Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases

Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study

Background

Esophageal perforation and rupture (EPR) is a serious, potentially life-threatening condition. However, no treatment methods have been established, and data concerning factors affecting mortality are limited. This report presents the prognostic factors of mortality in EPR based on experience in the management of such patients.

Methods

For this retrospective analysis, 79 patients diagnosed as having EPR between 2006 and 2016 and managed at Gyeongsang National University Hospital were examined. The management method was determined in accordance with the location and size of the EPR, laboratory findings, and radiological findings. Thirty-nine patients were treated with surgery; and 40, with nonsurgical management.

Results

The most common cause of EPR was foreign body (fish bone or meat bone), followed by vomiting, iatrogenic causes, and trauma. Thirty-nine patients underwent primary repair of EPR, of whom 4 patients died. Forty patients underwent nonsurgical management, of whom 3 patients died. The remaining patients were discharged. Mortality correlated with the size of the EPR (> 25 mm) and the segmented neutrophil count percentage (> 86.5%) in the white blood cell test and differential.

Conclusions

The mortality risk was increased when the EPR size and the segmented neutrophil count percentage in the white blood cell test and differential was high. Delayed diagnosis, which was considered an important predictive factor in previous investigations, was not statistically significant in this study.

Trial registration: Not applicable.

[Acute and chronic mediastinitis]

BACKGROUND

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice.

MATERIAL AND METHOD

A selective literature search was carried out.

RESULTS

An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good.

CONCLUSION

After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Esophageal perforation caused by a fish bone treated with surgically indwelling drainage and fibrin glue injection for fistula formation

We herein report a case of thoracic esophageal perforation caused by a fish bone. The patient was a 68-year-old female who presented with a persistent sore throat after eating sea bream four days previously. She was diagnosed with an esophageal perforation and posterior mediastinal abscess formation by chest computed tomography and inflammatory findings in her blood test. Surgically indwelling drainage was able to effectively control the leakage of contaminants and infection. Endoscopic injection of fibrin glue into the long-standing thoracic-esophageal fistula promoted closure of the esophageal wall defect and enabled her to restart oral intake. This case report suggests that effective drainage and the use of fibrin glue sealant may be one of the treatment options for esophageal perforation.