The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions

Platelet-rich plasma therapy for postoperative esophageal fistula in a pediatric patient

Postoperative management of esophagocutaneous fistulas in pediatric patients is challenging, often resulting in prolonged hospitalization and increased morbidity. Platelet-rich plasma (PRP) has emerged as a promising adjunctive treatment for such complications. We present the case of a 7-month-old infant who developed an esophago-cutaneous fistula following esophagocoloplasty for esophageal atresia type A. Despite initial conservative management, the fistula persisted, prompting the application of PRP gel derived from umbilical cord blood. After four applications of PRP, complete closure of the fistula was achieved, leading to both functional and aesthetic results. This case highlights the potential of PRP in managing refractory postoperative esophageal fistulas in pediatric patients and underscores the need for further research to optimize treatment protocols and validate its efficacy for this sort of complications.

A Case of an Atypical Presentation of Spontaneous Esophageal Rupture

Spontaneous esophageal rupture is an uncommon medical phenomenon that involves a sudden increase in intraesophageal pressure with negative intrathoracic pressure. Here, a 21-year-old female with no history of medical illness was admitted to our accident and emergency department with a one-day history of sudden retrosternal chest pain with other symptoms. There was no foreign body ingestion, vomiting, fever, cough, trauma, or recent procedures. Physical examination revealed a soft abdomen with epigastric tenderness and normal respiratory and cardiovascular examinations. The patient underwent a chest X-ray and a computed tomography scan of the neck and chest, which revealed retropharyngeal air extending to the mediastinum with anterior chest surgical emphysema. Oesophago-gastro-duodenoscopy revealed mild gastritis with no evidence of foreign body or esophagus injury. The patient was prescribed paracetamol, pantoprazole, and clindamycin. On follow-up, the patient was doing well with no active complaints. Conservative management of spontaneous esophageal rupture can result in good clinical outcomes with no requirement for additional interventions.

Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation

Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.

Esophageal Perforation Presenting Initially as Multiple Brain Abscesses Secondary to Streptococcus intermedius

Brain abscess is a life-threatening infection that can occur secondary to contiguous or hematogenous spread. Several underlying conditions can lead to brain abscesses, such as dental infection, otitis media, sinusitis, and immunosuppression. Esophageal perforation leading to brain abscesses is extremely rare. We report a rare case of a 32-year-old man who presented to the emergency department with progressive headaches and upper-extremity weakness. Upon further evaluation, computed tomography (CT) revealed multiple brain abscesses secondary to Streptococcus intermedius infection. The patient eventually underwent esophagogastroduodenoscopy (EGD), which showed a perforation in the middle third of the esophagus. This case highlights the importance of considering esophageal perforation as a predisposing condition for brain abscesses.

Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort

BACKGROUND

Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.

METHODS

Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.

RESULTS

Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).

CONCLUSIONS

Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

The Etiology, Diagnosis, and Management of Esophageal Perforation

BACKGROUND

Esophageal perforation is a serious and potentially life-threatening medical emergency. Given multiple etiologies and varying clinical presentations of the perforated esophagus, the diagnosis is commonly delayed, complicating expeditious and optimal intervention.

METHODS

We thoroughly reviewed the latest literature on the subject and herein describe the various treatment strategies in varying settings.

RESULTS

Treatment depends on multiple factors including the cause and location of the perforation, the time interval between the inciting event and presentation to the managing clinician, the overall medical stability of the patient, comorbidities including pre-existent esophageal pathology or prior foregut operations, and both the location and extent of extra-esophageal fluid collections. Because of these various considerations, determining the best diagnostic and therapeutic approach requires considerable clinical experience and judgment on the part of the physician. Management principles include (1) adequate fluid resuscitation; (2) expeditious administration of appropriate broad-spectrum antibiotics; (3) repair, occlusion, exclusion, diversion, or exteriorization of the perforation site; (4) drainage of extraluminal fluid collections; (5) relief of distal obstruction; and (6) nutritional support.

CONCLUSIONS

For decades, operative intervention has been the mainstay of therapy for esophageal perforation. More recently, endoscopic therapies, including stenting, clipping, suturing, or endoscopic vacuum therapy, have been introduced, expanding the clinician's therapeutic armamentarium while supplanting surgical approaches in many cases. With further experience and introduction of novel therapies, the management of esophageal perforation undoubtedly will continue to evolve.

Esophageal perforations - a population-based nationwide study in Sweden with survival analysis

BACKGROUND

Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality.

METHOD

All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality.

RESULTS

879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide.

CONCLUSIONS

90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.

Thoracic esophageal perforation by the use of Magill forceps in infant, success with non-operative treatment: case report

Background

Esophageal perforation is a rare surgical pathology in children. Thoracic esophageal perforation is more severe than cervical esophageal perforation. Iatrogenic cause, mainly by endoscopy, is the most common in esophageal perforation. However, perforation induced by “Magill forceps” is exceptional.

Case presentation

A systematic physical examination revealed pyrexia severe respiratory distress and right-sided pleural effusion.

We report the success of non-operative treatment applied to thoracic esophageal perforation due to Magill forceps in a 24-month-old male infant. The immediate and short-term outcomes were excellent.

Conclusions

Non-operative treatment is possible in iatrogenic perforation of thoracic esophageal in infants. This treatment delivers excellent outcome in carefully selected patients.

Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: Systematic review and meta-analysis

Background and study aims  Esophageal defects (leaks, fistulas, and perforations) are associated with significant morbidity and mortality. Endoluminal vacuum-assisted closure (EVAC) is a novel intervention that entails the use of sponges in the defect along with negative pressure to achieve granulation tissue formation and healing and has been gaining popularity. We performed a systematic review and pooled analysis of available literature to assess the safety and effectiveness of EVAC for esophageal defects. Patients and methods  We queried PubMed/Medline, Embase, Cochrane, and Web of Science through September 25, 2020 to include all pertinent articles highlighting the safety and effectiveness profile of EVAC for esophageal defects. Pooled rates, 95 % confidence intervals (CIs), and heterogeneity ( I ² ) were assessed for each outcome. Results  A total of 18 studies with 423 patients were included (mean age 64.3 years and males 74.4 %). The technical success for EVAC was 97.1 % (CI: 95.4 %-98.7 %, I ²  = 0 %). The clinical success was 89.4 % (CI: 85.6 %-93.1 %, I ²  = 36.8 %). The overall all-cause mortality and adverse events (AEs) noted were 7.1 % (CI: 4.7 %-9.5 %, I ²  = 0 %) and 13.6 % (CI: 8.0 %-19.1 %, I ²  = 68.9 %), respectively. The pooled need for adjuvant therapy was 15.7 % (CI: 9.8 %-21.6 %, I ²  = 71.1 %). Conclusions  This systematic review and meta-analysis showed high rates of technical success, clinical success, and low all-cause mortality and AEs using EVAC. Although the technique is a promising alternative, the lack of comparative studies poses a challenge in making definite conclusions regarding use of EVAC compared to other endoscopic modalities, such as clips and stents.

Hypopharyngeal perforation caused by blunt trauma during consensual fellatio: an expectant management approach

Perforation of the pharynx is a rare occurrence but has the potential to cause mediastinitis and has an attendant mortality risk. Though numerous mechanisms have been described, we report a unique case of a young woman who presented with a sore throat, odynophagia and subcutaneous emphysema, a short time after performing fellatio. A contrast swallow confirmed hypopharyngeal perforation. She was managed expectantly with nasogastric feeding and empirical antibiotics. The perforation took 4 weeks to heal, but there were no residual swallowing problems at 3-month follow-up. We will explore the incidence and causes of pharyngeal perforation and discuss the options for and risks of surgical repair. This case highlights that non-surgical management of such injuries can be both safe and feasible, and reinforces the importance of ensuring confidentiality and the need for vigilance regarding potential non-consensual injury.

Non-operative management of bilateral contained thoracic esophageal perforation: a case report

BACKGROUND

Despite profound advances in conservative management of esophageal perforation, patients' selection for this type of treatment requires expert clinical judgment. Surgical intervention has been historically introduced as the optimal management in multifocal ruptures.

CASE PRESENTATION

Here, we presented a 30-year-old man whose barium esophagogram confirmed bilateral perforations in the lower third of the esophagus contained in the mediastinum, and contrast drained back into the esophageal lumen. Concerning available contrast imaging studies and thoracic surgeons, conservative non-operative management was considered despite pneumomediastinum, a mild right-sided pleural effusion, and minimal leukocytosis. The patient was followed up for two months without any complications.

CONCLUSIONS

Bilateral and multifocal esophageal perforations can be managed conservatively provided that the leaks are confined to the mediastinum and drain back to the esophageal lumen, and other criteria for conservative management are met.