Surgical management of late esophageal perforation

Current status of surgical treatment of Boerhaave's syndrome

BACKGROUND

Surgical treatment is usually required for Boerhaave's syndrome (post-emetic esophageal perforation), and the technique should be chosen based on the local infection status and patient's general condition. This study was performed to examine the current status of surgical treatment of Boerhaave's syndrome in Japan.

METHODS

Ninety-five patients with Boerhaave's syndrome who underwent surgical treatment from January 2010 to December 2015, obtained from a national survey were retrospectively analyzed. The details of each surgical treatment and the type of treatment performed according to the patients' characteristics were examined.

RESULTS

Primary closure was performed in 75 (78.9%) patients, T-tube insertion in 15 (15.8%), and esophagectomy in 5 (5.3%). The length of the postoperative stay was significantly shorter in patients who underwent primary closure (p = 0.0011). Esophagectomy tended to be performed more often in patients with a long perforation and was performed significantly more often in patients with a high C-reactive protein concentration (p = 0.0118). The postoperative hospital stay was significantly longer in patients with leakage of the primary closure site (p < 0.0001). As a result, leakage of the primary closure site was significantly correlated with a long duration from symptom onset to patient presentation (p = 0.042), diagnostic imaging of the intrathoracic perforation (p = 0.013), and abscess formation in the mediastinal cavity (p = 0.006).

CONCLUSIONS

Selection of an appropriate surgical procedure may contribute to reduced mortality rates in patients with esophageal rupture. With regard to primary closure, it is necessary to understand that leaks are likely to occur in patients with a long duration from symptom onset to presentation or with severe intrathoracic/mediastinal inflammation, and to select an appropriate surgical procedure in consideration of the degree of invasiveness and QOL.

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

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

The surgical management of spontaneous esophageal perforation (Boerhaave's syndrome) ‒ 20 years of experience

Spontaneous esophageal perforation (Boerhaave's syndrome) is an uncommon and challenging condition with significant morbidity and mortality. Surgical treatment is indicated in the large majority of cases and different procedures have been described in this respect. We present the results of a mono-institutional evaluation of the management of spontaneous esophageal perforation over a 20-year period. The charts of 25 patients with spontaneous esophageal perforation treated at the Surgical Department of the University Hospital of Lausanne were retrospectively studied. In the 25 patients, 24 patients were surgically treated and one was managed with conservative treatment. Primary buttressed esophageal repair was performed in 23 cases. Nine postoperative complications were recorded, and the overall mortality was 32%. Despite prompt treatment postoperative morbidity and mortality are still relevant. Early diagnosis and definitive surgical management are the keys for successful outcome in the management of spontaneous esophageal perforation. Primary suture with buttressing should be considered as the procedure of choice. Conservative approach may be applied in very selected cases.

Role of endoscopic clipping in the treatment of oesophageal perforations

With advances in endoscopic technologies, endoscopic clips have been used widely and successfully in the treatment of various types of oesophageal perforations, anastomosis leakages and fistulas. Our aim was to summarize the experience with two types of clips: The through-the-scope (TTS) clip and the over-the-scope clip (OTSC). We summarized the results of oesophageal perforation closure with endoscopic clips. We processed the data from 38 articles and 127 patients using PubMed search. Based on evidence thus far, it can be stated that both clips can be used in the treatment of early (< 24 h), iatrogenic, spontaneous oesophageal perforations in the case of limited injury or contamination. TTS clips are efficacious in the treatment of 10 mm lesions, while bigger (< 20 mm) lesions can be treated successfully with OTSC clips, whose effectiveness is similar to that of surgical treatment. However, the clinical success rate is significantly lower in the case of fistulas and in the treatment of anastomosis insufficiency. Tough prospective randomized multicentre trials, which produce the largest amount of evidence, are still missing. Based on experience so far, endoscopic clips represent a possible therapeutic alternative to surgery in the treatment of oesophageal perforations under well-defined conditions.

Transabdominal approach assisted by thoracoscopic drainage for lower esophageal perforation

The effectiveness of use of thoracoscopy for esophageal perforation has not been fully evaluated. We herein report a case of esophageal perforation for which a transabdominal approach assisted by thoracoscopic drainage was performed.

Boerhaave's syndrome: Thoracolaparoscopic approach

We present a case of Boerhaave’s syndrome managed thoracolaparoscopically. A 45-year- old man presented with hydropneumothorax following severe retching. He was treated with Intercostal drainage insertion as the primary management and referred to a tertiary care centre. There endoscopic stapling was attempted, following which he developed a leak. He presented to us with severe sepsis and mediastinal collection on the ninth day following the perforation. We treated him with thoracoscopic mediastinal toilet, laparoscopic-assisted feeding jejunostomy and cervical oesophagostomy. The patient was managed conservatively. A computed tomography (CT) scan was repeated at intervals of 15 days. He was continued on full jejunostomy feeds. Regular assessment of the oesophagus injury was conducted via the CT scan. The patient had complete healing of the perforation at end of two months. His oesophagostomy was closed and he remained symptom-free at follow-up. We conclude that thoracoscopy has an important role to play in the management of patients with mediastinal sepsis and late presentation of Boerhaave’s perforation.

A successful strategy for surgical treatment of Boerhaave's syndrome

BACKGROUND

This retrospective single-institution study presents a successful treatment strategy for Boerhaave's syndrome.

METHODS

During 1995-2008, 15 patients with spontaneous esophageal perforation were treated. Patients were grouped according to time from symptoms to referral (early, <24 h; late, >24 h). In group I (early, n = 8 patients) treatment comprised primary surgical esophageal repair in seven cases and endoscopic clipping in one case. In group II (late, n = 7 patients) treatment comprised esophagectomy without primary reconstruction (4 cases) or controlled esophagocutaneous fistula (3 cases). Measures of outcome included age (years), delay to diagnosis (h), severe sepsis on admission, mortality, and hospital and intensive care unit (ICU) stay.

RESULTS

The overall hospital mortality rate was 6.6% (1/15), being 0% (0/8) in group I and 14.2% (1/7) in group II. Patient age (49.6 vs. 68.6 years, P < 0.0001), delay to diagnosis (17.75 vs. 69 h, P < 0.0001), severe sepsis on admission (0 vs. 4, P = 0.0256), and ICU stay (4 vs. 14 days, P = 0.006) were all greater in group II.

CONCLUSIONS

Early diagnosis and carefully selected therapeutic tactics can reduce the mortality rate of Boerhaave's syndrome to an acceptably low level. Methods of organ preservation and minimally invasive techniques can be applied successfully in the treatment.

A successful strategy for surgical treatment of Boerhaave's syndrome

BACKGROUND

This retrospective single-institution study presents a successful treatment strategy for Boerhaave's syndrome.

METHODS

During 1995-2008, 15 patients with spontaneous esophageal perforation were treated. Patients were grouped according to time from symptoms to referral (early, <24 h; late, >24 h). In group I (early, n = 8 patients) treatment comprised primary surgical esophageal repair in seven cases and endoscopic clipping in one case. In group II (late, n = 7 patients) treatment comprised esophagectomy without primary reconstruction (4 cases) or controlled esophagocutaneous fistula (3 cases). Measures of outcome included age (years), delay to diagnosis (h), severe sepsis on admission, mortality, and hospital and intensive care unit (ICU) stay.

RESULTS

The overall hospital mortality rate was 6.6% (1/15), being 0% (0/8) in group I and 14.2% (1/7) in group II. Patient age (49.6 vs. 68.6 years, P < 0.0001), delay to diagnosis (17.75 vs. 69 h, P < 0.0001), severe sepsis on admission (0 vs. 4, P = 0.0256), and ICU stay (4 vs. 14 days, P = 0.006) were all greater in group II.

CONCLUSIONS

Early diagnosis and carefully selected therapeutic tactics can reduce the mortality rate of Boerhaave's syndrome to an acceptably low level. Methods of organ preservation and minimally invasive techniques can be applied successfully in the treatment.

Barotraumatic oesophageal perforation with bilateral tension pneumothorax

Barotraumatic oesophageal perforation with bilateral tension pneumothorax is extremely rare and this is a first case reported in the literature. The possibility of the oesophageal perforation due to high-pressure gas flow should be kept in mind and the standard of diagnosis is oesophagography.

Endoscopic T-tube placement in the management of lye-induced esophageal perforation: Case report of a safe treatment strategy

Esophageal perforation is associated with a significant risk of morbidity and mortality. We report herein a case of lye-induced esophageal perforation managed successfully by employing endoscopic T-tube placement with a successful outcome.

[Foreign body perforation of the thoracic esophagus]

BACKGROUND

Esophageal perforation due to foreign body (FB) ingestion is an unusual occurrence. This study aims to define diagnostic difficulties of esophageal perforation by FB.

PATIENTS AND METHODS

A chart review of patients on our service with FB esophageal perforation was carried out. Diagnosis of perforation was made by CT scan and/or esophagoscopy. Surgery was indicated when a FB could not be removed endoscopically or on a case-by-case basis according to clinical/laboratory, radiologic, and/or endoscopic findings.

RESULTS

Seven patients (age range: 27 to 80 years) were admitted for esophageal FB perforation. All patients presented with dysphagia. Two patients presented with signs of sepsis more than 24 hours after FB ingestion. Perforation was diagnosed at initial evaluation in five cases (three by endoscopy, two by CT) and after FB extraction in two cases. Six patients underwent surgery (suture repair: n=4; esophageal exclusion: n=1; mediastinal drainage: n=1). Five surgeries were performed at the initial diagnosis and one after failure of medical management. Mortality was zero; one patient developed esophageal fistula.

CONCLUSION

Diagnosis of FB esophageal perforation is difficult and is delayed in up to a quarter of patients. The perforation can be due to the FB itself or may be incurred during endoscopic extraction. Both CT and endoscopy are necessary for diagnosis and treatment. Most patients require surgical intervention.

Successful late management of esophageal perforation with T-tube drainage

The late management of spontaneous esophageal perforation is the most challenging problem for the surgeon. In this paper, we present a case in whom a spontaneous esophageal perforation was successfully treated by T-tube drainage after unsuccessful conservative treatment. The patient, a 68-year-old male, was admitted to the hospital with sudden upper abdominal pain. After 2 days, esophageal perforation was diagnosed, and conservative management was begun. Thereafter, the subcutaneous emphysema disappeared, and the patient's temperature decreased. However, on day 13, the patient's temperature spiked above 38°C, and computed tomography showed a mediastinal abscess. An emergency left thoracotomy with laparotomy was performed. Since a 2-cm longitudinal perforation with severe inflammatory reactions was observed, the T-tube drainage method was performed. The patient was discharged without postoperative complications and has not experienced any gastrointestinal symptoms, such as gastroesophageal reflux or dysphagia. In conclusion, the T-tube drainage method appears to be a simple and effective method for the late management of esophageal perforation with severe inflammatory reaction.

Retrograde tube drainage for esophageal anastomotic leaks and perforation

The mortality and morbidity of esophageal anastomotic leaks or perforations remain high. We performed retrograde transanastomotic esophageal sump tube drainages for esophageal anastomotic leak or perforation in three patients. Our method is a modified procedure of the T-tube drainage. The Levin gastric tube was simply inserted into the esophagus via anastomotic leak or perforation to develop a defined fistula. All three patients were treated with a satisfactory outcome. An advantage of this method is that it is technically easy, and available for patients whose diseases are difficult to treat with standard T-tube drainage. In addition, one of our patients was successfully managed non-operatively by fluoroscopical guidance. This retrograde esophageal sump tube drainage was technically very easy, safe and useful for esophageal anastomotic leaks or perforations.

Reversing Esophageal Discontinuity

Catastrophic esophageal or gastric disruption drive the decision to "disconnect" the esophagus to prevent ongoing mediastinal soilage. The operations used to establish esophageal discontinuity are not standardized and vary widely, the surgeon often focusing on saving the patient's life, not on how alimentary continuity will ultimately be restored. Patients who survive the initial disastrous infectious complications are typically desperate to have further surgery to allow them to eat again. Relatively little is written about the decisions involved in reversing esophageal discontinuity--the timing of the operation, preoperative assessment and preparation, planning and conduct of the operation, and outcome. The nuances of reestablishing alimentary continuity in this disparate patient population are the focus of this article.

Tratamiento de las perforaciones del esófago torácico

OBJECTIVE

To evaluate the results of the treatment of patients with thoracic esophageal perforation in order to determine the most appropriate management of this entity.

PATIENTS AND METHOD

We performed a retrospective study of 21 patients (mean age 59 years; 24-82) who presented with thoracic esophageal perforation to our hospital between 1991 and 2004.

RESULTS

In 13 patients (62%) treatment was performed within 24 hours. In the remaining 8 patients the mean delay was 7.2 (2-12) days. In 4 patients (26%) the perforation was confined to the mediastinum and conservative treatment was provided. Of these patients, 1 developed empyema and underwent esophageal resection. Extramediastinal involvement was confirmed in 17 patients (73%) and was treated by a variety of surgical procedures: esophagectomy (n=2), drainage alone (n=2), primary closure (n=2) and reinforced primary repair (n=11). Two patients with simple closure and 1 with reinforced primary closure developed leakage of the suture line resulting in death. The 3 patients who underwent esophagectomy survived. In patients with perforation confined to the mediastinum mortality was 0%, whereas in those with extramediastinal involvement mortality was 23%.

CONCLUSIONS

Thoracic esophageal perforation leads to high mortality rates and requires early diagnosis and immediate treatment. Conservative management is appropriate in only a few selected patients. When surgical treatment is indicated, we advocate reinforced primary repair regardless of the interval between injury and operation, except when the esophagus is in such poor condition that esophagectomy is the only option.

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.

Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae

BACKGROUND AND AIMS

Esophageal perforation is associated with high morbidity and mortality. Surgery and drainage are considered primary management. Conservative management is an option in a select group. Conservative treatment requires drainage, control of infection, nutritional support, and considerable patience.

METHODS

We describe 3 cases in which endoscopic metallic clips were placed to close mature perforations with associated fistulae. All 3 patients underwent mucosal approximation of the defects under direct endoscopic visualization.

RESULTS

A review of the literature revealed only 4 other reports of the use of endoclipping for esophageal perforation, one diagnosed immediately, a second within 24 hours, a third diagnosed after 2 days and endoclipped after prolonged mediastinal drainage, and a fourth believed to be chronic. The cases presented here represent well-established, mature defects.

CONCLUSIONS

Endoscopic treatment of mature esophageal perforation with metallic clips can be performed to promote closure. In combination with other conservative medical efforts, this method can be used safely and effectively for selected patients.

Covered metallic stent treatment of a patient with spontaneous rupture of the esophagus

A patient with a potentially fatal condition as a result of esophago-pneumo-broncho fistula was successfully treated with the insertion of a self-expanded covered metallic stent. Severe regurgitation resulted in the removal of the stent 3 months after insertion. Stricture after removal of the stent required pneumatic balloon dilation. The use of a self-expanded covered metallic stent is effective for the treatment of spontaneous esophageal rupture; however, early removal of the stent is recommended.