Esophageal perforation: the importance of early diagnosis and primary repair

Esophageal Perforation Resulting From Nonaccidental Trauma in a Neonate: A Case Report

Esophageal perforation (EP) resulting from nonaccidental trauma in a neonate is extremely rare. We report a previously healthy 12-day-old neonate presenting with stridor, respiratory distress, and bloody vomitus. Clinical, radiographic, and endoscopic evaluations confirmed the diagnosis of EP. The patient received respiratory support, remained on nothing by mouth (NPO) status, and was administered parenteral nutrition for seven days until healing was confirmed. Upon resuming oral feeding, the neonate tolerated it well and was discharged home. A follow-up endoscopy, six weeks later, revealed normal findings. Early recognition and treatment of EP are crucial to prevent complications. To our knowledge, this is the youngest reported case of EP due to nonaccidental trauma.

Pulmonary artery penetration due to fish bone ingestion: A rare case report

Accidental fish bone ingestion is a common manifestation at emergency departments. In most cases, ingested foreign bodies usually pass uneventfully through the gastrointestinal tract and complications only present in less than 5% of all patients. In this report, we present the first documented case of pulmonary artery injury due to a fish bone in a 63-year-old male patient hospitalized with hemoptysis after accidentally swallowing a fish bone 30 days ago. This patient subsequently had surgery and endoscopy to safely remove the foreign body and then recovered well on a follow-up examination. For cases of fish bone ingestion, contrast-enhanced chest computed tomography is one of the most essential tools to assess vascular problems and associated mediastinal infections-risk factors for life-threatening and long-term recurrent inflammation. Reconstructing planes along the foreign body axis and changing windows when analyzing CT scans is necessary to avoid missing lesions and dilemmas.

Two Cases of Severe Complications Due to an Esophageal Fish Bone Foreign Body

Cases of foreign body ingestion are encountered relatively often in clinical settings; however, serious complications are rare. In such cases, mediastinal abscess due to esophageal perforation can become a life-threatening complication. We encountered two cases of severe complications due to an esophageal fish bone foreign body. The first case was a 40-year-old male with an intramural esophageal abscess due to a fish bone after eating fish five days before visiting the hospital. The patient underwent surgical treatment, but the esophageal abscess did not improve; so, the abscess was drained through endoscopic mucosal dissection, and the abscess improved. In the second case, a 64-year-old male, who had eaten fish three days before visiting the hospital, had esophageal perforation by a fish bone, and abscess formation in the mediastinum and the lesser sac in the abdominal cavity were observed. Although surgical treatment was performed, the intra-abdominal abscess formation was not controlled; so, percutaneous drainage (PCD) was inserted, and the abscess improved. Both patients were discharged without any complications. Here, we report two cases that were improved through surgical treatments and additional treatments such as endoscopic dissection and PCD.

Esophageal perforation etiology, outcome, and the role of surgical management - an 18-year experience of surgical cases in a referral center

INTRODUCTION

Esophageal perforation is a surgical emergency with a high rate of morbidity and mortality. Its poor prognosis is mainly associated with previous patient-specific comorbidities and a lack of timely diagnosis and treatment. The objective of this study was to investigate the etiological factors and different surgical methods of treatment with consideration of mortality rate and comorbidities.

METHOD

The present cross-sectional study was conducted on patients who underwent surgical intervention due to esophageal injury from 2002 to 2019 (18 years). Demographic and clinical characteristics along with performed surgical interventions were evaluated accordingly.

RESULTS

In this study, 69 patients with a mean age of 38.8 years were evaluated, of which 45 (65.2%) cases were men. In terms of location of the perforation, the thoracic portion of the esophagus followed by the cervical and abdominal esophagus were more frequently injured with a rate of 32 (46.4%), 30 (43.5%), and 19 (27.5%) cases, respectively. Accordingly, foreign body ingestion followed by penetrating injuries were the most common causative agents leading to esophageal perforation.

CONCLUSION

Obtaining the desired results from the treatment of this condition depends on factors such as patients' previous comorbidities, cause of the rupture, the location of the esophageal damage, and delay in the start of treatment. Since there is no single gold standard treatment strategy, each patient should be individually evaluated.

Utility of fluoroscopic oesophagography in the setting of spontaneous and blunt traumatic pneumomediastinum

AIM

To determine the incidence of positive fluoroscopic oesophagography in patients presenting with spontaneous or blunt traumatic pneumomediastinum.

MATERIALS AND METHODS

Retrospective chart review was performed on patients who underwent fluoroscopic oesophagography for spontaneous or blunt traumatic pneumomediastinum between 2001-2019. Patients were excluded for history of oesophageal surgery, penetrating trauma, oesophageal cancer, or tracheal/oesophageal instrumentation.

RESULTS

Two hundred and fifty-two patients met the inclusion criteria; 170 presented with spontaneous pneumomediastinum and 82 presented with blunt traumatic pneumomediastinum. Fluoroscopic oesophagography was positive in eight patients with spontaneous pneumomediastinum, for a positivity rate of 4.7% (8/170). There was one false-negative case in a patient who presented with spontaneous pneumomediastinum and was found to have a non-full-thickness oesophageal injury on endoscopy. Fluoroscopic oesophagography was negative in all patients with blunt traumatic pneumomediastinum (0/82). The sensitivity and specificity of fluoroscopic oesophagography were 88.9% (8/9) and 100% (243/243), respectively. Oesophageal injury was more common in patients with spontaneous pneumomediastinum and a pleural effusion (5/11, 45.4%) than in patients with spontaneous pneumomediastinum and no pleural effusion (4/159, 2.5%, p<0.001).

CONCLUSION

The present findings do not support routine oesophagography in patients with blunt traumatic pneumomediastinum. Conversely, a positivity rate of 4.7% in patients with spontaneous pneumomediastinum suggests oesophagography may be warranted in this population, particularly if an associated pleural effusion is present.

Long-term retainment of a foreign body in the esophagus in an adult: a case report

Ingestion of a foreign body (FB) is a common emergency encountered in otorhinolaryngology. In most cases, FBs pass through the digestive tract spontaneously without any serious consequences, but some of them require nonsurgical interventions, and more severe cases require surgical interventions. The types of FBs ingested may differ in different countries and regions. In adults, bones, fish bones, and dental prostheses are most commonly found in the esophagus, and most of the FBs are retained in the esophagus less than 1 month. To the best of our knowledge, this is the first report of an unusual FB (a beer bottle cap) that was stuck in the upper esophagus for longer than 4 months. The main complaints of the patient were a sore throat and FB sensation, and an FB was diagnosed by a chest radiograph and computed tomography of the esophagus. He then had rigid endoscopic removal of the FB performed under anesthesia with propofol sedation. During a 3-month follow-up, the patient was asymptomatic and no esophageal stricture was observed. Impaction of FBs in the gastrointestinal tract can lead to severe adverse events. Therefore, early detection and timely management of FBs are important.

Is thoracic esophagostomy an option in esophageal perforation in pediatric patients?

Esophagostomy and subsequent esophagectomy are extremely rare operations in the management of benign esophageal perforations in children. In this report, we present a 20-month-old female in whom we performed thoracic esophagostomy and subsequent intrathoracic esophagogastric anastomosis due to esophageal perforation caused by a chronic foreign body. The patient was discharged on the 10th postoperative day, and no complications were observed in the patient, who was followed for four years. The thoracic esophagostomy procedure helps preserve the esophageal length and easy execution of the esophagogastric anastomosis in the thorax. We believe it can be a safe and useful technique in carefully selected cases.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting

Boerhaave's syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%-50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave's syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.

Learning Spatiotemporal Features for Esophageal Abnormality Detection From Endoscopic Videos

Esophageal cancer is categorized as a type of disease with a high mortality rate. Early detection of esophageal abnormalities (i.e. precancerous and early cancerous) can improve the survival rate of the patients. Recent deep learning-based methods for selected types of esophageal abnormality detection from endoscopic images have been proposed. However, no methods have been introduced in the literature to cover the detection from endoscopic videos, detection from challenging frames and detection of more than one esophageal abnormality type. In this paper, we present an efficient method to automatically detect different types of esophageal abnormalities from endoscopic videos. We propose a novel 3D Sequential DenseConvLstm network that extracts spatiotemporal features from the input video. Our network incorporates 3D Convolutional Neural Network (3DCNN) and Convolutional Lstm (ConvLstm) to efficiently learn short and long term spatiotemporal features. The generated feature map is utilized by a region proposal network and ROI pooling layer to produce a bounding box that detects abnormality regions in each frame throughout the video. Finally, we investigate a post-processing method named Frame Search Conditional Random Field (FS-CRF) that improves the overall performance of the model by recovering the missing regions in neighborhood frames within the same clip. We extensively validate our model on an endoscopic video dataset that includes a variety of esophageal abnormalities. Our model achieved high performance using different evaluation metrics showing 93.7% recall, 92.7% precision, and 93.2% F-measure. Moreover, as no results have been reported in the literature for the esophageal abnormality detection from endoscopic videos, to validate the robustness of our model, we have tested the model on a publicly available colonoscopy video dataset, achieving the polyp detection performance in a recall of 81.18%, precision of 96.45% and F-measure 88.16%, compared to the state-of-the-art results of 78.84% recall, 90.51% precision and 84.27% F-measure using the same dataset. This demonstrates that the proposed method can be adapted to different gastrointestinal endoscopic video applications with a promising performance.

Transoral Endoscopic Approach to Repair Early Pharyngeal Perforations After Anterior Cervical Spine Surgery without Failure of Instrumentation: Our Experience and Review of Literature

BACKGROUND

Pharyngoesophageal injury during anterior cervical spine surgery is a rare and potentially life-threatening complication; generally it is the result of intraoperative manipulation or hardware erosion and sometimes may be due to weakness of the pharyngoesophageal wall from pre-existing pathologic conditions, such as diabetes, gastritis, or obesity.

CASE DESCRIPTION

We describe the management strategies in patients with an early postoperative hypopharyngeal perforation that occurred after anterior cervical spine surgery without failure of instrumentation, and we present a case treated endoscopically at our institution.

CONCLUSIONS

Appropriate treatment for pharyngoesophageal perforations is controversial and not investigated in detail. There is a lack of prospective studies comparing initial conservative versus surgical approaches to treatment. In addition, endoscopic management is growing as a therapeutic option, but no consensus concerning the indications for an endoscopic approach in the treatment of pharyngoesophageal injury in anterior cervical spine surgery is currently reached. A common theme proposed in the literature is that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. A customized interdisciplinary surgical approach is essential for successful treatment. Use of the transoral endoscopic approach is a useful noninvasive method to treat this rare but potentially devastating complication.

Endoscopic injection of human fibrin sealant in treatment of intrathoracic anastomotic leakage after esophageal cancer surgery

OBJECTIVE

To investigate the application of endoscopic injection of human fibrin sealant in treatment of patients with intrathoracic anastomotic leakage after esophagectomy.

METHODS

A total of 179 patients who underwent intrathoracic anastomosis after esophageal cancer surgery in our department From December 2012 to May 2015 were retrospectively analyzed. The clinical data and treatment of 7 patients with postoperative intrathoracic anastomotic leakage were analyzed and discussed. On Day 28 after operation, the 7 patients were given endoscopic injection of human fibrin sealant to seal the anastomotic leakage, and the changes in drainage volume, body temperature, CRP, white blood cell count and other indicators were compared before and after endoscopic intervention.

RESULTS

After endoscopic injection of human fibrin sealant in all 7 patients with intrathoracic anastomotic leakage, the volume of para-anastomotic drainage, CRP, and WBC count were improved compared with those before treatment. Relevant data were analyzed, and the differences were statistically significant (P = 0.019, P = 0.001, P = 0.014, respectively). No statistically significant difference was observed in the body temperature before and after treatment (P = 0.217).

CONCLUSION

For patients with intrathoracic anastomotic leakage after esophageal cancer surgery, endoscopic injection of human fibrin sealant to seal the anastomotic leakage has positive therapeutic effects of reducing exudation around the anastomotic leakage, reducing systemic inflammatory response, and improving clinical symptoms including dysphagia, weight loss without trying, chest pain, pressure or burning, worsening indigestion or heartburn and coughing or hoarseness.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Evaluation of the medical economics and safety: two methods for the endoscopic removal of jujube pits

OBJECTIVE

to evaluate the medical economics and safety of two methods for the endoscopic removal of jujube pits, one with a transparent cap combined with a stone basket and the other with a transparent cap combined with foreign body forceps.

METHODS

consecutive patients with a suspected jujube pit ingestion in the esophagus between January 2008 and December 2017 were enrolled into the study. Fifty-three patients who met the criteria were divided into two groups. Group A patients were treated by a transparent cap combined with a stone basket and group B patients were treated by a transparent cap combined with foreign body forceps. The following clinical data were collected: age, sex, location of jujube pits, complications, operation time, extraction success and average hospital costs.

RESULTS

a total of 53 patients who met the criteria were enrolled into the study; 29 cases in group A and 24 cases in group B. Endoscopic removal was successful in 98.1% (52/53) of the patients and the remaining 1.9% (1/53) required surgery. Severe complications were less frequent in group A than in group B (p = 0.017). Surgery time was not significantly different between the two groups (p = 0.647). The extraction success in group A was higher than in group B (p = 0.001). The medical costs including the total cost, inspection, treatment, radiation and drug cost were not significantly different between the two groups (p > 0.05 in all cases).

CONCLUSION

endoscopic baskets are suitable for cases of jujube pit ingestion and have a higher extraction success and a lower proportion of severe complications. Surgery time was not significantly extended and the medical costs did not increase.

Retrospective observational analysis of esophageal foreign bodies: a novel characterization based on shape

This single-center retrospective study aims to investigate the clinical features of esophageal foreign bodies (EFBs) and determine the influence of EFB shapes on management and prognosis. A total of 427 patients aged 13 to 95 years with suspected EFB ingestion were enrolled between January 2013 and June 2018, 183 of whom were male. EFBs were divided into six shapes: pin (n = 161), sheet (n = 97), trident (n = 51), spindle (n = 66), irregular (n = 46), and sphere (n = 6). Spindle-shaped EFBs correlated with a significantly higher rate of perforation and severe complications (P < 0.001 and P = 0.021, respectively) than any other EFB shape, while sheet-shaped EFBs were linked to less severe complications (P = 0.006). The number of pressure points was provided to stratify the risk of poor prognosis for each shape. EFBs with only two pressure points (pin and spindle EFBs) required more advanced management strategies and were correlated with a higher number of patients suffering esophageal perforation (27.11%) and severe complications (12.44%) when compared with other shapes (χ² = 11.149 and P = 0.001; χ² = 5.901 and P = 0.015, respectively). Spindle shape was an independent risk factor for poor prognosis, and contributed a more clinical risk than the pin shape. In conclusion, clinical features, management, perforation rate, and severe complications differed based on EFB shape. The EFBs with two pressure points, especially the spindle-shaped EFBs, were more dangerous compared with those with more pressure points.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

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.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Minimally invasive management of esophageal perforation

Esophageal perforation is a medical emergency associated with high morbidity and mortality. There is no consensus on the optimal treatment of this life-threatening condition. Conventional treatment of esophageal perforation is surgical. However, more recently, endoscopic treatment has become the treatment of choice given its less invasive nature compared to surgical treatment. This includes endoscopic clip administration, endoscopic stent placement, endoscopic suturing, endoscopic vacuum therapy and tissue sealants which are all administered via the endoluminal route. Whilst small defects (<2 cm) may be closed with endoscopic clips, larger defects require stent placement or suturing. Removable esophageal stent is an effective method of treatment in cases with esophageal perforation as they allow minimal invasive repair of perforation and rapid nutrition. Endoscopic suturing can be used both to fix the stent to prevent migration and to primarily close the perforation. If perforation is associated with a mediastinal collection, drainage is mandatory and this procedure can be performed by computed tomography guided percutaneous drainage, thoracoscopy or endoscopic vacuum therapy. In some cases, a combination of these minimally invasive methods is required. Since endoscopic methods provide better quality of life and outcomes and shorten length of hospitalization, such methods have become the treatment of choice for esophageal perforation.

Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center

Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.

Analysis of the management and risk factors for complications of esophageal foreign body impaction of jujube pits in adults

Introduction

Foreign body impaction is a common emergency in the field of otolaryngology. The prevalence of a jujube pit as an esophageal foreign body has increased in the Jiaodong Peninsula. However, reports on this are scarce.

Aim

To investigate the methods for diagnosing and treating esophageal foreign body impaction of a jujube pit and to determine the risk factors for complications.

Material and methods

We conducted a retrospective review of the medical records of patients who were diagnosed with esophageal impaction of a jujube pit. Demographic, clinical, radiological, and endoscopic data were collected and analyzed.

Results

Neither plain radiography nor esophagogram provided enough information on the surrounding issues and complications. The rate of secondary radiological examination was 51.61% for the patients who did not undergo prior computed tomography. The success rate of rigid esophagoscopy was 95.45%; 18 of these patients (27.27%) had previously undergone flexible esophagoscopy without foreign body removal. Logistic regression showed that the time from ingestion to presentation and the jujube pit size were independent risk factors for complications.

Conclusions

Computed tomography without contrast material is the preferred diagnostic method for adults with esophageal jujube pit impaction, and rigid esophagoscopy can be used for therapy even though the first flexible esophagoscopy failed. Large diameter of the jujube pit constituting the esophageal foreign body (≥ 25 mm) and long duration between pit ingestion and presentation (> 12 h) were associated with increased complications in the patients in this study.

Spontaneous healing of a shredded esophagus after ACDF without direct repair

Esophageal perforation is a catastrophic complication of anterior cervical discectomy and fusion (ACDF). While direct surgical repair has been reported as optimal for restoration of upper gut function, we present the case of a 58-year-old woman who achieved complete resolution when treated only with debridement and drainage. We find that a supportive approach, surgical management without direct repair, may play a vital role in select patient populations in order to avoid potentially long-term consequences or radical treatments, like esophageal diversion. Decisions regarding direct repair versus debridement and inspection only should be made on a case-by-case basis through a multidisciplinary approach.

Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation

BACKGROUND

Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches.

METHODS

We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy.

RESULTS

From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%.

CONCLUSIONS

Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.

Non-surgical management of Boerhaave's syndrome: a case series study and review of the literature

BACKGROUND AND STUDY AIMS

 Boerhaave's syndrome (BS) is a life-threatening condition with morbidity and mortality rates as high as 50 % in some reports. Until recently, surgical intervention has been the mainstay of management plans. With advances in therapeutic endoscopy, however, there has been increasing interest in non-surgical options including endoscopic esophageal stenting.

PATIENTS AND METHODS

 We reviewed the medical records of all patients diagnosed with BS and managed with endoscopic interventions between November 2011 and November 2016. The following variables were collected: patient demographics, clinical presentations, locations of esophageal perforation, primary interventions, complications, and outcomes.

RESULTS

 Six patients were found to be diagnosed with BS during the study period. The median age at presentation was 55. There were 4 males and 2 females. The most common site of perforation was in the distal esophagus. The most common presenting symptom was chest pain (67 %) following an episode of vomiting or retching. Four patients (66.7 %) developed septic shock. Endoscopic treatment with a fully covered esophageal stent was the primary intervention in all patients (100 %). Interventional radiology was consulted in all cases for fluid drainage and chest tube placements. Clinical resolution of the BS was achieved in all patients (100 %) without any subsequent surgical interventions. There were no deaths within the study group, and the average follow-up duration was 2 years.

CONCLUSION

 Endoscopic treatment seems to be an effective management strategy in patients with BS. We also noted satisfactory results in patients presenting with sepsis, presumably due to urgent, interventional radiology-guided fluid drainage.

Successfull management of a cervical oesophageal injury after an anterior cervical approach: a case report

The anterior surgical approach for spinal repair, with or without the insertion of stabilizing hardware, is an established procedure in the management of anterior cervical spine (ACS) pathology. Esophageal injury during this approach is a rare complication that can be life threatening. No treatment protocol has yet been standardized. In addition to conservative measures, several surgical approaches have been presented, ranging from primary repair to reconstruction with local, regional, or distant flaps. The SCM muscle flap, used as reinforcement of a primary suture or as a patch to the lesion is in our opinion an effective treatment for persisting or recurring esophageal fistulae after anterior cervical spine surgery.

Treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement

BACKGROUND

Spontaneous rupture of the esophagus is a rare but life-threatening thoracic emergency, with high rates of clinical misdiagnosis and mortality. This article summarizes our experience in the treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement.

METHODS

We retrospectively assessed the medical records of 19 patients with spontaneous esophageal rupture treated using our intervention protocol. Patients received local anesthesia and sedation prior to undergoing transnasal drainage catheter placement into the thoracic abscess cavity, followed by temporary esophageal stent and jejunal feeding tube placement. After the operation, abscess lavage, nutritional support, and anti-inflammatory treatment were given. The transnasal thoracic drainage catheter, esophageal stent, and feeding tube were removed after the healing of the abscess cavity.

RESULTS

In all, 19 covered esophageal stents were placed in 19 patients with spontaneous esophageal rupture. All operations were technically successful. After an average of 84.06 days, the stents were successfully removed from 17 patients. No cases of massive hemorrhage, esophageal rupture, or other complications occurred during stent removal. An 82-year-old patient died of heart failure 2 months after the operation. One patient died of sudden massive hematemesis and hematochezia 55 days after the operation. In one patient, the esophageal injury failed to heal completely.

CONCLUSION

Our treatment protocol is simple, minimally invasive, and efficacious and may be an alternative for patients who are not candidates for surgery, have a high risk of postoperative complications, or wish to undergo minimally invasive surgery.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Esophageal foreign bodies in adults with different durations of time from ingestion to effective treatment

Objective

This study was performed to identify the differences in clinical characteristics, operative methods, complications, and postoperative hospitalization stays for adults with esophageal foreign bodies with different durations of time from ingestion to effective treatment.

Methods

We retrospectively reviewed the medical records of 221 patients with a diagnosis of a foreign body in the esophagus, confirmed by rigid esophagoscopy, flexible esophagoscopy, or surgery. The differences between the two groups (Group A, ≤24 hours from ingestion to effective treatment; Group B, >24 hours from ingestion to effective treatment) were analyzed.

Results

Sharp foreign bodies comprised the majority of objects in the two groups, including jujube pits, bones (excluding fish bones), fish bones, dentures, and seafood shells. Foreign bodies located in the upper esophagus were more commonly observed in Group A than B. Significant differences were observed in the complication rate and length of postoperative hospitalization stays. Adults with esophageal foreign bodies had a high complication rate.

Conclusions

Rigid esophagoscopy can be used to remove sharp and bulky foreign bodies if more effective methods are unavailable. Effective treatment within 24 hours resulted in fewer complications and shorter postoperative hospitalization stays.

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature

STUDY DESIGN

Multicenter retrospective case series and review of the literature.

OBJECTIVE

To determine the rate of esophageal perforations following anterior cervical spine surgery.

METHODS

As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis.

RESULTS

The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired.

CONCLUSIONS

Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.

An unusual approach for the treatment of oesophageal perforation: Laparoscopic-endoscopic cooperative surgery

Boerhaave syndrome describes a transmural oesophageal rupture that develops following a spontaneous, sudden intraluminal pressure increase (i.e. vomiting, cough). It has a high rate of mortality and morbidity because of its proximity to the mediastinum and pleura. Perforation localisation and treatment initiation time affect the morbidity and mortality. In this article, we aim to present our successful laparoscopic-endoscopic cooperative surgery in a 59-year-old female who was referred to our clinic with a diagnosis of spontaneous lower oesophageal perforation. Laparoscopy and a simultaneous oesophageal stent application may be assumed as an effective alternative to conventional surgical approaches in cases of spontaneous lower oesophageal perforation.

Perforation of esophagus and subsequent mediastinitis following mussel shell ingestion

Esophageal perforation is a very rare occurrence because accidental swallowing of foreign bodies is uncommon in adults. Thus, perforation due to swallowing of a foreign body and subsequent development of mediastinitis is rarely encountered by physicians. We experienced such a case and described an adult male patient who had perforated esophagus after accidentally swallowing a mussel shell. The patient visited our emergency department complaining of painful dysphagia for 4 days. A review of history revealed that he consumed a spicy seafood noodle soup containing mussel shells 4 days ago. Computed tomography (CT) of the chest showed the foreign body in the esophagus and pneumomediastinum was identified. We removed the mussel shell fragment using rigid esophagoscopy; explo-thoracotomy, debridement of mediastinal abscess and irrigation were performed.

A penetrating dorsal thoracic injury that is lucky from every aspect: A case report

INTRODUCTION

Penetrating thoracic trauma management represents a major problem for emergency department staff. In these cases, we reported a patient, who can be deemed very lucky, because of both the trauma mechanism and the provided first aid at scene.

PRESENTATION OF CASE

A 30-year-old man was transported to the emergency surgery outpatient clinic after being stabbed from his back. A knife entered thorax from the dorsal region paravertebrally between two scapulae. No vascular and thoracic injuries were detected in the CT. The knife was then pulled and removed, and pressure dressing was applied on the wound. He was discharged with full recovery on the second day of admission.

DISCUSSION

Thoracic traumas may present as blunt or penetrating traumas. Trauma with penetrating dorsal thoracic injuries is usually in the form of stabbing, sharp penetrating object injuries, or firearm injuries. The aim of a successful trauma management is to determine whether a life-threatening condition exists. The general rules of penetrating trauma management are to avoid in-depth exploration for wound site assessment, to avoid removal of penetrating object without accurate diagnosis, and to keep in mind the possibility of intubation for airway security in every moment.

CONCLUSION

During the initial care of patients with penetrating trauma, the object should not be removed from its place. Our patient was lucky enough in that no thoracic pathology developed during the accident and he was not subjected to any secondary trauma during ambulance transport.

Missed diagnosis of oesophageal perforation in ankylosing spondylitis cervical fracture: Two case reports and literature review

Oesophageal perforation after blunt injury cervical fracture in patients with ankylosing spondylitis (AS) is rarely reported. The early diagnosis of oesophageal perforation is extremely important. We present two cases of patients with AS who sustained cervical fracture dislocation and spinal cord injury. The ossified sharp fragments caused oesophageal perforation, and the delayed diagnoses had serious consequences. Oesophageal perforation should be suspected in patients with AS and cervical fracture if bone fragments are pressing against the oesophagus and a gas shadow is visible around the fracture site on computed tomography imaging.

Superior omohyoid muscle flap repair of cervical esophageal perforation induced by spinal hardware

Cervical esophageal perforation is a rare and life-threatening condition. Its prompt diagnosis and treatment require a high index of suspicion. Cervical spine hardware is an uncommon cause of posterior esophageal perforation. Management has included a variety of musculofascial flaps for surgical repair. We present 2 cases of cervical esophageal perforation induced by spinal hardware that were repaired with a superior omohyoid muscle (SOM) flap for closure and/or primary closure reinforcement. Advantages and techniques of the SOM flap are discussed.

Evaluation of urgent esophagectomy in esophageal perforation

Background

Esophageal trauma is considered one of the most severe lesions of the digestive tract. There is still much controversy in choosing the best treatment for cases of esophageal perforation since that decision involves many variables. The readiness of medical care, the patient's clinical status, the local conditions of the perforated segment, and the severity of the associated injuries must be considered for the most adequate therapeutic choice.

Aim

To demonstrate and to analyze the results of urgent esophagectomy in a series of patients with esophageal perforation.

Methods

A retrospective study of 31 patients with confirmed esophageal perforation. Most injuries were due to endoscopic dilatation of benign esophageal disorders, which had evolved with stenosis. The diagnosis of perforation was based on clinical parameters, laboratory tests, and endoscopic images. ‪The main surgical technique used was transmediastinal esophagectomy followed by reconstruction of the digestive tract in a second surgical procedure. Patients were evaluated for the development of systemic and local complications, especially for the dehiscence or stricture of the anastomosis of the cervical esophagus with either the stomach or the transposed colon.

Results

Early postoperative evaluation showed a survival rate of 77.1% in relation to the proposed surgery, and 45% of these patients presented no further complications. The other patients had one or more complications, being pulmonary infection and anastomotic fistula the most frequent. The seven patients (22.9%) who underwent esophageal resection 48 hours after the diagnosis died of sepsis. At medium and long-term assessments, most patients reported a good quality of life and full satisfaction regarding the surgery outcomes.

Conclusions

Despite the morbidity, emergency esophagectomy has its validity, especially in well indicated cases of esophageal perforation subsequent to endoscopic dilation for benign strictures.

Delayed presentation of pharyngeal erosion after anterior cervical discectomy and fusion

Dysphagia after anterior cervical discectomy and fusion (ACDF) is common, with a prevalence ranging between 28% and 57% of cases. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. A review of literature reveals a paucity of case reports detailing work-up and successful management options. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. The diagnosis was made with direct laryngoscopy and treatment consisted of plate removal and pharyngeal repair, followed by revision fusion with deformity correction. This case and the accompanying pertinent review of the literature highlight the importance of a thorough evaluation of dysphagia, especially in the mid- and late-term postoperative period following ACDF, when most cases of dysphagia should have been resolved. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. Unresolved dysphagia should be a red flag for surgeons as it may be the presentation of erosive esophageal/pharyngeal damage, a rare but serious complication following ACDF.

Rare cause of oesophagus perforation

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Oesophagus perforation is a very serious clinical event.

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Mortality rates increase because inexperienced physicians cannot make a diagnosis.

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Although there is no consensus in literature on surgical treatment choices.

INTRODUCTION

Oesophagus perforations, which are generally caused by iatrogenic injuries, are a serious clinical event. There are still high rates of mortality and morbidity and there is no gold standard of surgical treatment.

PRESENTATION OF CASE

The case is here presented of a 54-year old female with complaints of dysphagia after having swallowed a bone in food, who was determined with oesophagus perforation on CT examination.

DISCUSSION

Oesophagus perforation generally occurs secondary to interventional procedures and rarely develops associated with foreign bodies. Treatment depends on the perforation site and dimension.

CONCLUSION

While conservative primary surgical repair may be chosen for cervical lesions, more aggressive approaches such as resection and delayed reconstruction are recommended for thoracic lesions. Early determination and appropriate treatment are life-saving.

The success of surgery in the first 24 hours in patients with esophageal perforation

OBJECTIVE

Esophageal perforation (EP) is a critical and potentially life-threatening condition with considerable rates of morbidity and mortality. Despite many advances in thoracic surgery, the management of patients with EP is still controversial.

MATERIALS AND METHODS

We retrospectively reviewed 34 patients treated for EP, 62% male, mean age 53.9 years. Sixty-two percent of the EPs were iatrogenic. Spontaneous and traumatic EP rates were 26% and 6%, respectively. Three patients had EP in the cervical esophagus and 31 in the thoracic esophagus.

RESULTS

Mean time to initial treatment was 34.2 hours. Twenty patients comprised the early group <24 h) and 14 patients the late group (>24 h). Management of the EP included primary closure in 30 patients, non-surgical treatment in two, stent in one and resection in one. Mortality occurred in nine of the 34 patients (26%). Mortality was EP-related in four patients. Three of the nine patients that died were in the early group (p<0.05). Mean hospital stay was 13.4 days.

CONCLUSION

EP remains a potentially fatal condition and requires early diagnosis and accurate treatment to prevent the morbidity and mortality.

Blunt traumatic esophageal injury: Unusual presentation and approach

INTRODUCTION

Blunt esophageal injury is extremely rare event. However, it is a potential morbid injury unless managed early.

PRESENTATION OF CASE

We report a rare case of blunt esophageal injury for a 28-year old male who presented with history of fall of heavy object over the right side of the chest. Diagnostic work up including chest X-ray, computerized tomography scans and gastrografin esophagogram revealed lower esophageal rupture. Right mini-thoracotomy with esophageal repair was performed. Postoperative course was uneventful.

DISCUSSION

The exact mechanism of blunt esophageal injury remains uncertain. This report described a unique location of esophageal rupture after blunt trauma that happened on the right side. Diagnosis of esophageal injury needs high index of suspicion and accurate diagnostic workup.

CONCLUSION

Prompt diagnosis and management are the key for better prognosis in patients with blunt esophageal injury.

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies

PURPOSE

To evaluate the efficacy of surgical treatment for esophageal perforation.

METHODS

A systematic review of the literature was performed. We conducted a search strategy in the main electronic databases such as PubMed, Embase and Lilacs to identify all case series.

RESULTS

Thirty three case series met the inclusion criteria with a total of 1417 participants. The predominant etiology was iatrogenic (54.2%) followed by spontaneous cause (20.4%) and in 66.1% the localization was thoracic. In 65.4% and 33.4% surgical and conservative therapy, respectively, was considered the first choice. There was a statistically significance different with regards mortality rate favoring the surgical group (16.3%) versus conservative treatment (21.2%) (p<0.05).

CONCLUSION

Surgical treatment was more effective and safe than conservative treatment concerning mortality rates, although the possibility of bias due to clinical and methodological heterogeneity among the included studies and the level of evidence that cannot be ruled out.

Diagnosis of anastomotic leak: electrolyte detection versus barium fluoroscopy

BACKGROUND

We recently described a new method of diagnosing anastomotic leak using the detection of electrical changes induced by electrolyte extravasation from a surgically created gastric leak site in experimental rats. We sought to compare the sensitivity and specificity of anastomotic leak detection for this method to that of upper gastrointestinal (GI) barium fluoroscopy.

METHODS

Experimental rats with a surgically created gastric leak site and controls were interrogated as to the presence of leak using either the electrolyte-gated leak detection method or upper GI barium fluoroscopy. The sensitivity and specificity of leak detection for the two methods were compared.

RESULTS

The sensitivity and specificity of electrolyte-gated leak detection were both 100% (95% confidence interval 69-100%). Barium upper GI fluoroscopy misidentified one leak as a control and one control as a leak, for a sensitivity and specificity of 80% each (95% confidence interval 37-97%). No statistically significant difference was seen between electrolyte-gated leak detection and barium upper GI fluoroscopy in terms of the sensitivity and specificity of anastomotic leak detection.

CONCLUSIONS

Electrolyte-gated leak detection was similarly sensitive and specific for anastomotic leak detection as upper GI barium fluoroscopy, the current standard. The electrolyte-gated method has the advantages of an inert contrast agent (normal saline) and the possibility of performing leak interrogation at the bedside. Electrolyte-gated leak detection might represent a plausible alternative to upper GI barium fluoroscopy for routine postoperative anastomotic leak surveillance after esophagectomy or other foregut surgery.

Surgical treatment of esophageal perforations: the importance of a primary repair

PURPOSE

The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis.

METHODS

All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients.

RESULTS

The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19).

CONCLUSIONS

Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.