. Gen Thorac Cardiovasc Surg 2012; 61:38-42. [PMID: 22692701 DOI: 10.1007/s11748-012-0120-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 05/29/2012] [Indexed: 10/28/2022]
Abstract
The Alimaxx self-expanding metal stents were used in two morbidly obese patients with esophageal leaks complicating reoperative bariatric surgery. Although the patients could be maintained on oral intake with their sepsis controlled, surgery was ultimately required for non-healing after 3 weeks of conservative management. Self-expanding metal stent should be considered the preferred treatment in small esophageal leaks less than 1 cm in morbidly obese patients who generally pose a higher operative risk due to concomitant co-morbidities. Stents are also useful adjuncts in patients with larger leaks that are either inoperable or need further stabilization at presentation and those preferring an initial 2-3 weeks trial of conservative management before contemplating surgery.
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Affiliation(s)
- Jonathan O Nwiloh
- Section of Cardiothoracic Surgery, Atlanta Medical Center, 303 Parkway Drive, NE Atlanta, GA 30312, USA.
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17
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Habchi K, Blatt A, Schmutz T, Hoffmann M, Braun F. Syndrome de Boerhaave. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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18
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Nguyen NT, Rudersdorf PD, Smith BR, Reavis K, Nguyen XMT, Stamos MJ. Management of gastrointestinal leaks after minimally invasive esophagectomy: conventional treatments vs. endoscopic stenting. J Gastrointest Surg 2011; 15:1952-60. [PMID: 21904963 DOI: 10.1007/s11605-011-1658-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 08/08/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Gastrointestinal leak is a dreaded complication after esophagectomy. Conventional treatments for leak include conservative therapy, surgical reoperation, and even complete gastrointestinal (GI) diversion. The aim of this study was to evaluate the impact of endoluminal stenting in the management of esophagogastric leak after esophagectomy. METHODS Data on 18 (11.3%) of 160 patients who developed postoperative leaks after minimally invasive esophagectomy were reviewed. Indications for esophagectomy included carcinoma (n = 14), Barrett's with high-grade dysplasia (n = 3), and benign stricture (n = 1). Neoadjuvant therapy was used in 57.1% of patients with carcinoma. The first nine patients underwent conventional treatments for leak whereas the latter nine patients underwent endoscopic esophageal covered stenting as primary therapy. There were 5 cervical and 13 intrathoracic anastomotic leaks. Main outcome measures included patient characteristics, types of treatment, length of hospital stay, morbidity, and mortality. RESULTS Subjects were 16 males and 2 females with a mean age of 66 years. In the conventional treatment group, leaks were treated with neck drainage (n = 4), GI diversion (n = 2), and thoracoscopic drainage with or without repair or T-tube placement (n = 3). In the endoscopy group, all leaks were treated with endoscopic covered stenting with or without percutaneous drainage (n = 9). Control of leaks occurred in 89% of patients in the conventional treatment group vs. 100% of patients in the endoscopic stenting group. Three patients in the conventional treatment group (33%) required esophageal diversion compared to none of the patients in the endoscopy group. The 60-day or in-hospital mortality was 0% for both groups. CONCLUSION In our clinical practice, there has been a shift in the management of esophagogastric anastomotic leaks to nonsurgical therapy using endoscopic esophageal covered stenting. Endoluminal stenting is a safe and effective alternative in the management of GI leaks.
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Affiliation(s)
- Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA 92868, USA.
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19
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D’Journo XB. Editorial comment. Eur J Cardiothorac Surg 2011; 40:937-8. [DOI: 10.1016/j.ejcts.2011.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 01/11/2011] [Accepted: 01/13/2011] [Indexed: 10/19/2022] Open
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20
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Tettey M, Edwin F, Aniteye E, Sereboe L, Tamatey M, Entsua-Mensah K, Kotei D, Frimpong-Boateng K. Management of intrathoracic oesophageal perforation: analysis of 16 cases. Trop Doct 2011; 41:201-3. [DOI: 10.1258/td.2011.110120] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Intrathoracic oesophageal perforation remains a life-threatening lesion that requires early diagnosis and the appropriate intervention in order to reduce morbidity and mortality. Management depends largely on the cause of the perforation, the integrity of the oesophagus and the time lapse between the perforation and the commencement of treatment. Our aim was to evaluate the management options that were employed in the treatment of patients with oesophageal perforation and the outcome. The records of 16 patients (11 males and 5 females) who had been operated on from 1994–2009 were retrospectively reviewed. Their ages ranged between 2–66 years (mean 36.4). Malignant oesophageal perforations were excluded from the study. The aetiology was iatrogenic in 10 (62.5%), foreign bodies five (31.2%) and spontaneous one (6.2%). Six patients (37.5%) presented within 24 h of their injury and 10 (62.5%) presented after 24 h. Thoracotomy and intrathoracic primary repair was possible in five (31.2%) cases. Oesophagectomy, cervical oesophagostomy and feeding gastrostomy were carried out in 11 (68.8%). Oesophageal substitution was by colon, routed retrosternally. One patient (6.2%) died after oesophagectomy from overwhelming sepsis. Oesophageal perforation is a life-threatening condition. Early diagnosis and the institution of prompt and appropriate treatment ensure good outcome.
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Affiliation(s)
- M Tettey
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - F Edwin
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - E Aniteye
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - L Sereboe
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - M Tamatey
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - K Entsua-Mensah
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - D Kotei
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
| | - K Frimpong-Boateng
- National Cardiothoracic Centre, Korle Bu Teaching Hospital, Box KB846, Korle Bu, Accra, Ghana
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21
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Ross AS, Kozarek RA. Expandable stents: unique devices and clinical uses. Gastrointest Endosc Clin N Am 2011; 21:535-45, x. [PMID: 21684469 DOI: 10.1016/j.giec.2011.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The use of stents throughout the gastrointestinal tract has evolved over the past century. The evolution of endoscopic ultrasound and significant improvements in stent design are key factors that have allowed endoscopists to drive the use of stents in gastroenterology into new directions. Endoscopic creativity remains crucial in the evolution of any new endoscopic technology. Finally, the use of multidisciplinary teams, including endoscopists, radiologists, and surgeons, allows for the exchange of ideas and procedural planning necessary for successful innovation.
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Affiliation(s)
- Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Mailstop C3-GAS, 1100 9th Avenue, Seattle, WA 98101, USA.
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22
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Freeman RK, Vyverberg A, Ascioti AJ. Esophageal Stent Placement for the Treatment of Acute Intrathoracic Anastomotic Leak After Esophagectomy. Ann Thorac Surg 2011; 92:204-8; discussion 208. [DOI: 10.1016/j.athoracsur.2011.02.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 02/03/2011] [Accepted: 02/07/2011] [Indexed: 11/15/2022]
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Schweigert M, Dubecz A, Stadlhuber RJ, Muschweck H, Stein HJ. Risk of stent-related aortic erosion after endoscopic stent insertion for intrathoracic anastomotic leaks after esophagectomy. Ann Thorac Surg 2011; 92:513-8. [PMID: 21592460 DOI: 10.1016/j.athoracsur.2011.02.083] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrathoracic anastomotic leakage after esophagectomy is associated with high morbidity and mortality. Because of disappointing results after surgical reexploration endoscopic stent implantation was introduced as primary treatment option with improved outcome. Aortoesophageal fistula is a very rare complication and has thus far only anecdotally been reported after esophagectomy. The aim of this retrospective study was to investigate if endoscopic stent implantation increases the incidence of postoperative aortoesophageal fistula by reason of stent-related erosion of the thoracic aorta. METHODS Between January 2004 and October 2010, 213 patients underwent esophageal resection mainly for esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 25 patients. Seventeen patients received endoscopic implantation of a self-expanding stent as primary treatment. In 8 patients a rethoracotomy was mandatory. RESULTS After successfully accomplished endoscopic stent placement, complete closure of the anastomotic leak was radiologically proven in all 17 patients. In 13 cases, definitive closure and healing of the leak was achieved and the stent could subsequently be removed. In 1 patient, because of early recurrence of very malignant small cell cancer, the stent remained in situ. Three patients developed an erosion of the thoracic aorta with subsequent massive hemorrhage. The mean time between stent insertion and occurrence of aortoesophageal fistula was 26 days. All 3 patients died of exsanguination with severe hypovolemic shock. Postmortem examination confirmed an aortoesophageal fistula in each case. CONCLUSIONS While endoscopic stent implantation seems to be effective in the control of intrathoracic anastomotic leakage, nevertheless the incidence of aortoesophageal fistula caused by stent-related aortic erosion exceeds the thus far reported numbers. Awareness of this life-threatening complication after stent insertion is therefore mandatory.
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Affiliation(s)
- Michael Schweigert
- Department of General and Thoracic Surgery, Klinikum Nürnberg Nord, Nürnberg, Germany.
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24
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Kanatas AN, Aldouri A, Hayden JD. Anastomotic leak after oesophagectomy and stent implantation: a systematic review. Oncol Rev 2010. [DOI: 10.1007/s12156-010-0045-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Agustsson T, Nilsson M, Henriksson G, Arnelo U, Juto JE, Lundell L. Treatment of postoperative esophagorespiratory fistulas with dual self-expanding metal stents. World J Surg 2009; 33:1224-8. [PMID: 19363689 DOI: 10.1007/s00268-009-0030-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Fistulas between the esophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after esophageal resection. The traditional therapeutic approach is to deviate the proximal portion of the esophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. METHODS One hundred sixty-seven consecutive esophageal resections were reviewed to address the outcome of a stent-based therapeutic strategy in cases with esophagorespiratory fistulas. The patency of each anastomosis was checked only at the time of clinical suspicion of leakage but then radiology, endoscopy, and bronchoscopy were used together. RESULTS Seven patients developed esophagorespiratory fistula. All of these fistulas were diagnosed more than 1 week after the operation. Two patients (27%) died due to the fistula. Four could be successfully treated but in two of these we were forced to change strategy and either perform a colonic interposition or externalize the esophagus. One of these patients subsequently developed total respiratory failure and required extracorporal membrane oxygenation (ECMO) to recover. CONCLUSIONS When an esophagorespiratory fistula is diagnosed, an attempt to close the fistula tract by SEMS from both the esophageal and the respiratory side is a feasible treatment option. This strategy has to be prolonged and aggressive with a commitment to repeatedly change stents and modify sizes and designs. Thereby a majority of these patients can be managed conservatively with prospects of a successful outcome.
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Griffiths EA, Yap N, Poulter J, Hendrickse MT, Khurshid M. Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK. Dis Esophagus 2009; 22:616-25. [PMID: 19302220 DOI: 10.1111/j.1442-2050.2009.00959.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23-86) years. The etiology of the perforations were Boerhaave's syndrome (n= 19), therapeutic endoscopy (n= 9), diagnostic endoscopy (n= 2), gastric lavage injury (n= 1), foreign body (n= 1), blunt chest trauma (n= 1), and spontaneous tumor perforation (n= 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair (n= 9), T-tube drainage (n= 7), emergency esophagectomy (n= 1), or intra-operative stent insertion (n= 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.
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Affiliation(s)
- E A Griffiths
- Department of General Surgery, Furness General Hospital, Barrow in Furness, Cumbria, UK.
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27
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Janjua AZS. Letter 1: Surgical treatment of oesophageal perforation (Br J Surg 2008; 95: 805-806). Br J Surg 2008; 95:1308-9; author reply 1309. [PMID: 18763240 DOI: 10.1002/bjs.6403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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28
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Efthimiou E, Stein L, Szego P, Court O, Christou N. Stent migration causing alimentary limb obstruction necessitating laparotomy and surgical stent extraction. Surg Obes Relat Dis 2008; 5:375-7. [PMID: 18848509 DOI: 10.1016/j.soard.2008.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 06/22/2008] [Accepted: 07/12/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Evangelos Efthimiou
- Section of Bariatric Surgery, Division of General Surgery, McGill University Health Center, Montreal, Quebec, Canada
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