Long-term observation following perforation and rupture of the esophagus

Long-term observation and functional state of the esophagus after primary repair of spontaneous esophageal rupture

BACKGROUND

Long-term outcome of patients treated for a spontaneous esophageal rupture (Boerhaave's syndrome) is seldom reported.

METHODS

From 1989 to 2004, 62 esophageal perforations were treated in a single institution. Eighteen patients presented with a spontaneous esophageal rupture. Among them, 15 could be treated with a transthoracic primary repair and constituted the material of the present study. A chart review was performed with special attention to survival, residual symptoms, and anatomic and motility disorders.

RESULTS

Three patients died postoperatively (20%). At last follow-up, 10 patients were alive and 2 had died from unrelated causes. At a median delay of 13 months (3 to 74), 7 patients accepted to undergo complementary investigations. None of them had any anatomic abnormality as checked by barium swallow. Six patients complained of mild symptoms from gastroesophageal reflux. Six patients (85%) presented with esophageal motility disorders on manometry and 4 (54%) had nocturne chronic reflux disease on pH monitoring. Two patients underwent endoscopic ultrasonography, of which one presented with a focal absence of one layer of the esophageal wall within the area of the suture. With time, no patient experienced recurrence, but one developed a cancer in the cervical esophagus.

CONCLUSIONS

These results suggest that esophageal functional disorders are the rule after primary repair of a Boerhaave's syndrome. Whether or not these findings are causal, coincidental, or related to the surgical treatment remains unclear. However, performance of routine postoperative explorations is strongly encouraged for a better understanding of this challenging condition.

Short- and long-term outcome of esophageal perforation

Esophageal perforation is an important complication of endoscopy and dilation, but few data are available regarding long-term outcome in these patients. Thirty-one consecutive patients with esophageal perforation were studied. Long-term outcome was determined by office follow-up and questionnaires via mail or telephone. The study group included 16 men and 15 women with a mean age of 61 +/- 4 years. Instrumentation was the principal cause of perforation (77%), and pain was the principal symptom in the majority of cases. However, some patients reported no pain, their only symptom being shortness of breast or dysphagia on swallowing saliva. Contrast examinations were used to establish the diagnosis, but results were initially negative in 3 of 27 patients (11%). Seven patients were treated nonsurgically (nasogastric drainage, antibiotics, and intravenous alimentation). Fourteen patients underwent primary closure of the esophageal rent. Six patients underwent surgical drainage, 3 underwent total esophagectomy, and 1 died during surgery before the esophagus was exposed. Thirty-day mortality was 6.4%. Mean hospital stay was 26 +/- 5 days. Postdischarge follow-up was available in 28 of the 29 patients (97%) surviving initial hospitalization, and the mean follow-up was 47 +/- 9 months. Nineteen patients had persistent dysphagia, and 6 underwent dilation again. One of these patients had a second perforation. Contrary to results of some earlier studies, the mortality from esophageal perforation was low in our study because of early intervention in suspected cases. Results of contrast studies are sometimes negative in the early stages after perforation, and studies may need to be repeated.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent spontaneous perforation of the esophagus

Boerhaave's syndrome is uncommon and its precise etiology is unclear. Information regarding the long-term outcome of patients surviving this injury is lacking. We present the case of a patient who suffered two spontaneous perforations of the esophagus that occurred 30 years apart.

Esophageal perforation: a continuing challenge

Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.