1
|
Conrad H, Sridhar P. What Is New with Cervical Perforations? A Clinical Review Article. Thorac Surg Clin 2024; 34:321-329. [PMID: 39332857 DOI: 10.1016/j.thorsurg.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
Approximately 15% of all esophageal perforations occur within the cervical esophagus. Advances in medical care and surgical technique overtime have led to decreased mortality associated with esophageal perforations. While early recognition, accurate characterization, and adequate drainage, or repair when appropriate, remain the mainstays in the management of cervical perforations, endoscopic innovation has provided a minimally invasive option in the management of this disease and expanded the armamentarium of options available to providers.
Collapse
Affiliation(s)
- Hope Conrad
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, 1625 North Campbell Avenue, Tucson, AZ, USA
| | - Praveen Sridhar
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, 1625 North Campbell Avenue, Tucson, AZ, USA.
| |
Collapse
|
2
|
Levin EG, Ritter A, Amitai A, Shpitzer T, Bachar G, Mizrachi A, Hamzany Y. Management and prognosis of iatrogenic perforations of the cervical oesophagus and hypopharynx. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2024; 44:214-222. [PMID: 39347546 PMCID: PMC11441517 DOI: 10.14639/0392-100x-n2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/08/2024] [Indexed: 10/01/2024]
Abstract
Objective The study aimed to identify factors affecting the management and prognosis of iatrogenic cervical oesophageal and hypopharyngeal perforations (iCEHPs). Methods We retrospectively analysed 24 patients treated for iCEHP between 2004 and 2021 at a tertiary university medical centre. Data on demographics, clinical features, imaging, management and outcomes were collected. Factors associated with primary management and patient outcome were assessed. Results The most common management approach was surgical neck exploration (15 patients, 62.5%). Surgical management was used in 93% of uncontained perforations compared to 11% of contained perforations (p < 0.001). Surgically-treated patients had higher levels of C-reactive protein (CRP) than conservatively-treated patients (median, 18.3 vs 4.8 mg/dL; p = 0.001). Delayed diagnosis (≥ 24 hours) was associated with increased mortality (100 vs 5%; p = 0.011). The mortality rate was significantly higher in patients who had a history of neck irradiation than in patients who did not (67 vs 5%; p = 0.032). Conclusions Early diagnosis of iCEHP improves outcomes. The appropriate management should be carefully selected on the basis of CRP level and imaging findings. Prior neck radiation is a poor prognostic factor.
Collapse
Affiliation(s)
- Einav G. Levin
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| | - Amit Ritter
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| | - Amir Amitai
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| | - Gideon Bachar
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| | - Aviram Mizrachi
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| | - Yaniv Hamzany
- Department of Otolaryngology − Head and Neck Surgery, Rabin Medical Center − Beilinson Hospital, Petach Tikva, Israel
- Department of Orthopedic Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
| |
Collapse
|
3
|
Richter F, Conrad C, Hoffmann J, Reichert B, von Schoenfels W, Schafmayer C, Egberts JH, Becker T, Ellrichmann M. Endoluminal Vacuum Therapy Using a New "Fistula Sponge" in Treating Defects of the Upper Gastrointestinal Tract-A Comparative, Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1105. [PMID: 39064534 PMCID: PMC11279286 DOI: 10.3390/medicina60071105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/17/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT's duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.
Collapse
Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Claudio Conrad
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
| | - Julia Hoffmann
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Benedikt Reichert
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Witigo von Schoenfels
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Clemens Schafmayer
- Department of General Surgery, University Hospital Rostock, 18057 Rostock, Germany;
| | | | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Mark Ellrichmann
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
| |
Collapse
|
4
|
Veziant J, Boudis F, Lenne X, Bruandet A, Eveno C, Nuytens F, Piessen G. Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study. Ann Surg 2023; 278:709-716. [PMID: 37497641 DOI: 10.1097/sla.0000000000006048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). BACKGROUND EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. METHODS Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. RESULTS Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. CONCLUSIONS We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.
Collapse
Affiliation(s)
- Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
| | - Fabio Boudis
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Xavier Lenne
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Az Groeninge Hospital, Kortrijk, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| |
Collapse
|
5
|
Montminy EM, Jones B, Heller JC, Attwell A. Endoscopic iatrogenic esophageal perforation and management: a retrospective outcome analysis in the modern era. BMC Gastroenterol 2023; 23:371. [PMID: 37907880 PMCID: PMC10617122 DOI: 10.1186/s12876-023-03004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Iatrogenic esophageal perforation (IEP) is a severe adverse event (AE) of upper endoscopy procedures (UEPs) associated with morbidity. Management has shifted from surgery to endotherapy with clip closure (CC), self-expanding metal stent (SEMS), and vacuum therapy (VT). Limited analyses measure outcomes during contemporary interventional endoscopy periods. METHODS IEPs associated with EGD, upper EUS, small bowel enteroscopy (SBE), and ERCP at a 3-hospital academic center from January 2011 to December 2023 were identified retrospectively from a centralized AE database. Additional information was obtained from medical records. Statistical analysis was performed using Microsoft Excel and STATA. RESULTS Thirty-two IEPs from 26 EGDs, 4 EUS, 1 SBE, and 1 ERCP were identified. IEPs occurred mostly after dilation (bougie N = 7; balloon, N = 5) or foreign body removal (N = 6). Most IEPs occurred in the lower esophagus (N = 10) or gastroesophageal junction (N = 8). Diagnosis was made at a median 2 h after the injury by endoscopy (N = 14), CT scan (N = 12), esophagram (N = 5), or x-ray (N = 1). Initial treatment included conservative therapy alone (N = 7), CC (N = 3), SEMS (N = 14), SEMS plus CC (N = 3), or surgery (N = 3). Eleven patients required additional treatment including repeat SEMS or adjustment (N = 4) or VT (N = 1). No surgical interventions were required after 2013. The median hospital stay was 3 days. Disposition included discharge to home (N = 25), long-term care facility (N = 2), 4 deaths (12.5% of IEPs), and 1 unknown. CONCLUSIONS IEPs are rare and occur throughout the esophagus after any UEP. The majority are recognized immediately and managed with endotherapy, or rarely, surgery today. These characteristics likely explain the low mortality in this study.
Collapse
Affiliation(s)
- Eric M Montminy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA
| | - Blake Jones
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA
| | - J Christie Heller
- Division of Gastroenterology and Hepatology, Denver Health Medical Center, Denver, CO, 80204, USA
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA.
- Division of Gastroenterology and Hepatology, Denver Health Medical Center, Denver, CO, 80204, USA.
- Denver Health Medical Center, 601 Broadway, MC 4000, Denver, CO, 80203, USA.
| |
Collapse
|
6
|
Momblan D, Gimeno Garcia AZ, Busquets D, Juzgado D, García Lledó J, Ferrero E, Tejedor-Tejada J, Junquera F, Díaz-Tasende J, Moris M, Rodriguez de Santiago E, Gornals J, Garrido C, Gonzalez-Vazquez S, Guarner-Argente C, Repiso A, Esteban JM, Loras C, Seoane A, Fernández-Simon A, Guevara HC, Ibarzabal A, Morales X, Curell A, Cardenas A, Ríos J, de Lacy AM, Sendino O. Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry. Am J Gastroenterol 2023; 118:1797-1806. [PMID: 37606066 DOI: 10.14309/ajg.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.
Collapse
Affiliation(s)
- Dulce Momblan
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antonio Z Gimeno Garcia
- Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - David Busquets
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Diego Juzgado
- Department of Gastroenterology, Hospital Quirón Madrid, Madrid, Spain
| | - Javier García Lledó
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Esther Ferrero
- Department of General and Digestive Surgery, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | | | - Félix Junquera
- Department of Gastroenterology, Hospital de Sabadell, Institut d´Investigació i Innovació Parc Taulí I3PT, CIBERehd, Sabadell, Spain
| | - José Díaz-Tasende
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Moris
- Department of Gastroenterology and Hepatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, IRYCIS, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Joan Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carmen Garrido
- Endoscopy Unit, Department of Gastroenterology, Son Espases University Hospital, Illes Balears, Spain
| | | | | | - Alejandro Repiso
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Jose Miguel Esteban
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Agustín Seoane
- Department of Gastroenterology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Henry Cordova Guevara
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ainitze Ibarzabal
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Xavier Morales
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Curell
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrés Cardenas
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Ríos
- Department of Clinical Farmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Maria de Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| |
Collapse
|
7
|
Luttikhold J, Pattynama LMD, Seewald S, Groth S, Morell BK, Gutschow CA, Ida S, Nilsson M, Eshuis WJ, Pouw RE. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023; 55:859-864. [PMID: 36828030 PMCID: PMC10465237 DOI: 10.1055/a-2042-6707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/24/2023] [Indexed: 02/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- Joanna Luttikhold
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Lisanne M. D. Pattynama
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Zürich, Switzerland
| | - Stefan Groth
- Centre of Gastroenterology, Klinik Hirslanden, Zürich, Switzerland
| | - Bernhard K. Morell
- Department of Gastroenterology and Hepatology, Universitätsspital, Zürich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zürich, Zürich, Switzerland
| | - Christian A. Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Satoshi Ida
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E. Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Rhode P, Plum P, Gockel I. [64/m-Vomiting and thoracic pain : Preparation for the medical specialist examination: part 31]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:18-22. [PMID: 37193937 DOI: 10.1007/s00104-023-01871-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Philipp Rhode
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - Patrick Plum
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland.
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| |
Collapse
|
9
|
Liao F, Yang Q, Zhan Z, Zhu Z, Pan X, Wang C, Li B, Zhu Y, Chen Y, Shu X. Routine nasogastric tube placement in patients with small esophageal perforation after endoscopic foreign body removal may be unnecessary: a propensity score matching analysis. Gastroenterol Rep (Oxf) 2023; 11:goad044. [PMID: 37521332 PMCID: PMC10386876 DOI: 10.1093/gastro/goad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/25/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Background Nasogastric tube (NGT) placement is part of the post-operative management of upper gastrointestinal perforation, but its routine use in esophageal perforation (EP) caused by foreign bodies remains unclear. The purpose of this research was to investigate the necessity for routine NGT placement in patients with EP after endoscopic foreign body removal. Methods A total of 323 patients diagnosed with EP caused by foreign bodies at the First Affiliated Hospital of Nanchang University between January 2012 and December 2021 were included in this retrospective study. Patients were divided into the NGT group and the non-NGT group according to whether or not NGT placement was performed. The perforation healing rate, post-operative adverse events, hospital stay, and death rate were analysed using a 1:1 propensity score matching model. Results Before matching, there were 263 patients in the NGT group and 60 patients in the non-NGT group. There were significant differences in the time to treatment, infection, albumin, and types of endoscopy between the two groups, while the length of hospital stay in the NGT group was significantly longer than that in the non-NGT group. After 1:1 propensity score matching, 48 pairs of patients were matched between the two groups. The perforation healing rate, post-operative adverse events, length of hospital stay, and death rate did not show significant differences between the two groups. Conclusions For patients with small EP caused by foreign bodies, routine NGT placement after endoscopic foreign body removal may be unnecessary.
Collapse
Affiliation(s)
| | | | | | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
- Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Xiaolin Pan
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Chong Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Bimin Li
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Yin Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Youxiang Chen
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Xu Shu
- Corresponding author. Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Donghu District, Nanchang, Jiangxi 330006, P. R. China. Tel: +86-791-88692505; Fax: +86-791-88623153;
| |
Collapse
|
10
|
Fairbairn K, Worrell SG. Esophageal Perforation. Thorac Surg Clin 2023; 33:117-123. [PMID: 37045480 DOI: 10.1016/j.thorsurg.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Esophageal perforation is a rare but fatal disease process that requires prompt diagnosis and treatment. Surgery has historically been required for treatment; however, there is currently a shift toward endoscopic management. Although no randomized controlled trials exist to compare patient outcomes, many case series and systematic analyses describe their indications, efficacy, and safety profile. Endoscopic stenting and endoscopic vacuum therapy are the 2 therapies most widely described across a diverse patient population and appear to be safe and effective when treating esophageal perforation, in the proper clinical setting. Guidelines and scoring systems exist to help direct management and stratify patient risk.
Collapse
|
11
|
Chirica M, Bonavina L. Esophageal emergencies. Minerva Surg 2023; 78:52-67. [PMID: 36511315 DOI: 10.23736/s2724-5691.22.09781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.
Collapse
Affiliation(s)
- Mircea Chirica
- Department of Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France -
| | - Luigi Bonavina
- Medical School, Division of General Surgery, IRCCS San Donato Polyclinic, University of Milan, Milan, Italy
| |
Collapse
|
12
|
Dai X, Wu S. Inadvertently Swallowed Needle Pierced the Pulmonary Artery in an Adult. Ann Thorac Cardiovasc Surg 2023; 29:40-43. [PMID: 34433728 PMCID: PMC9939673 DOI: 10.5761/atcs.cr.21-00161] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Esophageal foreign body (FB) is usually seen in children, prisoners, or patients with psychiatric disorders, most of which can be removed with endoscope. CASE PRESENTATION We herein report a mentally normal adult inadvertently swallowing a needle, which pierced through the esophagus into the adventitia of pulmonary artery. Computed tomography angiography confirmed its specific location, and urgently, surgical removal was performed after the endoscopic attempt. The patient recovered well and was discharged without any complication of the esophageal perforation. CONCLUSION Surgical treatment should be carried out aggressively if the esophageal FB is out of reach for endoscopic removal or if complications cannot be resolved endoscopically.
Collapse
Affiliation(s)
- Xiaoyi Dai
- Department of Cardiovascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shengjun Wu
- Department of Cardiovascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,Corresponding author: Shengjun Wu, MD. Department of Cardiovascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
| |
Collapse
|
13
|
Waddingham W, Kamran U, Kumar B, Trudgill NJ, Tsiamoulos ZP, Banks M. Complications of diagnostic upper Gastrointestinal endoscopy: common and rare - recognition, assessment and management. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000688. [PMID: 36572454 PMCID: PMC9806027 DOI: 10.1136/bmjgast-2021-000688] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 11/26/2022] [Indexed: 12/27/2022] Open
Abstract
A clear understanding of the potential complications or adverse events (AEs) of diagnostic endoscopy is an essential component of being an endoscopist. Creating a culture of safety and prevention of AEs should be part of routine endoscopy practice. Appropriate patient selection for procedures, informed consent, periprocedure risk assessments and a team approach, all contribute to reducing AEs. Early recognition, prompt management and transparent communication with patients are essential for the holistic and optimal management of AEs. In this review, we discuss the complications of diagnostic upper gastrointestinal endoscopy, including their recognition, treatment and prevention.
Collapse
Affiliation(s)
- William Waddingham
- Gastro-intestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Umair Kamran
- Department of gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Bhaskar Kumar
- Department of Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Nigel J Trudgill
- Department of gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Matthew Banks
- Gastro-intestinal Services, University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
14
|
Yang Q, Liu H, Shu X, Liu X. Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience. BMC Gastroenterol 2022; 22:537. [PMID: 36550403 PMCID: PMC9784251 DOI: 10.1186/s12876-022-02624-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Esophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP. METHODS We retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients. RESULTS There were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776-6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418-23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674-17.233, P = 0.018) were independent risk factors for poor prognosis. CONCLUSION Foreign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.
Collapse
Affiliation(s)
- Qinyu Yang
- grid.412604.50000 0004 1758 4073Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haipeng Liu
- grid.412604.50000 0004 1758 4073Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Xu Shu
- grid.412604.50000 0004 1758 4073Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoming Liu
- grid.412604.50000 0004 1758 4073Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| |
Collapse
|
15
|
Onken F, Senne M, Königsrainer A, Wichmann D. Classification und Treatment Algorithm of Small Bowel Perforations Based on a Ten-Year Retrospective Analysis. J Clin Med 2022; 11:jcm11195748. [PMID: 36233616 PMCID: PMC9572575 DOI: 10.3390/jcm11195748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Small bowel perforations are a rare diagnosis compared with esophageal, gastric, and colonic perforations. However, small bowel perforations can be fatal if left untreated. A classification of small bowel perforations or treatment recommendations do not exist to date. Methods: A retrospective, monocentric, code-related data analysis of patients with small bowel perforations was performed for the period of 2010 to 2019. Results: Over a 10-year period, 267 cases of small bowel perforation in 257 patients (50.2% male and 49.8% female; mean age of 60.28 years) were documented. Perforation’s localization was 5% duodenal, 38% jejunal, 39% ileal, and 18% undocumented. Eight etiologies were differentiated: iatrogenic (41.9%), ischemic (20.6%), malignant (18.9%), inflammatory (8.2%), diverticula-associated (4.5%), traumatic (4.5%), foreign-body-associated (1.9%), and cryptical (1.5%) perforations. Operative treatment combined with antibiotics was the most commonly used therapeutic approach (94.3%). The mortality rate was 14.23%, with highest rate for patients with ischemic perforations. Discussion: An algorithm for diagnostic and therapeutic steps was established. Furthermore, it was found that small bowel perforations are rare events with poor outcomes. Time to diagnosis and grade of underlying disease are the most essential parameters to predict perforation-associated complications.
Collapse
Affiliation(s)
- Flurina Onken
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Tübingen, Hoppe-Seyler-Str.3, 72076 Tübingen, Germany
| | - Moritz Senne
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-7071-2968165
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| |
Collapse
|
16
|
Edholm D, Andersson RE, Frankel A. Esophageal perforations - a population-based nationwide study in Sweden with survival analysis. Scand J Gastroenterol 2022; 57:1018-1023. [PMID: 35400263 DOI: 10.1080/00365521.2022.2060051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality. METHOD All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality. RESULTS 879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide. CONCLUSIONS 90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.
Collapse
Affiliation(s)
- David Edholm
- Department of Surgery, Linköping University, Linköping, Sweden.,Department Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Roland E Andersson
- Futurum, Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
| | - Adam Frankel
- Discipline of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| |
Collapse
|
17
|
Andreatta E, Lovece A, Milani V, Asti E, Bonavina L. Does the Pittsburgh Severity Score Predict Patients' Outcomes in Benign Esophageal Perforations? J Gastrointest Surg 2022; 26:1757-1759. [PMID: 35229251 DOI: 10.1007/s11605-022-05281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 02/19/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Erika Andreatta
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Andrea Lovece
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Valentina Milani
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
- IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.
- Department of Surgery, I.R.C.C.S. Policlinico San Donato, Piazza Malan 1, San Donato Milanese (Milano), 20097, Milan, Italy.
| |
Collapse
|
18
|
Kumar A, Singla V, Pulle MV, Asaf BB, Puri HV, Bishnoi S. Multidisciplinary, minimally invasive approach for oesophageal perforations with delayed presentation. J Minim Access Surg 2022; 18:353-359. [PMID: 35708379 PMCID: PMC9306118 DOI: 10.4103/jmas.jmas_28_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The present study aims to report the outcomes of a multidisciplinary, minimally invasive approach to treating patients with delayed presentation of oesophageal perforation. Patients and Methods The present study is a retrospective analysis of prospectively maintained data at a tertiary care centre. All patients with oesophageal perforation presenting over 48 h after the onset of symptoms and without oesophageal obstruction were included in the study. Self-expanding Metallic Stent (SEMS) or endoscopic clip placement was performed in all the patients, followed by video-assisted thoracoscopic surgery (VATS) debridement and decortication of pleural cavity collection. 'Success' was defined as, discharge without the need of oesophageal diversion and complete healing of leak site at 8 weeks with successful removal of the stent. Results Between March 2012 and December 2019, 12 patients (10 males, median age of 55 years- range of 39-71 years) with oesophageal perforation and delayed presentation underwent treatment with this approach. Ten patients had spontaneous perforation (83.3%) and one patient each had upper gastrointestinal endoscopy-induced and post-traumatic perforation. The median duration of symptoms was 8 days (range 3-31 days). SEMS was placed in ten patients and, in two patients, an over-the-scope clip was used. VATS decortication was done in ten patients (83.3%) and the remaining two (16.7%) underwent VATS debridement. One patient required oesophageal diversion and another patient expired due to sepsis. The overall success with this approach was 83.3%. Conclusion This multidisciplinary, minimally invasive approach is feasible in patients with thoracic oesophageal perforation and delayed presentation, with a high success rate.
Collapse
Affiliation(s)
- Arvind Kumar
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Vikas Singla
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | - Mohan Venkatesh Pulle
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Belal Bin Asaf
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Harsh Vardhan Puri
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sukhram Bishnoi
- Department of Thoracic Surgery, Institute of Chest Surgery and Chest Onco-Surgery, Medanta - The Medicity, Gurgaon, Haryana, India
| |
Collapse
|
19
|
Brinkmann S, Knepper L, Fuchs H, Hoelscher A, Kuhr K, Dos Santos DP, Plum P, Chon SH, Bruns C, Schroeder W, Leers J. Short- and long-term follow-up of patients with non-neoplastic esophageal perforation. Langenbecks Arch Surg 2022; 407:569-577. [PMID: 34562118 PMCID: PMC8933311 DOI: 10.1007/s00423-021-02327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/04/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Esophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. Although health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention, not much is known about HRQoL, particularly in the long-term follow-up of patients treated for non-neoplastic esophageal perforation with different treatment strategies. The aim of this study was to evaluate patients' outcome after non-neoplastic esophageal perforation with focus on HRQoL in the long-term follow-up. METHODS Patients treated for non-neoplastic esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were included. Primary outcome and management of esophageal perforation were documented. Long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD), and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal specific QoL (QLQ-C30 and QLQ-OES18). RESULTS Fifty-eight patients were included in the study. Based on primary treatment, patients were divided into an endoscopic (n = 27; 46.6%), surgical (n = 20; 34.5%), and a conservative group (n = 11; 19%). Short- and long-term outcome and quality of life were compared. HRQoL was measured after a median follow-up of 49 months. HRQoL was generally reduced in patients with non-neoplastic esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group. CONCLUSION HRQoL in patients with non-neoplastic esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery, not only in the short-term but also in the long-term follow-up.
Collapse
Affiliation(s)
- Sebastian Brinkmann
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Department of General, Visceral and Vascular Surgery, Marien Hospital Herne, Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| | - Laura Knepper
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hans Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Arnulf Hoelscher
- Department of General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | | | - Patrick Plum
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Wolfgang Schroeder
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jessica Leers
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| |
Collapse
|
20
|
Modi HN, Shreshtha U, Patel U, Kotecha H, Patel MD, Dileep P. Esophageal Perforation After Anterior Cervical Surgery: A Case Report and Literature Review. Clin Spine Surg 2022; 35:49-58. [PMID: 34232154 DOI: 10.1097/bsd.0000000000001231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
SUMMARY AND BACKGROUND Esophageal perforation (EP) after anterior cervical surgery is a rare but potentially life-threatening condition. EP caused by malpositioned implants in cervical spine injury with multiple comorbidities is challenging to treat simultaneously. STUDY This was a case report study. PURPOSE OF STUDY The aim of this study was to present successful treatment of EP in a subluxated C5-C6 level with implant failure, infection, septicemia, and comorbidities. The aim was to emphasize the need for a multispecialty approach while treating serious complications. CASE A 72-year-old woman presented to the ER with a history of operated cervical spine a week ago and having breathlessness, fever, wound infection, and tracheostomy in situ. After primary investigations, the patient was initially treated in the intensive care unit, where bleeding from the tracheostomy site was noticed. Upon endoscopy, EP was diagnosed due to implant failure. She was operated for revision cervical spine surgery (drainage of pus with anterior and posterior cervical fixation) and percutaneous endoscopic gastrostomy tube insertion (esophageal diversion). On exploration of EP, a decision was made to perform conservative treatment as initial tag sutures did not hold due to infection. Postoperatively, the patient developed rectal bleed 3 times, which was ultimately treated with cecal bleed embolization. The infected cervical wound was managed with an open dressing. The patient was managed with intermittent assisted ventilation through tracheostomy postoperatively. Barium swallow at 10 weeks confirmed healing of EP and oral feed was started. Tracheostomy closure was performed once the wound had healed, and the patient was discharged with improved neurology at 12 weeks. CONCLUSIONS Perioperative problems after cervical surgery such as breathing difficulty, wound discharge, and worsening of neurology may lead to suspicion of underlying EP due to implant failure. Upper gastrointestinal endoscopy needs to be considered for a prompt diagnosis. Revision spine surgery with treatment of perforation simultaneously and maintenance of enteral nutrition through a percutaneous endoscopic gastrostomy tube with a multispecialty approach is recommended for this potentially life-threatening condition.
Collapse
Affiliation(s)
- Hitesh N Modi
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | - Utsab Shreshtha
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | - Udit Patel
- Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited
| | | | | | - Pratibha Dileep
- Critical Care Medicine and Pulmonology, Zydus Hospital, Ahmedabad, Gujarat, India
| |
Collapse
|
21
|
Willems S, Daemen JHT, Hulsewé KWE, Belgers EHJ, Sosef MN, Soufidi K, Vissers YLJ, de Loos ER. Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience. Acta Chir Belg 2022:1-6. [PMID: 35020548 DOI: 10.1080/00015458.2022.2029035] [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: 11/01/2022]
Abstract
BACKGROUND Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome. METHODS Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality. RESULTS Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51-74 years) of whom 58% (n = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6-9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% (n = 2) and 25% (n = 3). CONCLUSION Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.
Collapse
Affiliation(s)
- Stefanie Willems
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Jean H. T. Daemen
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Karel W. E. Hulsewé
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Eric H. J. Belgers
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Meindert N. Sosef
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Khalida Soufidi
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Yvonne L. J. Vissers
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| | - Erik R. de Loos
- Department of Surgery, Zuyderland Medical Center, Heerlen, Sittard, The Netherlands
| |
Collapse
|
22
|
Liao F, Zhu Z, Pan X, Li B, Zhu Y, Chen Y, Shu X. Safety and Efficacy of Nonoperative Treatment in Esophageal Perforation Caused by Foreign Bodies. Clin Transl Gastroenterol 2022; 13:e00451. [PMID: 35060929 PMCID: PMC8806378 DOI: 10.14309/ctg.0000000000000451] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Esophageal foreign bodies are often treated by endoscopy, but the treatment of esophageal perforation caused by foreign bodies remains controversial. The purpose of this study was to investigate the safety and efficacy of nonoperative treatment of esophageal perforation caused by foreign bodies. METHODS We retrospectively analyzed 270 patients admitted to our hospital for esophageal perforation caused by foreign bodies from January 2012 to December 2020, all of whom received nonoperative treatment. RESULTS The mean age of the patients was 56 ± 17 years, and fish bones were the most common type of foreign body. A total of 61.2% of the perforations were in the cervical esophagus. All patients received nonoperative treatment initially, and the foreign body removal rate using endoscopy reached 97%. The perforation healing rate reached 94.8%, whereas 3 patients (1.1%) died during hospitalization. The median (range) duration of hospitalization was 4 days (3-6). Multivariable analysis showed age ≥ 66 years (odds ratio [OR]: 2.196; 95% confidence interval [CI]: 1.232-3.916; P = 0.008), men (OR: 1.934; 95% CI: 1.152-3.246; P = 0.013), and time to treatment (OR: 1.126; 95% CI: 1.027-1.233; P = 0.011) were independent risk factors for infection, whereas the risk of infection was lower when the foreign body type was fish bone (OR: 0.557; 95% CI: 0.330-0.940; P = 0.028). DISCUSSION Nonoperative treatment is safe and effective for esophageal perforation caused by foreign bodies. Even if perforation is combined with infection, active nonoperative treatment can still achieve a good effect. Early intervention can effectively reduce the risk of infection and improve patient outcomes.
Collapse
Affiliation(s)
- Foqiang Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiaolin Pan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| |
Collapse
|
23
|
Axtell AL, Gaissert HA, Morse CR, Premkumar A, Schumacher L, Muniappan A, Ott H, Allan JS, Lanuti M, Mathisen DJ, Wright CD. Management and outcomes of esophageal perforation. Dis Esophagus 2022; 35:6312958. [PMID: 34212186 DOI: 10.1093/dote/doab039] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. METHODS A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. RESULTS Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02-3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31-17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39-4.43], P = 0.046) and sepsis (OR 3.26 [1.44-7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. CONCLUSIONS Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.
Collapse
Affiliation(s)
- Andrea L Axtell
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Akash Premkumar
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Lana Schumacher
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James S Allan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
24
|
Moletta L, Pierobon ES, Capovilla G, Valotto G, Gavagna L, Provenzano L, Zanchettin G, Salvador R, Costantini M, Merigliano S, Valmasoni M. Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center. J Trauma Acute Care Surg 2022; 92:108-116. [PMID: 34561399 DOI: 10.1097/ta.0000000000003417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions. METHODS All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and >5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention. RESULTS Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p < 0.01), in-hospital mortality (p = 0.01), ICU admission (p < 0.01), need for surgical treatment (p < 0.01), and need for reintervention (p = 0.02). CONCLUSION Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation. LEVEL OF EVIDENCE Management, Therapeutic/Care; level IV.
Collapse
Affiliation(s)
- Lucia Moletta
- From the Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med 2021; 53:29-36. [PMID: 34971919 DOI: 10.1016/j.ajem.2021.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality. OBJECTIVE This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence. DISCUSSION Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting. CONCLUSIONS An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.
Collapse
|
26
|
Pickering O, Pucher PH, De'Ath H, Abuawwad M, Kelly J, Underwood TJ, Noble F, Byrne JP. Minimally Invasive Approach in Boerhaave's Syndrome: Case Series and Systematic Review. J Laparoendosc Adv Surg Tech A 2021; 31:1254-1261. [PMID: 33400893 DOI: 10.1089/lap.2020.0751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Boerhaave's syndrome is a life-threatening spontaneous perforation of the esophagus associated with significant morbidity and mortality. Historically, thoracotomy has been the mainstay of treatment, but is associated with high morbidity and pain. Minimally invasive approaches provide alternative treatment possibilities. This systematic review together with inclusion of a case series from a tertiary esophagogastric unit assesses current evidence focused on minimally invasive surgical management of this condition. Methods: A systematic review was conducted in line with MOOSE (Meta-analyses Of Observational Studies in Epidemiology) guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles focusing on the minimally invasive management of Boerhaave's syndrome were identified and scrutinized. We also report demographics and outcomes for a consecutive case series of patients with acute Boerhaave's syndrome managed via thoracoscopy. Results: Fifteen studies were included comprising 5 retrospective cohort studies and 10 case reports. Management strategies were divided into three categories: thoracoscopic, endoscopic, and laparoscopic. Overall mortality rates for each treatment modality were 2%, 13%, and 33%, and treatment success rates 98%, 38%, and 67%, respectively. Postoperative infective complications were seen in 79% of patients, with only 2 patients requiring salvage thoracotomy. In our local case series, we report 4 consecutive patients managed with thoracoscopy, with a 100% treatment success rate. Conclusion: Minimally invasive approaches in the management of Boerhaave's syndrome are safe and effective. We propose a selective management algorithm involving a minimally invasive approach to management of this life-threatening condition. Registered with local clinical outcomes team as service evaluation. (Approval number sev/0171).
Collapse
Affiliation(s)
- Oliver Pickering
- Department of General Surgery, St Mary's Hospital, Isle of Wight, Newport, United Kingdom
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Philip H Pucher
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Henry De'Ath
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
- Department of General Surgery, Frimley Park Hospital, Frimley, United Kingdom
| | - Mahmoud Abuawwad
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Jamie Kelly
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Timothy J Underwood
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Fergus Noble
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - James P Byrne
- Department of General Surgery, Southampton General Hospital, Southampton, United Kingdom
| |
Collapse
|
27
|
Tang A, Ahmad U, Raja S, Siddiqui HU, Sinopoli JN, O'Dell A, Pande A, Blackstone EH, Murthy SC. Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus. Ann Surg 2021; 274:e417-e424. [PMID: 33630450 DOI: 10.1097/sla.0000000000003648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Andrew Tang
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Usman Ahmad
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Siva Raja
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Hafiz U Siddiqui
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Jillian N Sinopoli
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Alexander O'Dell
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| | - Amol Pande
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Eugene H Blackstone
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland, OH
| |
Collapse
|
28
|
Lin J, Jimenez CA. Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review. Semin Diagn Pathol 2021; 39:113-119. [PMID: 34176697 DOI: 10.1053/j.semdp.2021.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 11/11/2022]
Abstract
Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.
Collapse
Affiliation(s)
- Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
29
|
Deng Y, Hou L, Qin D, Huang T, Yuan T. Current treatment and outcome of esophageal perforation: A single-center experience and a pooled analysis. Medicine (Baltimore) 2021; 100:e25600. [PMID: 33879724 PMCID: PMC8078246 DOI: 10.1097/md.0000000000025600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/02/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Esophageal perforation has been one of the serious clinical emergencies, because of the high mortality and complication rates. However, the current prognosis of esophageal perforation and the outcomes of available treatment methods are not well defined. This study attempted to pool the immediate outcomes of esophageal perforation in the past 2 decades. METHODS The clinical data of 22 consecutive adult patients with esophageal perforation in our center were analyzed. A pooled analysis was also conducted to summarize results from the literatures published between 1999 and 2020. Studies that met the inclusion criteria were assessed, and their methodological quality was examined. RESULTS The mortality and complication rates in our center were 4.55% and 31.82%, separately. The pooled analysis included 45 studies published between 1999 and 2019, which highlighted an overall immediate mortality rate of 9.86%. Surgical treatments were associated with a pooled immediate mortality of 10.01%, and for conservative treatments of 6.49%. Besides, in the past decade, the mortality and complication rates decreased by 27.12% and 46.75%, respectively. CONCLUSIONS In the past 2 decades, the overall immediate mortality rate of esophageal perforation was about 10% in the worldwide, and the outcomes of esophageal perforation treatment are getting better in the last 10 years. ETHICS REGISTRATION INFORMATION LW2020011.
Collapse
Affiliation(s)
| | - Luqi Hou
- Department of Research and Education, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545001, China
| | | | | | | |
Collapse
|
30
|
Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process. Eur Arch Otorhinolaryngol 2021; 278:3613-3623. [PMID: 33417148 DOI: 10.1007/s00405-020-06569-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy. METHODS An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree. RESULTS This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies. CONCLUSION This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.
Collapse
|
31
|
Allaway MGR, Morris PD, B Sinclair JL, Richardson AJ, Johnston ES, Hollands MJ. Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature. ANZ J Surg 2020; 91:1376-1384. [PMID: 33319446 DOI: 10.1111/ans.16501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature. METHODS A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed. RESULTS In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%. CONCLUSIONS We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.
Collapse
Affiliation(s)
- Matthew G R Allaway
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Paul D Morris
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Jane-Louise B Sinclair
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Arthur J Richardson
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Emma S Johnston
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Hollands
- Department of Upper Gastrointestinal Tract Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| |
Collapse
|
32
|
Wang Y, Hao D, Qian L, He X, Meng Y, Wang B. Esophageal perforation following pedicle screw placement for the treatment of upper thoracic spinal tuberculosis: a case report and review of the literature. BMC Musculoskelet Disord 2020; 21:756. [PMID: 33208114 PMCID: PMC7672849 DOI: 10.1186/s12891-020-03783-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background The technique of posterior pedicle screw fixation has already been widely applied in the treatment of upper thoracic spinal tuberculosis. However, lesions of tuberculosis directly invade the vertebrae and surrounding soft tissues, which increases the risk of esophageal perforation induced by the posterior pedicle screw placement. Herein, we report the first case of esophageal perforation following pedicle screw placement in the upper thoracic spinal tuberculosis, and describe the underlying causes, as well as the treatment and prognosis. Case presentation A 48-year-old female patient with upper thoracic spinal tuberculosis presented sputum-like secretions from the wound after she was treated with one-stage operation through the posterolateral approach. Endoscopy was immediately conducted, which confirmed that the patient complicated with postoperative esophageal perforation caused by screws. CT scan showed that the right screw perforated the anterior cortex of the vertebrae and the esophagus at the T4 level. Fortunately, mediastinal infection was not observed. The T4 screw was removed, Vacuum Sealing Drainage (VSD) was performed, and jejunum catheterization was used for enteral nutrition. After continuous treatment with sensitive antibiotics for 2.5 months and 5 times of VSD aspiration, the infected wound recovered gradually. With 18-month follow-up, the esophagus healed well, without symptoms of dysphagia and stomach discomfort, and CT scan showed that T2–4 had complete osseous fusion without sequestrum. Conclusion Tuberculosis increases the risk of postoperative esophageal perforation in a certain degree for patients with upper thoracic tuberculosis. The damages to esophagus during the operation should be prevented. The screws with the length no more than 30 mm should be selected. Moreover, close monitoring after operation should be conducted to help the early identification, diagnosis and treatment, which could help preventing the adverse effects induced by the delayed diagnosis and treatment of esophageal perforation.
Collapse
Affiliation(s)
- Yuhang Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China.,Xi'an Medical University, No. 74 Hanguang North Road, Xi'an, 710054, Shaanxi, China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Lixiong Qian
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Xin He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Yibin Meng
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Biao Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China.
| |
Collapse
|
33
|
Ranjan SR, Majumdar S, Manickavasagam J, Flach S. Tissue glue: a potential role in the management of intraoperative oesophageal perforation. BMJ Case Rep 2020; 13:13/7/e232568. [PMID: 32737024 DOI: 10.1136/bcr-2019-232568] [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: 11/03/2022] Open
Abstract
An 85-year-old man suffering from oropharyngeal dysphagia due to a pharyngeal pouch and cricopharyngeal spasm underwent endoscopic stapling of the pouch under general anaesthesia. During the procedure, an iatrogenic perforation of the oesophagus was noticed. After considering several options, 5 mL of Tisseel tissue glue was used to seal the perforation intraoperatively. The patient was started on intravenous co-amoxiclav, kept nil by mouth and fed via a nasogastric tube. After 4 days of observation mediastinal collection and any leakage was ruled out with a gastrografin contrast swallow procedure. At this point he was considered safe for oral intake.
Collapse
Affiliation(s)
| | | | - Jaiganesh Manickavasagam
- Department of Otorhinolaryngology, Ninewells Hospital, Dundee, UK .,Tayside Academic Science Centre, University of Dundee, Dundee, UK
| | - Susanne Flach
- Otorhinolaryngology and Head & Neck Surgery, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| |
Collapse
|
34
|
Sendino O, Loras C, Mata A, Momblán D, Andujar X, Cruz M, Cárdenas A, Marquez I, Uchima H, Cordova H, de Lacy AM, Espinós J. Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:431-438. [PMID: 32680732 DOI: 10.1016/j.gastrohep.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract. PATIENTS AND METHODS This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany). RESULTS 11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak. CONCLUSION EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.
Collapse
Affiliation(s)
- O Sendino
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
| | - C Loras
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - A Mata
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - D Momblán
- Servicio de Cirugía Gastrointestinal, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - X Andujar
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - M Cruz
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - A Cárdenas
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - I Marquez
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - H Uchima
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - H Cordova
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - A M de Lacy
- Servicio de Cirugía Gastrointestinal, ICMDiM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - J Espinós
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España; Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| |
Collapse
|
35
|
Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis. Surg Endosc 2020; 35:3492-3505. [PMID: 32681374 PMCID: PMC8195755 DOI: 10.1007/s00464-020-07806-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022]
Abstract
Background Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave’s syndrome (BS). Methods We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. Results Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8–5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2–7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2–6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1–3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1–3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. Conclusions This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome. Electronic supplementary material The online version of this article (10.1007/s00464-020-07806-y) contains supplementary material, which is available to authorized users.
Collapse
|
36
|
Athanasiou A, Spartalis E, Spartalis M, Griffiths EA. Management of oesophageal perforation based on the Pittsburgh Perforation Severity Score: still a matter of debate. Eur J Cardiothorac Surg 2020; 57:198. [PMID: 30843053 DOI: 10.1093/ejcts/ezz061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/09/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- Antonios Athanasiou
- Department of Upper GI, Bariatric & Minimally Invasive Surgery, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Eleftherios Spartalis
- Department of General Surgery, Laboratory of Experimental Surgery and Surgical Research, University of Athens, Athens, Greece
| | - Michael Spartalis
- Department of General Surgery, Laboratory of Experimental Surgery and Surgical Research, University of Athens, Athens, Greece
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Cancer and Genomic Sciences, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
37
|
Sekiya S, Ebihara Y, Yamamura Y, Tanaka K, Nakanishi Y, Asano T, Noji T, Kurashima Y, Murakami S, Nakamura T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. Two emergency cases of spontaneous esophageal perforation treated using a minimally invasive abdominal and left thoracic approach. Asian J Endosc Surg 2020; 13:406-409. [PMID: 31531935 DOI: 10.1111/ases.12754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/05/2019] [Accepted: 08/16/2019] [Indexed: 11/30/2022]
Abstract
Boerhaave's syndrome is a rare life-threatening disease that requires prompt intervention. Thoracotomy has traditionally been considered the gold standard approach for treatment, but other minimally invasive approaches have recently been reported. Our institute reported the efficacy of minimally invasive abdominal and left thoracic approach in the treatment of patients with esophagogastric junction cancer and introduced it for the treatment of two patients with Boerhaave's syndrome. We intraoperatively sutured the rupture sites and irrigated the pleural cavity using thoracoscopy. Then, after confirming the absence of intraabdominal contamination, we performed jejunostomy or gastrostomy using laparoscopy. Patients' vital signs remained stable intraoperatively, and their postoperative periods were uneventful with no leakage or stricture. The minimally invasive abdominal and left thoracic approach for Boerhaave's syndrome is convenient and useful as it provides excellent visualization of the thoracic and abdominal cavities with the possibility of quickly switching between views.
Collapse
Affiliation(s)
- Sho Sekiya
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yoshiyuki Yamamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| |
Collapse
|
38
|
Sohda M, Kuwano H, Sakai M, Miyazaki T, Kakeji Y, Toh Y, Matsubara H. A national survey on esophageal perforation: study of cases at accredited institutions by the Japanese Esophagus Society. Esophagus 2020; 17:230-238. [PMID: 32415409 DOI: 10.1007/s10388-020-00744-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/26/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To get a clear view of the current state of treatment for esophageal perforation in Japan. Esophagus perforations are the most serious gastrointestinal tract perforations and are associated with high morbidity and mortality. The optimal treatment choice remains unknown. METHODS We conducted a retrospective clinical review of 182 esophageal perforation cases at 108 hospitals accredited by the Japanese Esophageal Society between January 2010 and December 2015. RESULTS We found that 20.9% of patients were incorrectly diagnosed initially. We observed mediastinum emphysema in 83.5% of patients, and serious abscess formations of the mediastinum and intrathoracic cavity in 38.6% and 29.6%, respectively. The lower esophagus was the most commonly perforated site (77.7%). Management of esophageal perforations included nonoperative treatment in 20 patients (11%) and operative treatment in 162 patients (89%). The overall mortality rate was 6.9%. The survivors had significantly shorter times from symptom appearance to visit (p = 0.0016), and from time to visit to diagnosis confirmation (p = 0.0011). Moreover, patients older than 65 years, white blood cells less than 3000/mm3, C-reactive protein > 10 mg/L, or abscesses in the thoracic cavity showed significantly higher mortality than others. CONCLUSION Shortening the time from onset to the start of treatment contributes to reduce mortality in patients with esophageal perforation. Moreover, strict medical treatment is necessary to lower the mortality rate of elderly patients with strong inflammation and abscesses in the thoracic cavity.
Collapse
Affiliation(s)
- Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yoshihiro Kakeji
- Division of Gastro-Intestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
39
|
Abila AW, Nditika ME, Kipkemoi RD, Ondigo S, Khwa-Otsyula BO. Primary repair of esophageal perforation: Case report. Int J Surg Case Rep 2020; 71:159-162. [PMID: 32454452 PMCID: PMC7248577 DOI: 10.1016/j.ijscr.2020.04.026] [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: 02/18/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mortality after esophageal perforation is high irrespective of the treatment modality. The rarity of traumatic esophageal perforations has made it difficult to conduct comprehensive studies that can answer pertinent questions with regard to management. PRESENTATION OF CASE We report a case of through and through thoracic esophageal injury caused by an assailant's arrow in a young physically active male adult. Diagnosis was made on-table. He successfully underwent primary repair of the esophageal injury 16 h post injury via a left thoracotomy. Recurrent lung collapse and pleural effusion was managed with tube thoracostomy and chest physiotherapy. DISCUSSION Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion. CONCLUSION Primary repair of traumatic injury to a healthy esophagus is feasible for cases diagnosed early and without significant mediastinal contamination as in our case. Associated injuries are more likely in such cases to lead to increased morbidity and prolonged hospital stay and must be handled carefully.
Collapse
Affiliation(s)
- Akello W Abila
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Faculty of Health Sciences, Egerton University, Nakuru, Kenya.
| | - Mburu E Nditika
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya
| | - Rono D Kipkemoi
- Faculty of Health Sciences, Egerton University, Nakuru, Kenya
| | - Stephen Ondigo
- Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barasa O Khwa-Otsyula
- Department of Surgery and Anesthesiology, Moi University, School of Medicine, Eldoret, Kenya; Department of Cardiothoracic Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| |
Collapse
|
40
|
Tantai XX, Wang M, Guo XD, Wang JH, Ma SY. Overtube-assisted technique for insertion of linear endoscopic ultrasonography. Gastroenterol Rep (Oxf) 2020; 8:158-160. [PMID: 32280476 PMCID: PMC7136711 DOI: 10.1093/gastro/goz015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 08/30/2018] [Accepted: 12/27/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Xin-Xing Tantai
- Division of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Mo Wang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Xiao-Dan Guo
- Division of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Jin-Hai Wang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| | - Shi-Yang Ma
- Division of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, P. R. China
| |
Collapse
|
41
|
Lee AHH, Kweh BTS, Gillespie C, Johnson MA. Trans-hiatal repair for Oesophageal and Junctional perforation: a case series. BMC Surg 2020; 20:41. [PMID: 32122343 PMCID: PMC7053070 DOI: 10.1186/s12893-020-00702-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/21/2020] [Indexed: 12/27/2022] Open
Abstract
Background Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population. Case presentation We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations. Conclusions Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.
Collapse
Affiliation(s)
- Adele H H Lee
- Upper Gastrointestinal Surgery Unit, St Vincent's Hospital, Melbourne, Ward 7 East, Upper Gastrointestinal Surgery Unit, Melbourne, Victoria, 3065, Australia.
| | - Barry T S Kweh
- Upper Gastrointestinal Surgery Unit, St Vincent's Hospital, Melbourne, Ward 7 East, Upper Gastrointestinal Surgery Unit, Melbourne, Victoria, 3065, Australia.
| | - Carla Gillespie
- Upper Gastrointestinal Surgery Unit, St Vincent's Hospital, Melbourne, Ward 7 East, Upper Gastrointestinal Surgery Unit, Melbourne, Victoria, 3065, Australia
| | - Mary Ann Johnson
- Upper Gastrointestinal Surgery Unit, St Vincent's Hospital, Melbourne, Ward 7 East, Upper Gastrointestinal Surgery Unit, Melbourne, Victoria, 3065, Australia
| |
Collapse
|
42
|
Giulini L, Schweigert M, Stein HJ, Dubecz A. Reply to Athanasiou et al. Eur J Cardiothorac Surg 2020; 57:198-199. [PMID: 30843064 DOI: 10.1093/ejcts/ezz062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/07/2022] Open
Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Michael Schweigert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hubert J Stein
- Department of Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University, Nuremberg, Germany
| |
Collapse
|
43
|
Hayakawa S, Mitsui A, Kato Y, Morimoto S, Watanabe K, Shamoto T, Wakasugi T, Kuwabara Y. Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report. Surg Case Rep 2019; 5:149. [PMID: 31641962 PMCID: PMC6805831 DOI: 10.1186/s40792-019-0711-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous esophageal rupture is a rare but serious disease with high mortality. Conservative treatment and endoscopic therapy have been reported, but surgical treatment is still a basic modality of therapy. In addition to thoracotomy, recent studies have reported treatment with thoracoscopic surgery and laparoscopic transhiatal repair. In this study, we report a patient who underwent laparoscopic transhiatal suture closure for spontaneous esophageal rupture with favorable postoperative course. We also discuss indication for laparoscopic surgery for spontaneous esophageal rupture. CASE PRESENTATION A 70-year-old man visited our hospital with chief complaints of epigastric pain and vomitus niger. He was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus by computed tomography and upper gastrointestinal (GI) series. At 11 h after the onset of symptoms, we performed laparoscopic transhiatal suture closure and lavage drainage. We performed transhiatal esophageal replacement using the 5-hole approach. We observed a perforation of 2 cm in diameter at the site of the rostral portion approximately 4 cm from the esophageal hiatus. All layers were closed with three stitches using 3-0 absorbable sutures. No perforation was observed in the thoracic cavity. The total operative time was 178 min, and total bleeding was 2 ml. He had no postoperative complications and was discharged on day 15 after the procedure. He received continuous proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by esophagogastroscopy. The patient was advised to improve his lifestyle and has shown no signs of recurrence over 2 years from the date of surgery. CONCLUSIONS Simple closure of all the layers using laparoscopic transhiatal simple closure was useful in the treatment of esophageal rupture as a less invasive approach for patients who meet the following conditions: stable general condition, intrathoracic perforation, and the perforation site is identified as the lower esophagus by pre-operative examination.
Collapse
Affiliation(s)
- Shunsuke Hayakawa
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan.
| | - Akira Mitsui
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Yuko Kato
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Shota Morimoto
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Kaori Watanabe
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Tomonari Shamoto
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Takehiro Wakasugi
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| | - Yoshiyuki Kuwabara
- Department of General surgery, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-Ku, Nagoya, 462-8508, Japan
| |
Collapse
|
44
|
Abstract
A runner competing in a 100 mile trail race presented with severe lower chest pain and right upper abdominal pain. His pain started immediately after he took an over the counter non steroidal anti-inflammatory pill a few hundred metres after leaving the aid station. When he took the pill, he immediately had to vomit and spit out the pill. On arriving back at the aid station, he was noted to have severe left-sided chest pain that worsened with reclining. He also had profound dyspnoea. Initial vital signs were unremarkable. The runner was immediately transported to an emergency room and eventually found to have an oesophageal rupture. After surgical intervention and a lengthy recovery, the runner is back to participating in sport.
Collapse
Affiliation(s)
- Andrew Pasternak
- Silver Sage Center for Family Medicine, Reno, Nevada, USA.,Department of Family Medicine, University of Nevada Reno, Reno, Nevada, USA
| | - JoAnn Ellero
- Associated Anesthesiologists of Reno, Reno, Nevada, USA
| | - Stephen Maxwell
- Sutter Medical Center Sacramento, Roseville, California, USA
| | | |
Collapse
|
45
|
Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series. Ann Med Surg (Lond) 2019; 44:62-67. [PMID: 31316769 PMCID: PMC6611994 DOI: 10.1016/j.amsu.2019.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries. Materials and methods A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level. Results Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects. Conclusion Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome. Sixteen patients were treated for esophageal injuries at the PRTH. Two patients suffered blunt esophageal trauma and 14 patients had penetrating trauma to the esophagus. Most patients had a prompt diagnosis of traumatic esophageal perforation, while 3 patients had a delayed diagnosis. Regarding esophageal location, of the 16 patients, 9 presented cervical, 6 thoracic, and 1 abdominal esophageal injury. Only 2 deaths occurred among our 16 patients, including 1 in delayed diagnosed subjects.
Collapse
|
46
|
Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
Collapse
Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| |
Collapse
|
47
|
Chirica M, Kelly MD, Siboni S, Aiolfi A, Riva CG, Asti E, Ferrari D, Leppäniemi A, Ten Broek RPG, Brichon PY, Kluger Y, Fraga GP, Frey G, Andreollo NA, Coccolini F, Frattini C, Moore EE, Chiara O, Di Saverio S, Sartelli M, Weber D, Ansaloni L, Biffl W, Corte H, Wani I, Baiocchi G, Cattan P, Catena F, Bonavina L. Esophageal emergencies: WSES guidelines. World J Emerg Surg 2019; 14:26. [PMID: 31164915 PMCID: PMC6544956 DOI: 10.1186/s13017-019-0245-2] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023] Open
Abstract
The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.
Collapse
Affiliation(s)
- Mircea Chirica
- 1Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, NSW 2640 Australia
| | - Stefano Siboni
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Alberto Aiolfi
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Carlo Galdino Riva
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Emanuele Asti
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Davide Ferrari
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Ari Leppäniemi
- Department of Emergency Surgery, University Hospital Meilahti Abdominal Center, Helsinki, Finland
| | - Richard P G Ten Broek
- 5Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pierre Yves Brichon
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Yoram Kluger
- 7Department of General Surgery, Rambam Health Campus, Haifa, Israel
| | - Gustavo Pereira Fraga
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Gil Frey
- 6Department of Thoracic Surgery, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche, France
| | - Nelson Adami Andreollo
- 8Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Federico Coccolini
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | | | | | - Osvaldo Chiara
- 12General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy
| | - Salomone Di Saverio
- 13Cambridge Colorectal Unit, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | | | - Dieter Weber
- 15Trauma and General Surgery, Royal Perth Hospital, Perth, Australia
| | - Luca Ansaloni
- 9General, Emergency and Trauma Surgery Department, Bufalini Hospital Cesena, Cesena, Italy
| | - Walter Biffl
- 16Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA USA
| | - Helene Corte
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Imtaz Wani
- 18Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Pierre Cattan
- 17Department of Surgery, Saint Louis Hospital, Paris, France
| | - Fausto Catena
- 20Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Luigi Bonavina
- 3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| |
Collapse
|
48
|
Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome). Surg Endosc 2019; 33:3494-3502. [PMID: 31144123 DOI: 10.1007/s00464-019-06863-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 05/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain. METHODS Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed. RESULTS Ten patients (80% male) with a mean age of 61.3 years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 ± 12 h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8 days (range 3-26), while inpatient LOS was 23.1 ± 12.5 days (range 14-46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%. CONCLUSION Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.
Collapse
|
49
|
Vermeulen BD, Siersema PD. Diagnosis and endoscopic treatment of esophageal leakage: a systematic review. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
50
|
Mureșan M, Mureșan S, Balmoș I, Sala D, Suciu B, Torok A. Sepsis in Acute Mediastinitis - A Severe Complication after Oesophageal Perforations. A Review of the Literature. J Crit Care Med (Targu Mures) 2019; 5:49-55. [PMID: 31161141 PMCID: PMC6534941 DOI: 10.2478/jccm-2019-0008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite recent advancements in antibiotic therapy and the progress made in critical care and modern diagnostic methods, acute mediastinitis continues to be a severe condition. DIAGNOSIS AND TREATMENT Acute mediastinitis can occur in the context of cardio-thoracic surgery, oesophageal perforations and oropharyngeal infections condition. Forty-five percent of oesophageal perforations occurs during simple endoscopy. Spontaneous perforation (Boerhaave syndrome) accounts for 15% of perforations, and twelve percent are due to the ingestion of foreign bodies. Other causes include blind or penetrating trauma, and circa 9% to intraoperative lesions. CT scan is the standard investigation that reveals direct signs of mediastinitis.The oral administration of contrast substances can underscore the level of oesophageal perforation. Conservative treatment is the first-choice treatment and surgical treatment is reserved only for specific situations.The principles of surgical treatment consist of drainage, primary suture, oesophageal exclusion with or without the application of oesophagectomy, endoscopic vacuum wound assisted therapy of the perforation and associated paraoesophageal mediastinal drainage and endoscopic stenting associated with drainage. CONCLUSIONS The lowest mortality rate is recorded in patients with perforations diagnosed less than twenty-four hours after the onset of symptoms. Surgical treatment remains the gold standard especially in cases of thoracic and abdominal perforations while further investigations are mandatory before endoscopic stenting is carried out.
Collapse
Affiliation(s)
- Mircea Mureșan
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Simona Mureșan
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Physiology Department, Târgu Mureș, Romania
| | - Ioan Balmoș
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Daniela Sala
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| | - Bogdan Suciu
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Thoracic Surgery Department, Târgu Mureș, Romania
| | - Arpad Torok
- University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2, Târgu Mureș, Romania
| |
Collapse
|