Conservative management of a three-day-old esophageal perforation with feeding jejunostomy and prokinetic drug

Outcome of treatment modalities for spontaneous esophageal rupture: a meta-analysis and case series

BACKGROUND

Current treatment modalities for spontaneous esophageal perforation remain controversial because of their rarity.

OBJECTIVE

To describe our institution's experience in managing patients with spontaneous esophageal rupture and conduct a meta-analysis of existing studies to determine the best evidence-based treatment options.

METHODS

The authors enrolled patients with spontaneous esophageal rupture who underwent their first treatment at our institution. The authors also identified studies through a systematic search of the MEDLINE, EMBASE, and Cochrane Library databases before 1 April 2024, for inclusion in the meta-analysis.

RESULTS

This case series included data from 17 patients with delayed diagnosis who were treated with esophageal stents, with an immediate mortality rate of 5.9%. In addition to the cases from our institution, the authors obtained 944 patients from 46 studies in the final analysis. The combined immediate mortality rate was 11% (95% CI: 0.08-0.15). The combined reintervention rate was 11% (95% CI: 0.05-0.19). The combined immediate mortality was 6% (95% CI: 0.04-0.09) after primary closure, 14% (95% CI: 0.02-0.32) after T-tube drain repair, 2% (95% CI: 0.00-0.15) after esophagectomy, 8% (95% CI: 0.03-0.15) after stent placement, and 22% (95% CI: 0.03-0.47) after conservative treatment. The subgroup analysis based on the timing of the intervention showed that the immediate mortality rate in patients initiating treatment within 24 h of rupture was 3% (95% CI: 0.01-0.08), whereas that in patients initiating treatment >24 h later was 12% (95% CI: 0.08-0.18).

CONCLUSION

Outcomes are best after esophagectomy, and primary closure or esophageal stenting is a good option compared with other treatment modalities. Prognosis is related to the timing of intervention, and accurate diagnosis and treatment within 24 h significantly reduces the risk of death in patients. Patients with delayed diagnosis may have a better prognosis with stent placement.

Endoscopic Management of Benign Esophageal Ruptures and Leaks

OPINION STATEMENT

Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.