Quality-of-life study on four patients who underwent esophageal resection and delayed reconstruction for Boerhaave's syndrome

Short- and long-term follow-up of patients with non-neoplastic esophageal perforation

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.

A case of esophageal rupture caused by long-term exposure to vinegar and resolved by damage control strategies

A 75-year-old woman had the habit of drinking vinegar. She had emergent transport to our hospital because of vomiting and unconsciousness. The patient underwent emergency surgery for esophageal rupture and septic shock. Intraoperatively, a 25 mm perforated area was found, and the visible esophageal mucosa was black. Because the suture closure or anastomosis was difficult and the shock was prolonged, she was placed in the intensive care unit after undergoing resection of the thoracic esophagus and thoracic drainage. Fifteen hours after the first surgery, we performed external esophagostomy and enterostomy. The third surgery was a retrothoracic cervical esophagogastric anastomosis, and reconstructive surgery was performed 60 days after the first surgery. Prolonged exposure to vinegar may have resulted in esophageal mucosal necrosis. This is a valuable case in which the esophageal mucosa was necrotic, and we performed esophagectomy and reconstruction as a damage control strategy to save her life.

Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications

BACKGROUND

Less invasive operations such as laparoscopic surgery have been developed for treating gastrointestinal malignancies. However, the advantages of video-assisted thoracoscopic surgery for esophageal cancer (VATS-e) with regard to postoperative morbidity and mortality remains controversial.

METHODS

We investigated the postoperative clinical course of patients who underwent esophagectomy for esophageal cancer in terms of systemic inflammatory response syndrome (SIRS) induced by VATS-e (VATS-e group) or conventional open surgery (OS group) combined with laparoscopic gastric tube reconstruction.

RESULTS

Compared with the OS group (n = 27), the VATS-e group (n = 22) had a greater thoracic operation time (VATS-e versus OS, 181 ± 56 vs 143 ± 45 minutes, respectively), and lesser duration of stay in the intensive care unit (17 ± 2 vs 32 ± 21 hours, respectively). The VATS-e group also had a lesser SIRS duration (1.5 vs 4.3 days), a lesser incidence of SIRS, a lesser number of positive SIRS criteria, and lesser serum interleukin-6 levels immediately after operation and on postoperative day (POD) 1. The heart rate in the VATS-e group was less than that in the OS group on POD 3. The respiratory rate in the VATS-e group was significantly less than that in the OS group on PODs 3, 5, and 7. Although no difference was observed in the frequencies of postoperative complications between the 2 groups, the VATS-e group had less postoperative pneumonia.

CONCLUSION

VATS-e attenuates postoperative SIRS, and is therefore a potentially less invasive operative procedure.

Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre

INTRODUCTION

The aim of this study was to review the management and outcome of patients with Boerhaave's syndrome in a specialist centre between 2000-2007.

PATIENTS AND METHODS

Patients were grouped according to time from symptoms to referral (early, < 24 h; late, > 24 h). The effects of referral time and management on outcomes (oesophageal leak, reoperation and mortality) were evaluated.

RESULTS

Of 21 patients (early 10; late 11), three were unfit for surgery. Of the remaining 18, immediate surgery was performed in 8/8 referred early and 6/10 referred late. Four patients referred late were treated conservatively. Oesophageal leak (78% versus 12.5%; P < 0.05) and mortality (40% versus 0%; P < 0.05) rates were higher in patients referred late. For patients referred late, mortality was higher in patients managed conservatively (75% versus 17%; not significant).

CONCLUSIONS

The best outcomes in Boerhaave's syndrome are associated with early referral and surgical management in a specialist centre. Surgery appears to be superior to conservative treatment for patients referred late.

[Second time esophageal reconstruction surgery: coloplasty and gastroplasty]

OBJECTIVE

To analyze the morbidity and mortality of second time esophageal reconstruction in an Esophagogastric Unit.

PATIENTS AND METHOD

Second time esophageal reconstruction surgery with coloplasty and gastroplasty was performed on 20 patients, from January 2001 to October 2006. The morbidity and mortality of each technique has been analyzed retrospectively.

RESULTS

The mean age of the 16 males and 4 women operated on was 54.3 +/- 17.5 years. The diagnoses at the first surgery were: 7 caustic ingestions, 7 Boerhaave syndrome, 3 iatrogenic perforations, 1 tracheal-esophageal fistula, 1 esophageal-jejunal dehiscence and 1 necrosis of the gastroplasty after transhiatal oesophagectomy. There were 14 (70%) right coloplasties, 4 (20%) left coloplasties and 2 (10%) gastroplasties with gastric conditioning. In 11 of the 20 patients gastroplasty was ruled out due to gastrectomy (8 cases) or previous gastric surgery (3 cases). It was noted on analyzing the morbidity: pleural effusion (65%), respiratory failure (45%), atelectasis (35%) and cervical anastomosis dehiscence (35%). Five patients were re-intervened: 3 due to intra-abdominal sepsis and 2 due to hemoperitoneum. Mortality was 10% (2 cases). In subsequent follow up there was 5% (1 case) of stenosis of the anastomosis.

CONCLUSIONS

Esophageal reconstruction technique which in specialist units has an acceptable mortality rate (10%) and an insignificant morbidity. Coloplasty was the technique most used on these patients.

Treatment strategy for Boerhaave's syndrome

Esophageal rupture is a potentially mortal condition. Rapid and correct diagnosis, and urgent surgical treatment with esophagectomy is indicated, but conservative and other surgical treatments have also been reported recently. The treatment strategies for esophageal rupture are discussed here, based on our experiences with four cases during the last 10 years. They were admitted urgently and each was treated by a different method. Three of them underwent emergency operations, one undergoing primary closure of the ruptured esophagus, another received a T-tube insertion from the ruptured site with omental flap, and the third an esophagogastrectomy. The fourth case was treated conservatively. All patients survived and were discharged 36-144 days post treatment. One of them was readmitted for debridement of necrotic rib. In conclusion, the prompt and accurate diagnosis of esophageal rupture is crucial for a subsequent successful treatment. Conservative treatment or operation including esophagectomy will be determined by the severity of the condition.

Challenges in reversing esophageal discontinuity operations

BACKGROUND

After catastrophic esophageal or gastric disruption results in esophageal discontinuity, operations to restore swallowing are surgical challenges.

METHODS

A retrospective review and assessment of functional results was performed in 40 patients (average age 59.9 years) who had 42 operations to reverse esophageal discontinuity between 1973 and 2002.

RESULTS

Esophageal discontinuity resulted from gastric necrosis after esophagectomy and esophagogastrostomy (n = 10) or hiatal hernia repair (n = 4), esophageal perforation complicating dilatation (n = 5), failed colonic or jejunal interpositions (n = 5), caustic ingestion (n = 4), Boerhaave syndrome (n = 4), esophagogastric anastomotic leak (n = 3), and other causes (n = 6). Eighteen patients (43.9%) required prolonged mechanical ventilation. Thirty-one (75.6%) had an end cervical esophagostomy; 6, an anterior thoracic esophagostomy; 2, lateral esophagostomy and in situ native esophagus stapled and divided distally; and 1 each, a stapled, divided esophagus without esophagostomy and a stapled undivided esophagus without esophagostomy. Twenty-six patients (63.4%) had undergone partial or total gastrectomy. Ten (24.4%) had vocal cord paralysis. Operations reestablishing continuity included colonic interposition in 23 (56.1%), substernal gastric interposition in 7 (17.1%), esophagectomy and cervical anastomosis in 6, esophageal reanastomosis in 3, staged jejunal interposition in 1, and Roux-en-Y esophagojejunostomy in 1. There were no hospital deaths. Twenty-eight patients (68.3%) had postoperative complications. Length of stay averaged 20.6 days. Follow-up for 40 patients averaged 54.5 months. Functional results (39 patients) were excellent in 12 (30.8%), good in 15 (38.5%), fair in 10 (25.6%), and poor in 2 (5.1%).

CONCLUSIONS

Successful reversal of esophageal discontinuity requires individualized assessment and ingenuity. Despite appreciable morbidity, the ultimate result is generally gratifying.