The role of oesophageal diversion and exclusion in the management of oesophageal perforations

Exploring the landscape of oesophageal discontinuity procedures and creation of cervical oesophagostomy in the modern era: a scoping review protocol

INTRODUCTION

Oesophageal discontinuity remains a challenge for thoracic and foregut surgeons globally. Whether arising emergently after catastrophic oesophageal or gastric disruption or arising in the elective setting in the case of staged reconstruction for esophagectomy or long gap atresia in the paediatric population, comprehensive review of this patient population remains unexplored within the surgical literature.The goal of this scoping review is to map the landscape of literature exploring the creation and takedown of cervical oesophagostomy with the intent to answer four questions (1) What are the primary indications for oesophageal discontinuity procedures? (2) What are the disease-specific and healthcare utilisation outcomes for oesophageal discontinuity procedures? (3) What is the primary indication for reversal procedures? (4) What are the disease-specific and healthcare utilisation outcomes for reversal procedures?

METHODS

This review will follow the Arksey and O'Malley (2005) framework for scoping reviews. Paediatric (<18 years old) and adult (>18 years old) patients, who have received a cervical oesophagostomy in the context of a gastrointestinal discontinuity procedure or those who have had reversal of a cervical oesophagostomy, will be included for analysis. We will search MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases for papers from 1990 until 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria.

ETHICS AND DISSEMINATION

No ethics approval is required for this review. Results will be disseminated through scientific presentations and relevant conferences targeted for researchers examining upper gastrointestinal/foregut surgery.

REGISTRATION DETAILS

This protocol is registered with Open Science Framework (osf.io/s3b4g).

Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study

BACKGROUND : Endoscopic vacuum therapy (EVT) is a novel treatment for esophageal perforations. This study aimed to describe initial experience with EVT of esophageal perforations due to iatrogenic cause, Boerhaave syndrome, or other perforations not related to prior upper gastrointestinal surgery. METHODS : Data from patients treated with EVT for esophageal perforation at five hospitals in three European countries, between January 2018 and October 2021, were retrospectively collected. The primary end point was successful defect closure by EVT, with or without the use of other endoscopic treatment modalities. Secondary end points included mortality and adverse events. RESULTS : 27 patients were included (median age 71 years). The success rate was 89 % (24/27, 95 %CI 77-100). EVT failed in three patients: two deceased during EVT (septic embolic stroke, pulmonary embolism) and one underwent esophagectomy due to a persisting defect. Two adverse events occurred: one iatrogenic defect expansion during sponge exchange and one hemorrhage during sponge removal. Median treatment duration was 12 days (interquartile range [IQR] 6-16) with 1 sponge exchange (IQR 1-3). CONCLUSION : EVT is a promising organ-preserving treatment for esophageal perforations, with a success rate of 89 %. More experience with the technique and indications will likely improve success rates.

Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects

Introduction

Endoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent.

Patients and methods

This prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events.

Results

In total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed.

Conclusion

The vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.

Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video)

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.

A Novel and Simple Method of Managing Thoracic Esophageal Perforation: The "ASSIST" Approach

INTRODUCTION

Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes).

METHODS

Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake.

RESULTS

Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet.

CONCLUSIONS

The "ASSIST" method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities.

Extraluminal migration of ingested fish bone in the upper aerodigestive tract: A series of three cases with broad clinical spectrum of manifestations and outcomes

Introduction

Incidental fish bone ingestion may penetrate the upper aerodigestive tract and cause extraluminal migration due to late presentation or missed diagnosis. The migrated fish bone exhibits a wide spectrum of clinical manifestations, ranging from mild symptoms to potentially fatal complications.

Presentation of case

We report three cases of extraluminal fish bone migration with diverse clinical presentations and complications. The first patient had mild throat symptoms and a fish bone that travelled through the neck and migrated towards the subcutaneous tissue without causing complications. The second patient developed deep neck abscess and thoracic complications as a result of the migrated foreign body, but recovered after surgical exploration and foreign body removal. The third patient presented late in sepsis and upper airway obstruction, subsequently succumbed to multiorgan failure before any surgical intervention.

Discussion

Thorough physical and endoscopy examinations are essential in patients with fish bone ingestion. Normal endoscopic findings in a symptomatic patient should always raise the suspicion of a migrated fish bone. A radiographic imaging study is often helpful in locating the foreign body and potential complications. The migrated fish bone that acts as the source of infection in the neck should be traced and removed surgically. The resulting abscess, if present, must be drained. The management of a migrated fish bone can be challenging and often require multi-discipline collaboration.

Conclusion

The migration of the ingested fish bone outside the upper aerodigestive tract can cause serious complications and death in some cases. Clinicians should always maintain a high level of suspicion towards extraluminal migration in a patient with a history of fish bone ingestions but normal endoscopic findings. We emphasize the importance of early recognition and prompt surgical intervention to remove the migrated fish bone to minimise the potential morbidity and mortality.

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Incidental fish bone ingestion can penetrate and migrate out of aerodigestive tract.

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The manifestations of a migrated fish bone vary from mild symptoms to severe complications.

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The complications are determined by the site and path of the fish bone migration.

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A normal endoscopy finding does not rule out extraluminal fish bone migration.

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Early recognition and prompt surgical intervention can reduce morbidity.

Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis

A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle-Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81-0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45-4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24-2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17-5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12-4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23-7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Aberrant Right Subclavian Artery to Esophageal Fistula: A Rare Case and Its Management

A 29-year-old woman underwent esophageal stent placement after developing esophageal stenosis in the setting of tracheoesophageal fistula repair in childhood. The patient developed hemoptysis from an esophageal to aberrant right subclavian artery fistula; this was managed with several staged procedures involving arterial stent placement, carotid-to-subclavian bypass, and aberrant subclavian artery ligation. The patient then underwent pericardial patch repair of her perforated esophagus. This case illustrates the importance of understanding congenital anatomy and frequent associations, such as tracheoesophageal fistula and aberrant right subclavian artery; furthermore, it demonstrates the importance of multidisciplinary care for complex cases.

Practice of cervical end-esophageal exteriorization in patients with severe intrathoracic anastomotic leakage after esophagectomy

Objective

This study aimed to summarize the clinical experience of severe intrathoracic anastomotic leakage encountered in clinical practice by using cervical end-esophageal exteriorization.

Methods

We undertook a retrospective review of four patients who developed severe anastomotic leakage after subtotal esophagectomy at our department. Four patients with a life-threatening condition and failed conservative management were re-operated on from the original incision using an exteriorized cervical end-esophageal gastric conduit. We returned the gastric conduit to the abdomen and placed a feeding jejunostomy or gastrostomy catheter. Until inflammation was controlled, we re-established intestinal continuity with the gastric or colon conduit, pulled up to the neck by a retrosternal channel.

Results

Four patients with esophagectomy and severe intrathoracic anastomotic leakage underwent re-operation. The gastric conduit was returned to the abdomen and cervical end-esophageal exteriorization was performed. Inflammation was rapidly controlled after surgery. Three patients received a second re-operation to re-establish intestinal continuity on days 63, 63, and 16 after the first re-operation. One patient refused re-operation to re-establish intestinal continuity. All four patients survived.

Conclusion

Cervical end-esophageal exteriorization in patients with severe intrathoracic anastomotic leakage results in rapid control of inflammation. This creates an opportunity to re-establish gastrointestinal continuity, leading to survival of patients.

Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula

Upper gastrointestinal perforations, fistula, and anastomotic leaks are severe conditions with high mortality. Temporary endoscopic placement of fully covered self-expanding metal stent (fSEMS) has emerged as treatment option. Stent migration is a major drawback of currently used stents. Migration is often attributed to a relatively too small stent diameter as esophageal stents were initially intended for the treatment of strictures. This study aimed to investigate the safety and efficacy of a large-diameter fSEMS for treatment of these conditions. Data were retrospectively collected from patients who received this stent in the Netherlands between March 2011 and August 2013. Clinical success was defined as sufficient leak closure after stent removal as confirmed by endoscopy or X-ray with oral contrast without surgical intervention or placement of another type of stent. Adverse events were graded according a standardized grading system. Stent placement was performed in 34 patients for the following indications: perforation (n = 6), anastomotic leak (n = 26), and fistula (n = 2). Technical success rate was 97% (33/34). Clinical success rate was 44% (15/34) after one stent and 50% (17/34) after an additional stent. There were no severe adverse events and stent-related mortality. The overall adverse event rate was 50% (all graded 'moderate'). There were 14 (41%) stent migrations (complete n = 8, partial n = 6). Other adverse events were bleeding (n = 2) and aspiration pneumonia (n = 1). Reinterventions for failure of the large-diameter fSEMS were placement of another type of fSEMS (n = 4), surgical repair (n = 3), or esophagectomy (n = 1). Eleven patients (32%) died in-hospital because of persisting intrathoracic sepsis (n = 10) or preexistent bowel ischemia (n = 1). This study suggests that temporary placement of a large-diameter fSEMS for the treatment of upper gastrointestinal perforations, fistula, and anastomotic leaks is safe in terms of severe adverse events and stent-related mortality. The larger diameter does not seem to prevent stent migration.

Complex Esophageal Reconstruction Procedures Have Acceptable Outcomes Compared With Routine Esophagectomy

BACKGROUND

Complex esophageal reconstruction (CER) is defined as restoring esophageal continuity in a previously operated field, using a nongastric conduit, or after esophageal diversion. This study compares the outcomes of CER with non-CER (NCER), which uses an undisturbed stomach for reconstruction.

METHODS

This single-institution retrospective cohort study compares 75 CERs with 75 NCERs from 1995 to 2014 that were matched for cancer versus benign disease. Distributions of demographic characteristics, comorbidities, and complications were compared between CER and NCER. Odds of mortality at 30 and 90 days were calculated with logistic regression. Overall survival was illustrated with Kaplan-Meier method and Cox proportional hazards regression.

RESULTS

Although patients were similar in age, sex, and preoperative comorbidities, more non-white patients underwent CER (p = 0.04). Most NCER patients had adenocarcinoma (44%) or Barrett's high-grade dysplasia (39%); most CER patients had other benign disease (44%) or squamous cell carcinoma (24%, p < 0.01). CER had statistically significantly higher rates of reoperation, pneumonia, infection, and gastrointestinal complications, and longer median length of stay than NCER. Odds of mortality for CER and NCER at 30 days (odds ratio [OR] 1.0, 95% CI: 0.1 to 16.3), 90 days (OR 2.6, 95% CI: 0.5 to 13.9) and overall (adjusted hazard ratio 1.56, 95% CI: 0.9 to 2.7) were not statistically significantly different.

CONCLUSIONS

Compared with NCER, CER patients had higher rates of return to the operating room, more postoperative infections and gastrointestinal complications, and longer length of stay. However, 30-day, 90-day, and overall survival were similar. CER should be offered to patients with acceptable risks and anticipated long-term survival.

Traumatic oesophageal perforation due to haematoma

INTRODUCTION

Traumatic oesophageal perforation is a rare, life-threatening emergency that requires early recognition and prompt surgical management.

PRESENTATION OF CASE

We present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.

DISCUSSION

In treatment of oesophageal haematoma in patients on vitamin-K antagonists, strict control of the International Normalized Ratio (INR) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes. Three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma, azygos vein and the lower part of thoracic trachea; or could be an immediate rupture walled-off until the patient became symptomatic; or the intramural hematoma gradually lysed and causing late perforation.

CONCLUSION

Although extremely rare, an oesophageal haematoma and late complications must be considered in patients on anti-coagulant therapy following blunt thoracic trauma and complaining only of chest pain.

Management of esophageal perforation and anastomotic leak by transluminal drainage

INTRODUCTION

The management of esophageal perforations and leaks remains a challenge. Although there are broad management principles, each situation may require a different surgical approach. The aim of this report was to describe the management of these esophageal crises by transluminal drainage via a transabdominal approach.

METHODS

Between 2005 and 2009, patients with anastomotic or gastric staple line leak (n = 4) or esophageal perforation (n = 2) underwent transabdominal surgery and transluminal drainage. This simple technique has, to the best of our knowledge, not been previously reported.

RESULTS

All six patients survived. The median intensive care unit and hospital stays were 12 days (range 0-32) and 63 days (range 32-99), respectively. At a median follow-up time of 25 months (range 15-60), five of the six patients remain alive and well. One patient with node positive esophageal carcinoma has died from relapsed disease.

CONCLUSIONS

Transabdominal transluminal drainage should be added to the list of potential techniques that can be employed in management of esophageal leaks and perforations. It is a valuable adjunct to the armamentarium of the esophageal surgeon for dealing with these challenging situations.

Management of Esophageal Perforation in Adults

Perforation of esophagus in the adult is a very morbid condition with high morbidity and mortality. The ideal treatment is controversial. The main causes for esophageal perforation in adults are iatrogenic, traumatic, spontaneous and foreign bodies. The morbidity and mortality rate is directly related to the delay in diagnosis and initiation of optimum treatment. The reported mortality from treated esophageal perforation is 10% to 25%, when therapy is initiated within 24 hours of perforation, but it could rise up to 40% to 60% when the treatment is delayed beyond 48 hours. Primary closure of the perforation site and wide drainage of the mediastinum is recommended if perforation is detected in less than 24 hours. Treatment option for delayed or missed rupture of esophagus is not very clear and is controversial. Recently a substantial number of patients with esophageal perforation are being managed by nonoperative measures. Patients with small perforations and minimal extraesophageal involvement may be better managed by nonoperative treatment Major prognostic factors determining mortality are the etiology and site of the injury, the presence of underlying esophageal pathology, the delay in diagnosis and the method of treatment. For optimum outcome for management of esophageal perforations in adults a multidisciplinary approach is needed.

Short-term esophageal stenting in the management of benign perforations

OBJECTIVES

The standard approach to benign esophageal perforations consists of conservative treatment or surgery. In this study, we investigated the efficacy of short-term stent placement for nonmalignant esophageal perforations.

METHODS

This is a prospective single-center study of patients with benign esophageal perforations in whom a removable self-expandable stent was placed. Data were collected from a prospective database, endoscopy records, and operation reports. To obtain follow-up data, we contacted the patients, their relatives, or their general practitioner.

RESULTS

A total of 33 patients underwent stent insertion owing to an iatrogenic perforation (n=19), Boerhaave's syndrome (n=10), or other causes (n=4); this resulted in an immediate and complete sealing of the lesion in 32 patients (97%). Stents migrated in 11 patients (33%). Four patients required an esophageal resection for failed stent therapy (n=3) and failed stent removal (n=1). The 90-day mortality rate was 15%. A total of 33 endoscopic stent extractions were attempted. Overall, 23 stents were extracted within 6 weeks (group I) and 10 stents between 6 and 84 weeks (group II). Extractions were uncomplicated in all patients in group I (100%) vs. in 5 patients in group II (50%) (P=0.001). Six extraction-related complications occurred in group II, including two self-limiting bleedings, three stent fractures, and one impacted stent.

CONCLUSIONS

In patients with a benign esophageal perforation, temporary stent therapy is effective and provides a good alternative to surgery. Complications due to stent removal can be prevented by removal of the prosthesis within 6 weeks after insertion, without compromising the efficacy of treatment.