Poorly Differentiated Biliary Adenocarcinoma Leading to Boerhaave syndrome: A Case Report and Review of the Literature

Boerhaave syndrome is a transmural disruption of the esophagus, due to an increase in esophageal pressure and is associated with high morbidity and mortality. There are cases reported secondary to bowel obstructions such as incarcerated hernias and gallstone ileus. Here, we describe an unusual autopsy case of Boerhaave syndrome, due to bowel obstruction secondary to biliary adenocarcinoma, which has never been reported in the literature. The patient was an 87-year old male presenting with severe chest and epigastric pain. Computed tomography showed fluid-filled esophagus, gastric distention and an ill-defined mass within the liver. Patient underwent esophagogastroduodenoscopy, which revealed esophageal rupture. Patient expired within 20 hours of admission. On autopsy, the decedent was found to have an esophageal perforation and an inferior hepatic mass, which morphologically and immunohistochemically was consistent with a biliary adenocarcinoma.

Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data: A case report

RATIONALE

Spontaneous esophageal rupture (Boerhaave syndrome) is a rare, though frequently fatal, event. It is generally caused by a sudden increase in pressure inside the esophagus. In some cases, full-thickness perforations of the esophagus may develop from previous lesions that initially involve only the esophageal mucosa (Mallory-Weiss syndrome) and which, following further triggering events, give rise to a transmural lesion.

PATIENT CONCERNS

Here, we present the case of a 45-year-old subject who suddenly died of acute cardio-respiratory failure, an autopsy was performed to identify the cause of death.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

The autopsy examination revealed a full-thickness rupture of the esophageal wall. Through the integration of necroscopy findings, anamnestic data, and histopathological examination, it has been possible to establish that complete esophageal rupture resulted from the evolution of a previous partial lesion of the esophageal wall, and that an untreated Mallory-Weiss syndrome evolved into a rapidly fatal Boerhaave syndrome.

LESSONS

This case shows that distal esophageal tears, rather than constituting a distinct entity, may be part of a spectrum of diseases and that a partial lesion of the esophageal wall caused by barogenic injury may evolve into a full-thickness rupture following further barotraumas.

Left atrio-esophageal fistula of a possibly iatrogenic aetiology

The study presents an exceptionally rare case of an esophago-left atrial fistula, which was diagnosed during a forensic post-mortem examination. Due to complex nature of the disease and many attempts to cure the patient, the authors did not manage to identify the aetiology of the fistula. It was only implied that the fistula might have been a distant complication of intraoperative endocardial ablation or it might have appeared as a consequence of perforation of the esophageal wall or left atrial wall of the enlarged heart with the end of an intubation tube or nasogastric tube.

Temporary insertion of a covered self-expandable metal stent to treat esophageal perforation due to endoscopic submucosal dissection

There are no previous reports of esophageal perforation due to endoscopic submucosal dissection developing into pyothorax. We herein describe a case of esophageal healing following perforation in a 60-year-old woman undergoing esophageal endoscopic submucosal dissection. Post-procedural computed tomography revealed pyothorax in the right thoracic cavity, compressing the right lung. The pyothorax did not improve despite treatment with thoracic drainage because the esophageal lumen was connected to the right thoracic cavity. In order to close the site of esophageal perforation, we inserted a covered self-expandable metal stent. The affected site subsequently healed without complications, allowing the drainage tube and stent to be removed.

Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model (with videos)

BACKGROUND

Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC).

OBJECTIVE

Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations.

DESIGN

Comparative animal study.

SETTING

Approved animal facility.

SUBJECTS

Eighteen pigs.

INTERVENTIONS

Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed.

MAIN OUTCOME MEASUREMENT

Long-term survival and histological quality of the repair.

RESULTS

The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure (P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal (P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals.

LIMITATIONS

Animal study of limited size.

CONCLUSIONS

Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.

[A rare cause of haematemesis with fatal gastrointestinal bleeding]

A 73-year-old man was admitted to the hospital due to severe hematemesis and collapse, severe anemia and inflammation. Two months ago, the patient had been treated with antibiotics due to septicemia with staphylococcus aureus. At that time CT scan had shown only thoracic arteriosclerosis. The subsequent high urgency upper endoscopy identified a circular mucosal defect in distal esophagus as bleeding origin. The patient died 10 hours after admission. Performing autopsy, a fistula between the thoracic aortic aneurysm and the distal esophagus was found in the background of severe arteriosclerosis. The rapid onset of an aneurysm with rupture after a bacterial infection is typical for a mycotic aneurysm.

[Rare occurrence of fulminant acid burn of the esophagus]

Peptic ulcer due to Zollinger-Ellison syndrome is a rare entity. In this case report a 55-year-old man had a medical history of esophageal reflux, vomiting, and diarrhea for 10 years. Despite continuous medication with a proton pump inhibitor, no complete recovery from symptoms was achieved. A diagnosis of gastrinoma was at first not considered. After discontinuation of the proton pump inhibitor for only a few days, the strong stimulation of the gastrinoma led to fulminant hydrochloric acid burn of the distal esophagus with iatrogenic or spontaneous perforation at the esophagogastral junction. We describe the operative treatment as a two-stage reconstruction with colon interposition and resection of the primary tumor in the duodenum.

Spontaneous oesophageal perforation

An autopsy was performed on a young adult, who apparently died during his sleep. Mediastinitis was established and empyema was also found in left pleural cavity. The oesophagus examination showed a tear in left side. The lesion occurred in the distal oesophagus and showed the leak communicating freely with the left pleural space. Oesophageal perforation was the source of empyema, resulted from barotrauma to the lower oesophagus during the effort of vomiting. Death caused by septic shock. Boerhaave syndrome is a serious and rapidly fatal spontaneous oesophagus rupture. Forceful ejection of gastric contents in an unrelaxed oesophagus against a closed glottis is the mechanism described. The tear thus produced is vertical. The case report discusses the historical, statistical, pathophysiological, diagnostic and therapeutic aspects of Boerhaave syndrome. The syndrome is a cause of sudden death, which be known by forensic pathologists.

Fatal hemorrhage secondary to ulcerated epiphrenic pseudodiverticulum

A 47-year-old man was found unconscious after experiencing severe hematemesis. He had a history of alcohol abuse, hepatic cirrhosis, and previous episodes of gastrointestinal bleeding. Imaging studies indicated that the left gastric artery was the probable source of bleeding. A severe coagulopathy was also noted clinically. Angiographic embolization of the left gastric artery failed to staunch bleeding, and the patient died shortly after admission. Autopsy demonstrated a large, ulcerated epiphrenic esophageal pseudodiverticulum, the base of which was in close proximity to an esophageal branch of the left gastric artery. Cystic dilatation of adjacent esophageal submucosal glands was also seen. Gelatin embolic material, without associated thrombus formation, was found within the left gastric artery. Esophageal pseudodiverticulosis is an uncommon disorder that may be associated with dysphagia, stricture, and odynophagia. Bleeding and perforation are very rare complications. This case may be the first fatality proven by autopsy to be secondary to esophageal pseudodiverticulosis.

Delayed hypopharyngeal and esophageal perforation after anterior spinal fusion: primary repair reinforced by pedicled pectoralis major flap

STUDY DESIGN

This report documents a case of delayed hypopharyngeal and esophageal perforation after anterior spinal fusion and reviews relevant literature.

OBJECTIVES

Presentation of an alternative solution of primary repair and reinforcement of a delayed esophageal and hypopharyngeal perforation after anterior spinal fusion.

SUMMARY OF BACKGROUND DATA

Anterior plating is generally used for stabilization after cervical spine trauma. Esophageal and hypopharyngeal perforation is a rare but potentially life-threatening complication due to mediastinitis with consecutive septic shock and multiorgan failure.

METHODS

Our patient was operated on after cervical trauma caused by car accident. The neurologic condition did not improve in the postoperative period. About 4 months later, the patient had increasing dysphagia as well as episodes of odynophagia. Flexible esophagoscopy showed a perforation of a part of the plate from the hypopharynx down to the proximal esophagus. Primary repair reinforced by a pedicled pectoralis major flap was done without complications.

RESULTS

Postoperative fluoroscopy as well as endoscopy showed no signs of perforation. Swallowing was possible without any further episodes of dysphagia or odynophagia. Neck movement was unconfined.

CONCLUSIONS

Primary repair reinforced by pedicled pectoralis major flap has been shown to be an alternative in case of combined hypopharyngeal and esophageal perforation due to orthopedic spine stabilization. Advantage of the pectoralis major muscle flap is no functional loss of neck movement.

Abdominal foregut perforations in children: a 10-year experience

PURPOSE

Intraabdominal foregut perforations in children are rare. We conducted a retrospective review with the aim of defining their etiologies, treatment, outcomes, and prognosis.

METHODS

Abdominal foregut perforations treated during a 10-year period were reviewed. Perforations secondary to blunt or penetrating trauma and inadvertent perforations sustained, recognized, and repaired during surgical procedures, were excluded.

RESULTS

Fourteen perforations were identified, including 1 esophageal, 8 gastric, and 5 duodenal perforations. Seven perforations (50%) occurred in the neonatal period. Of the 7 neonates, 3 (43%) were premature. Nine patients (64%) had significant comorbidities. Six (43%) perforations were spontaneous, 5 (36%) were iatrogenic, and 3 (21%) were direct complications of underlying conditions. Primary repair of the perforation was completed in 11 patients (79%), and staged repair in 1 patient. Significant morbidities related to the perforation occurred in 36% of patients. Twelve patients (86%) survived to discharge. The 10 long-term survivors are on full oral feeds.

CONCLUSIONS

Pediatric abdominal foregut perforations have diverse etiologies. Half occur in neonates, evenly divided between term and premature babies. Major comorbidities are common. One third are iatrogenic and potentially preventable. Primary repair should be performed when feasible. Patients who survive the initial complications have excellent long-term outcomes.

Esophageal perforation secondary to angio-invasive Candida glabrata following hemopoietic stem cell transplantation

Esophageal perforation due to Candida glabrata is a rare entity. This organism is uncommonly recognized to be angio-invasive and cause gastrointestinal tract perforation. Herein, we describe a case of invasive C. glabrata infection leading to esophageal perforation in a patient undergoing hemopoietic stem cell transplantation.

Surgical treatment of esophageal perforation

BACKGROUND/AIMS

In spite of the progress made during the last few decades, esophageal perforation continues to carry a serious prognosis. The aim of this study is to present our experience with surgical treatment of esophageal perforation.

METHODOLOGY

Eight patients with esophageal perforation were submitted to surgical treatment with varying time intervals between the perforation and the operation. The surgical technique was individualized according to the location of the perforation and the severity of the local inflammatory and necrotic findings. Follow-up data was obtained by follow-up examination or telephone contact with the family doctors. The medical records were reviewed. The cause, the location and the clinical manifestations of perforation, the underlying esophageal disease, the imaging techniques and other examinations which were used to establish diagnosis, the time interval between the perforation and the operation, the surgical techniques, the outcome, the complications, the duration of postoperative hospitalization, and the late results were analyzed.

RESULTS

The perforation was due to iatrogenic injury in 6 of 8 patients. Underlying esophageal disease was present in 4 patients. The mean time interval between the perforation and the operation was 4.3 days. Primary repair was attempted in 5 patients, exclusion-diversion of the esophagus in 2 and thorough drainage in 1 patient. There was no mortality. Primary closure was achieved in 80% of the patients in whom primary repair was attempted. Seven out of 8 patients were alive 46-150 (mean, 99.12) months after the operation.

CONCLUSIONS

Surgery is the treatment of choice for patients with esophageal perforation including those seen more than 24 hours after the onset of symptoms. The chosen surgical technique depends on the location of perforation and the severity of local inflammatory and necrotic findings.

A rare complication after thyroidectomy: esophageal perforation

A 67 year-old woman with recurrent multinodular goiter was admitted for bilateral near total thyroidectomy. On the postoperative period, a turbid fluid came from suction drain which was due to an esophageal perforation. Esophagoscopy and contrast computerized tomography revealed a perforation in the upper third part of the esophagus. Following nonoperative treatment by restricting oral intake, parenteral administration of antibiotics, and parenteral nutrition for 10 days, the patient has recovered and was discharged without any sequela. We discussed the cause of perforation according to the possible reasons frequently seen in the literature. Among iatrogenic reasons, unsuccessful intubation trials were more common than neck surgery. Key words: Esophagus, perforation, surgery, intubation, thyroidectomy

Esophageal necrosis and perforation of the left main bronchus following photodynamic therapy of esophageal carcinoma

Photodynamic therapy is an effective palliative treatment of esophageal cancer. Minor complications associated with this therapy include pleural effusions, fever or esophageal strictures. In addition to this major complications such as respiratory-esophageal fistula and bronchus perforation have been described. We report here our experience with a patient who developed a complete esophageal necrosis and perforation of the left main bronchus following photodynamic therapy. The surgical and intensive care management of the patient is described and the literature discussed.

Fatal Hemorrhage following perforation of the aorta by a barb of the Gianturco-Rösch esophageal stent

Self-expanding metal stents are an established option in the palliative treatment of malignant stenoses of the esophagus. Herein, we report on a 60-year-old man with a recurrent stenosis that developed 2 months after radiochemotherapy for a squamous cell carcinoma in the middle part of the esophagus. To relieve progressive dysphagia, a Gianturco-Rösch stent (Cook-Z stent, 10 cm, PE-covered, manufactured by William Cook Europe) was implanted. Six weeks later, precipitous massive hemoptysis leading to the collapse and death of the patient occurred. Autopsy showed that a barb in the middle of the stent had perforated the aortic arch, resulting in massive bleeding into the gastrointestinal tract, and aspiration. Although hemorrhage and esophageal perforation are known late complications of all types of metal stents, our case is the first description of a perforation involving a fixation barb. These barbs are a particular feature of the European version of the Cook-Z stent, and are intended to prevent stent migration. In future, any hemorrhage observed after stent implantation should prompt a search for perforation by a barb (autopsy!). If necessary, the European version of the Gianturco Z stent should be modified.

[Mortality from iatrogenic esophageal perforations is high: experience of 54 treated cases]

OBJECTIVE

To underline the severity of instrumental esophageal perforations and to discuss their management.

PATIENTS AND METHODS

Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000.

RESULTS

Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy (n = 24), endoscopic dilation (n = 13), attempted tracheal intubation (n = 5), foreign body extraction (n = 5), treatment of esophageal varices (n = 4), trans-esophageal echocardiography (n = 2), and duodenal prosthesis implantation (n = 1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean = 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones.

CONCLUSION

Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.

Fatal mediastinitis after routine laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now considered a routine operation with a low complication rate. In this case study, the authors present a laparoscopic cholecystectomy patient who died of masked mediastinitis and concomitant septicemia caused by an unrecognized esophageal perforation after difficult intubation. The authors call attention to the need for early detection of perforating mediastinitis to prevent a lethal outcome from this infrequent but life-threatening condition.

Submucosal esophageal dissection--a rare case report

The severity of submucosal dissection is intermediate between transmural rupture and mucosal tear in the esophagus. We describe a case of submucosal dissection of the esophagus with characteristic features of mucosal bridge endoscopically and "double-barreled" in radiography. The patient was successfully treated by intermittent esophageal tamponade of 5-day duration using a Sengstaken-Blackmore tube, and total parenteral nutrition. His course was uneventful in a follow-up period of 5 years.

Fatal upper esophageal hemorrhage caused by a previously ingested chicken bone: case report

Perforation of the upper esophageal wall by ingested bones can cause sudden death and death under suspicious circumstances. Perforation usually takes place at sites of physiologic and pathologic strictures. Temporary bleeding from the respiratory and digestive tracts is an important signal and may be crucial in the diagnosis of esophageal perforation and small vessel injury by ingested bone. Polymorphism and long symptomatology can cause diagnostic and therapeutic failure, thus presenting a special medicolegal problem. We present a case report of unknown cause of death and death under suspicious circumstances resulting from ingested bone perforation of upper esophagus. A chicken bone had been swallowed about 6 months before death caused by hemorrhage from a decubitus in the cervical esophagus. The patient underwent urgent surgery because of suspected bleeding of a ventricular ulcer.

A prospective evaluation of the endoscopic spectrum of overtube-related esophageal mucosal injury

BACKGROUND

Placement of an overtube is required for endoscopic variceal ligation. The spectrum of overtube-related esophageal mucosal injury is unknown. We made a prospective comparison of two types of overtubes and a determination of the frequency, severity, and risk factors for overtube-related injury.

METHODS

Two overtubes (60F, 20 cm, "new" overtube; and 60F, 25 cm, "old" overtube) were used and placed using the bougie-assisted technique. Mucosal integrity was documented before and after variceal ligation. Overtube contact time, bands number, setting (emergent versus elective), type of overtube, degree of coagulopathy, and development of symptoms after variceal ligation were recorded.

RESULTS

Fifty sessions in 29 patients were analyzed; 24% of sessions were emergent. The old overtube was used in 24 sessions and the new in 26. Mucosal injury occurred in 72% of sessions. Mean overtube contact time was 11.58 +/- 0.97 minutes, the mean number of bands placed per session was 6.4 +/- 0.4, and the mean international normalized ratio was 1.47 +/- 0.06. No risk factors correlated with mucosal injury except for the old overtube, which was associated with tears (p = 0.02).

CONCLUSIONS

Mucosal injury related to the overtube is frequent but clinically unimportant. Because mucosal tears occurred significantly more often with the old overtube, we suggest that its use should be avoided.

Esophageal rupture in a patient with idiopathic eosinophilic esophagitis

Idiopathic eosinophilic esophagitis is an extremely rare condition with fewer than 20 cases described in the literature. We present a case presenting as an emergency with esophageal perforation that eventually required subtotal esophagectomy.

The role of trauma in postmortem blood alcohol determination

In postmortem cases, a blood sample is frequently obtained by transthoracic (TT) puncture. The purpose of this study was to determine if, in traumatic death, blood samples collected by TT provided a valid sample for blood alcohol analysis. A retrospective study (1980-1986) was conducted to evaluate possible contamination of blood by GI alcohol in traumatic death cases. Out of 6000 cases reviewed, 19 cses with BACs > 500 mg/dl were found and 8 of these cases involved traumatic death with GI laceration and/or transection. The results of this study support the hypothesis that blood samples from the 8 cases had been contaminated, resulting in a falsely elevated BAC. A transthoracic study (1987-1989) was conducted under controlled conditions, where blood alcohol content of TT blood samples was compared with samples collected from the intact heart chamber. Seven out of 28 cases of traumatic injury revealed trauma to the GI tract. The results showed that when GI traumatic injury occurs and unabsorbed ethanol is present in the stomach, contamination of TT blood samples occurs and artificially elevated BACs are obtained. It is recommended that, in cases of traumatic injury, heart blood samples from the intact heart chamber, as well as samples of additional biological fluids, be collected to rule out the possibility of contamination and to ensure that the BAC used for forensic interpretation is accurate.

[Esophageal perforation by alkalis--a case report with conservative therapy]

In May 1993, a 59-year-old woman attempting suicide with toilet detergent (1% sodium hydroxide) was hospitalized as an emergency case. She developed sudden high fever (38-39 degrees C) on the 26th admission day. Thereafter diagnosis of left pyothorax due to perforation on caustic esophageal ulcer was made. Subsequent to thoracentesis continuous dranage of the left thoracic cavity ceased the fever after three days. Oral intake began on the 28th and extubation of the dranage was done on the 42nd after admission. Following hospital course of the patient was uneventful and the patient was discharged on the 111th day after admission. Esophagofluoroscopy taken at 6 months after discharge revealed no esophageal stenosis, and the patient returned to full social activities in good health.

[Esophageal lesions induced by iron tablets]

Oesophageal injury in the form of ulcers, with deposition of iron salts, was diagnosed histologically in 12 patients over a 3-years period. One patient died following perforation of the oesophagus. Not in any of the patients was the use of iron tablets thought of clinically as a possible cause of the lesion. This appears to be the most likely explanation, however, owing to the fact that the use of iron sulphate tablets of sustained release type was reported by ten out of 12 patients. The patients were all elderly and the majority were bedridden. Any gain from using iron medication in the elderly and bedridden should be weighed against the potential danger related to the use of iron sulphate tablets of sustained release type.

Esophageal necrosis and perforation associated with the anticardiolipin antibody syndrome

The anticardiolipin antibody syndrome has been previously associated with seven cases of gastrointestinal ischemia involving the duodenum, jejunoileum, or colon. In prior cases patients presented with gastrointestinal bleeding, abdominal pain, or an acute abdomen without gastrointestinal perforation. A patient with prior pulmonary emboli, right leg thrombophlebitis, and right popliteal artery thrombosis associated with anticardiolipin antibodies developed fatal esophageal ischemia. Postmortem examination revealed esophageal necrosis and perforation due to esophageal vascular thrombosis, as well as ischemic colitis and numerous other thromboembolic phenomena. This case report extends the gastrointestinal manifestations of the anticardiolipin antibody syndrome by describing esophageal involvement and by reporting the first case of alimentary tract perforation.

[Omental implantation technique for esophageal perforations--a clinical case and experimental studies]

We successfully used the omental implantation technique in a case of esophageal perforation in which simple closure was impossible because of extreme inflammatory changes. Although excellent results have been obtained by this method in gastroduodenal perforations, it has never been used before in cases of esophageal perforations. In this study we subsequently investigated the histological repair mechanism by carrying out animal experiments. Clinical case A 59-year-old male entered our hospital with the symptoms of chest pain and fever after endoscopic therapy for esophageal obstruction by food impaction. He underwent an emergency thoracotomy 54 hours after endoscopy. A perforation of about 2 cm in diameter was observed in the subthoracic esophageal wall which become too weak to close by stitching. This perforation was filled with an omental plug inserted from the peritoneal cavity under laparotomy. The patient recovered and his perforated lesion was completely repaired. Animal experiment In 10 hybrid adult dogs, omental implantation was performed on perforations of more than 1 cm in diameter in the subthoracic esophagus made by electric coagulation. One to four weeks postoperatively, these inserted omentums were observed endoscopically before sacrifice. The implanted omentums were endoscopically observed as elevated lesions after 2 weeks, but they became flat after 3 weeks and the mucosa seemed to be almost normal after 4 weeks. Histological investigation showed that the implanted omentums maintained their original structure accompanied by remarkable inflammatory changes 1 week postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation

Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is due principally to an inability to effectively close the perforation and prevent leakage. From 1982 to 1988, 7 consecutive patients (aged 16 to 73 years) were treated after a delayed diagnosis (26 hours to 25 days) of thoracic esophageal perforation. In all patients, the perforation was closed after debridement with total exclusion of the esophagus (T-tube cervical esophagostomy plus absorbable ligatures applied to the esophagogastric junction and the cervical esophagus distal to the esophagostomy). Radical decortication and wide mediastinal and pleural drainage were also done. Nutritional supply was given through a feeding gastrostomy. Antibiotics were administered according to the results of cultures. All patients survived. Continuity of the esophagus was established by removal of the T tube and spontaneous absorption of the ligatures. Endoscopy and esophagography performed 4 weeks after the initial operation showed a well-healed esophagus without stenosis or leakage in all patients. No secondary thoracotomy or esophageal reconstruction was necessary. No dysphagia was noted during follow-up (range, 12 to 50 months; mean follow-up, 23 months). We conclude that primary closure of the perforation and total esophageal exclusion with the use of absorbable ligatures and T-tube esophagostomy can provide a one-stage operation with good results for repair of thoracic esophageal perforation diagnosed late.

Vocal cord paralysis and oesophago-broncho-aortic fistula complicating foreign body-induced oesophageal perforation

A 61 year old man died after presenting with a 24 h history of haematemesis and haemoptysis, and one year history of hoarseness of voice. Post-mortem examination showed a dental plate eroding through the mid-oesophagus into a bronchus and into the descending arch of the aorta, with scarring suggestive of old perforation. An organized haematoma also involved the left recurrent laryngeal nerve. Vocal cord paralysis may be a manifestation of foreign body-induced oesophageal perforation, which can lead to death from an oesophago-broncho-aortic fistula. Both complications of oesophageal perforation from a foreign body have not to our knowledge been previously reported.

Diagnosis and management of esophageal perforations

Esophageal perforation remains a difficult diagnostic and management problem. Recommendations regarding treatment remain controversial. A 15-year experience with perforation of the esophagus from all causes was reviewed at Louisiana State University and Veterans Administration, Medical Centers (Shreveport, LA). The majority of the injuries involved the thoracic esophagus (28 or 54%), followed by the cervical (21 or 40%), and the intraabdominal esophagus (3 or 6%). Iatrogenic causes constituted most of the injuries (52%), followed by external trauma (23%), barogenic rupture (15%), and ingested foreign bodies (10%). Diatrizoate methylglucamine 66 per cent, sodium diatrizoate 10 per cent (Gastrografin; Squibb, Princeton, NJ) contrast studies and flexible esophagoscopy were performed in 44 and 22 patients, respectively. In the cervical esophagus, contrast studies were more sensitive and specific than endoscopy (P less than .01), but both studies were equally effective as diagnostic methods in thoracic perforations. Cervical perforations were treated with either drainage alone (7 patients) or primary repair with drainage (14 patients) with an operative mortality of 4.8 per cent. Several procedures were used in thoracic perforations, which carried a mortality of 36 per cent and were more lethal than cervical tears (P less than 0.2). Any thoracic esophageal perforation treated more than 24 hours after the onset of symptoms, irrespective of what procedure was used, was associated with a significantly higher mortality than if operated on earlier (P less than .001). Five patients with perforated carcinomas were treated by esophageal resection with no mortality. Significantly higher mortality was seen with a delay in diagnosis, thoracic perforations, and Boerhaave's Syndrome. A subset of patients with perforated carcinomas may benefit from esophageal resection with delayed reconstruction.

Endoscopic and histopathologic features of Degos' disease

The case is reported of a 69-year-old female with atrophic papules on the skin who developed multiple spontaneous intestinal perforations of which she eventually died. The skin lesions in combination with lesions in the gastrointestinal tract are typical for Degos' disease or malignant atrophic papulosis. The characteristic histopathological and endoscopic features of this rare disease are reported. This case demonstrates the importance of routinely performing endoscopy in Degos' disease to detect silent perforation, even in patients without gastrointestinal complaints.

Treatment of oesophageal perforation: a multivariate analysis

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.

Esophagocutaneous drainage to treat late and complicated esophageal perforation

Five patients with complicated esophageal perforation--three with spontaneous rupture, one with dehiscence after resection of a diverticulum, and one with an iatrogenic lesion--were successfully treated by esophagocutaneous drainage of the esophageal perforation. At thoracotomy, after careful debridement and cleaning of the mediastinum and pleura, a T-tube drain was placed in the esophagus through the perforation in addition to pleural drains. A feeding jejunostomy and a gastrostomy was carried out via a separate laparatomy in 4 cases. Postoperatively the patients were managed according to a protocol with subsequent removal of pleural drains, esophageal T-tube and, after esophageal healing, gastrostomy and feeding jejunostomy. Broad-spectrum antibiotics were given initially. Healing was slow but progressive and without major problems. The healing process was followed by repeated contrast swallows. In all cases the esophagus healed without residual stenosis within 8-12 weeks. This method seems to be a way to save the life and the esophagus of patients with esophageal perforations complicated by late discovery or failure of primary repair.

Incidence and pattern of oesophageal perforations in Kenyatta National Hospital

A retrospective study of 42 patients with perforations of the oesophagus during the period 1981-1987 indicated that 57.1% of the perforations were iatrogenic. Diseases of the oesophagus and in contiguous structures and foreign bodies in the oesophagus caused perforations in 31% of the cases. Perforations in 35.7% of the patients were located in the middle third of the oesophagus. The lower and upper thirds were affected in 31% of the patients in each site. The presenting physical signs included tachycardia (78.6%), fever (76.2%) and dyspnoea (59.5%). The main accompanying symptoms were chest pain and coughs in 100% and in 50% of the patients respectively. Radiographic findings showed hydropneumothorax in 40.5% of the cases and consolidation in 38.1% of the patients. Oesophagoscopy was positive in 78% of cases tested while thoracocentesis was positive in all cases that were tested.

Esophageal perforation: a therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Perforation of esophagus after endoscopic variceal sclerotherapy. Incidence and clues to pathogenesis

To determine the true incidence of endoscopic variceal sclerotherapy (EVS)-related esophageal perforation, a retrospective analysis of 900 EVS procedures using sodium tetradecyl sulfate performed on 170 patients during a five-year period (1980-1985) was carried out. Autopsy data of all patients who received EVS and who died (32 patients, 100%) during this period were available to confirm the diagnosis of perforation. Esophageal perforation was confirmed in 5 (2.9%) and was seen in patients with advanced alcoholic liver disease. Importantly, most patients did not manifest features of an esophageal leak, but presented instead as a deterioration in condition and died after a mean (+/- SD) 14 +/- 5.2 days. Analysis of the clinical and EVS data reveals that the risk of developing perforation is high when EVS is performed during active bleeding. The extravariceal location of sclerosant and microabscesses may be important predisposing factors. In our experience large-dose injection, deep ulceration, and balloon tamponade are less likely predisposing factors of this complication.

Complications of fiberoptic gastrointestinal endoscopy--five years' experience in a central hospital

Complications in relation to fiberoptic gastrointestinal endoscopy were recorded prospectively during the five-year period 1980-1984. Diagnostic esophago-gastroduodenoscopy (EGD) had non-fatal complications in ten out of 7,314 procedures (0.14%) and three deaths (0.04%). Therapeutic EGD had non-fatal complications in eight out of 440 procedures (1.8%) and two deaths (0.5%). Diagnostic endoscopic retrograde cholangiopancreatography (ERCP) had non-fatal complications in 15 out of 1,930 procedures (0.8%) and one death (0.05%). Therapeutic ERCP had non-fatal complications in 14 out of 554 procedures (2.5%) and six deaths (1.1%). Diagnostic colonoscopy had non-fatal complications in five out of 3,538 procedures (0.14%) and therapeutic colonoscopy in 21 out of 1,055 procedures (2.0%). There were no deaths in connection with diagnostic or therapeutic colonoscopy. The recommendations based on this series are: Put greater emphasis on a proper evaluation of indications and contraindications. Avoid sedation of patients with respiratory failure. If possible, postpone procedures which may cause bleeding in patients with impaired hemostasis until proper correction has been achieved.