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PubMed1999

[Management of esophageal perforation].

The majority of esophageal perforations is caused by endoscopic procedures, while the spontaneous rupture, also known as Boerhaave's syndrome, is rare. Regardless of the cause the esophageal perforation is an urgent surgical problem. The main diagnostic method is a water-soluble contrast study of the esophagus, probably supplemented by a CT-scan. In case of uncertain diagnosis or localisation eosophagoscopy should be performed. We believe that esophageal perforation should be operated, the factor "time" seems to be important for prognosis. In case of early surgical treatment (within 24 hours) a primary suture is sufficient and safe. Only after a delay in diagnosis with extended mediastinal spillage and necrosis of the esophageal wall the use of autogenous tissue to buttress the esophageal repair may be necessary. Esophagectomy should only be performed for perforated carcinomas. We treated 10 patients in a 4-years-period by primary surgical repair combined with drainage. Nine of them survived, only a 82-years old patient died because of an unresectable perforated esophageal carcinoma.

Adult↗
PubMed1977

Esophageal perforation following the use of esophageal obturator airway.

Two cases of distal esophageal perforation following the use of the esophageal obturator airway are reported. Plain radiograph findings of pneumomediastinum, subcutaneous emphysema, mediastinal widening, or pleural effusion suggest this entity; esophagography should be performed in the appropriate clinical setting. The recognition of this uncommon but serious complication is important because medical and/or surgical management is urgent.

Aged↗
PubMed1991

Transhiatal esophagectomy in the management of perforated esophageal cancer.

Instrumental perforation of esophageal malignancy is best managed by immediate esophagectomy. Transthoracic esophagectomy has been the technique most described in the management of patients with this injury. A recent series reported the successful use of transhiatal esophagectomy with primary cervical esophagogastrostomy in four patients with perforated esophageal cancers. We have also used this technique to treat a patient with instrumental perforation of a distal esophageal cancer. This case is presented to add to the published experience using transhiatal esophagectomy in the management of perforated esophageal malignancy. The merits of transhiatal esophagectomy warrant consideration of this approach as a useful alternative to transthoracic resection in the management of selected patients with perforated esophageal cancer.

Adenocarcinoma↗
PubMed1975

Esophageal perforation: an increasing challenge.

Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.

Abdomen↗
PubMed1995

Reinforced primary repair of thoracic esophageal perforation.

BACKGROUND: Treatment of esophageal perforation, especially when diagnosed late, remains controversial. METHODS: Twenty-eight patients were treated for thoracic esophageal perforation with reinforced primary repair regardless of time of presentation. RESULTS: Fifteen patients were treated early (< 24 hours) with no deaths. Two had contained postoperative leaks, which healed. Thirteen were treated late (mean, 5.5 days) with four deaths (3 with healed repairs). Postoperative leaks occurred in 7 patients; of the leaks, 4 healed, 2 became a controlled fistula, and 1 required reoperation. Primary healing with preservation of the native esophagus was achieved in 25 patients (89%). Among the 18 patients without evidence of sepsis preoperatively, post-operative leaks developed in 2 (11%). Ten patients had evidence of sepsis preoperatively, and postoperative leaks developed in 7 (70%). CONCLUSIONS: Patients who present with sepsis have an increased risk of postoperative leak and therefore should have the repair buttressed. Overall mortality was 14% and no deaths were due to persistent leaks or mediastinal sepsis. Reinforced primary repair retains the native esophagus and avoids the need for later reconstructive operations. In the absence of a nondilatable stricture or cancer, reinforced primary repair should be performed for most thoracic esophageal perforations, early or late.

Aged↗
PubMed1996

Invasive candidiasis complicating spontaneous esophageal perforation (Boerhaave syndrome).

Spontaneous esophageal perforation is a rare condition that frequently results in infectious complications. Empirical broad-spectrum antibacterial therapy is therefore part of the standard management. We describe two patients suffering from spontaneous esophageal perforation who developed invasive candidiasis with hematogenous dissemination. One patient died of multiple organ failure due to Candida sepsis. Preexistent Candida colonization, incomplete mediastinal drainage, broad-spectrum antibacterial therapy, and prolonged intensive care therapy place patients with esophageal perforation at high risk for secondary fungal infection. Intense microbiological searching is mandatory, but the distinction between colonization and infection may be impossible. Empirical antifungal treatment with imidazole derivatives, particularly in patients with potential risk factors, should be considered.

Candidiasis↗
PubMed1995

Current results of therapy for esophageal perforation.

BACKGROUND: Prior reviews of esophageal perforation with delayed recognition have reported mortality rates as high as 66%. We performed a retrospective review of patients with nonmalignant esophageal perforation to assess the outcome of current management techniques. PATIENTS AND METHODS: Charts were reviewed of all patients who were treated for nonmalignant esophageal perforation between 1980 and 1993. They were 23 men and 10 women, mean age 49 +/- 3 years, 19 of whom were diagnosed early (< or = 24 hours) and 14 of whom were diagnosed late (> 24 hours). RESULTS: Perforations were due to instrumentation (16), operative injury (7), spontaneous rupture (4), trauma (4), and other causes (2). Pre-existing esophageal disease was identified in 23 patients (70%), including achalasia (9), stricture (7), varices (5), and other (2). Treatment included closure and fundoplication or muscle wrap (10), closure with or without pleural flap (7), resection only (7), resection and reconstruction (3), drainage only (4), and observation (2). Nonfatal complications included empyema (4), arrhythmia (3), persistent leak following attempted closure (2), and other (5). They occurred in 50% of both the early and late diagnosis groups and were of comparable severity in both. The overall mortality was 9% (3/33). Causes of death were sepsis (1) and multisystem organ failure (2). Mortality was 5% (1/19) in patients diagnosed early and 14% (2/14) of those diagnosed late. CONCLUSIONS: Current mortality rates in nonmalignant esophageal perforation are improved compared to previously published rates of 19% for all patients with the condition, 9% following early and 29% following late diagnosis (47 patients overall). We conclude that, despite a high incidence of associated complications, the survival rate following nonmalignant esophageal perforation is improving and the impact of delayed recognition is decreasing.

Adolescent↗
PubMed2004

Selective approach in the treatment of esophageal perforations.

BACKGROUND: Treatment of esophageal perforation remains controversial and recommendations vary from initially non-operative to aggressive surgical management. Several factors are responsible for this life-threatening event, which has led to more individualized treatment ensuring adequate pleuromediastinal drainage with sufficient irrigation. We analyzed our data, evaluating morbidity and mortality in this selective approach. METHODS: During 1985 to 2001, 17 of the 38 patients with esophageal perforation treated in our hospital underwent primarily a thoracotomy, wide drainage and debridement of chest/ mediastinum and enteral hyperalimentation. Twenty-one patients (55%) initially were treated non-operatively (NPO, nasogastric tube, hyperalimentation, antibiotics and chest tube), but surgery was required in 9 patients (43%). RESULTS: Most perforations were iatrogenic (45%; 17/38) followed by spontaneous perforations (32%; 12/38). Cervical perforations were managed earlier (< 24 h) than thoracic tears, 8/10 (80%) and 17/28 (61%) respectively. Initial conservative treatment failed in all spontaneous ruptures and more in thoracic lesions (62%) than in cervical lesions (13%). Most patients with thoracic perforations and 'free' intrathoracic contamination underwent primary surgery. Surgery with adequate drainage (n = 23) was based on signs of sepsis, empyema and progression of pneumomediastinum/thorax. Mortality occurred in one patient (3%), initially treated conservatively. Median intensive care and duration of hospitalization were not different between the conservative (5 and 7 days, respectively) and the primary surgical approach (21 and 27 days, respectively), but were higher after secondary surgery (13 and 50 days, respectively). CONCLUSIONS: Spontaneous esophageal perforations require early surgical exploration with drainage and irrigation of mediastinum and pleural cavity, while most iatrogenic lesions can be managed conservatively. Cervical perforations can be treated adequately non-operatively, but thoracic perforations often require surgical intervention.

Adolescent↗
PubMed1997

Nonsurgical treatment of esophageal perforations after endoscopic palliation in advanced esophageal cancer.

BACKGROUND AND STUDY AIMS: Iatrogenic esophageal perforation during palliative endoscopic treatment in patients with incurable esophageal or cardiac cancer is a severe complication, associated with a high rate of mortality. The treatment remains controversial, since both nonsurgical and surgical treatment regimens are used. The present study describes a nonsurgical regimen. PATIENTS AND METHODS: Nine cases of perforation occurred in 142 consecutive patients referred for endoscopic palliation of dysphagia, corresponding to a perforation rate of 6%. Laser therapy was the main treatment used (argon plasma coagulation or Nd:YAG photocoagulation). RESULTS: Nonsurgical treatment was successful in six patients (75%). Two patients died (22%) as a direct result of esophageal perforation following endoscopic palliation procedures. CONCLUSION: These findings show an acceptable mortality rate using a nonsurgical treatment regimen involving broad-spectrum antibiotics, nasogastric suction, and parenteral nutrition, with pleural drainage and endoprosthesis placement in addition when indicated.

Aged↗
PubMed1998

Esophageal perforations encountered during the dilation of caustic esophageal strictures.

BACKGROUND: The most common cause of esophageal stricture in children is the accidental ingestion of strong alkalies and the life-threatening complication of dilations for treating caustic esophageal strictures is esophageal perforation. METHODS: During a 25-year period between 1971 and 1996, 195 patients with caustic esophageal strictures underwent repeated dilations program and 34 had 36 complicating perforations (17.4%) at the Hacettepe Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to evaluate the risks, results and outcome of esophageal perforations encountered among strictured esophaguses. Thirty-four patients, of whom 19 were male (56%) and 15 female (44%) with 25 (74%) being younger than 5 years of age, were evaluated retrospectively. RESULTS: There was no relation between the type of therapy against stricture formation and perforation of the esophagus. Seventy-five percent of perforations occurred during antegrade dilations with stiff woven dilator and most perforations (69.4%) occurred in the first, second or third dilations. Esophageal perforation was suspected during dilation procedure in 7 perforations while the remaining 29 were diagnosed following a suggestive clinical course. The diagnosis of perforation was confirmed by chest X-ray, esophagography, and esophagoscopy in 30, 5, and 1 perforations respectively. The treatments included antibiotics, digoxin and drainage through gastrostomy among 13 patients, and additionally chest tube drainage among 12 patients, and additionally feeding jejunostomy among 7 patients while three patients underwent only feeding jejunostomy in addition to antibiotics, digoxin and drainage through gastrostomy. Six patients (18%) died, 6 patients (18%) required esophageal replacement for previous cervical esophagostomy or persisting stricture that impairs swallowing. Esophageal strictures in 22 patients (64%) have been treated by dilations. Redilation therapy started within 3 months following perforation and 68% of patients required 2 to 3 years of chronic dilations to be accepted as normal swallowers. CONCLUSIONS: The esophageal perforations encountered during dilating caustic esophageal strictures present a spectrum from a minimal peri-esophageal leakage to massive rupture with pneumothorax causing mediastinal shift and sudden death. The diagnostic and therapeutic approaches should be individualised according to the place of the patient in this spectrum.

Burns, Chemical↗
PubMed2006

Videothoracoscopic drainage for esophageal perforation with mediastinitis in children.

BACKGROUND: Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. The treatment option for esophageal perforation with mediastinitis is not very clear and still controversial. METHODS: Between April 2000 and March 2004, 6 males and 2 females, with ages ranging from 2 to 6 years (mean, 3.8 years), underwent videothoracoscopic drainage for esophageal perforation with mediastinitis. RESULTS: The mean hospital length of stay for patients in our series was 34.1 days (range, 14-47 days). There was no perioperative mortality. All patients were discharged from hospital without major sequelae. CONCLUSIONS: Minimally invasive videothoracoscopic drainage is a feasible and effective method for esophageal perforation with mediastinitis in children.

Child↗
PubMed1993

Esophageal perforations masked by steroids.

Esophageal perforation is usually an acute, life-threatening event, and its diagnosis can be established on the basis of obvious clinical and radiographic findings. This article describes two cases whereby symptoms of esophageal perforations were masked by concomitant administration of steroids, thus causing marked delay in diagnosis and treatment. Esophageal rupture should be considered when patients receiving steroids develop unexplained fever with pleural effusion or pneumomediastinum, particularly following instrumentation or forceful retching.

Adult↗
PubMed1980

Management of esophageal perforation.

Early diagnosis of esophageal perforation is critical. The importance of performing sufficient surgery at the first procedure whenever possible is emphasized. If early primary closure cannot be achieved, then the initial therapeutic method of choice is resection or diversion followed by reconstruction. Drainage of the perforated esophagus alone does not appear to be satisfactory treatment. Our experience indicates that later elective surgery for the management of patients undergoing successful initial resuscitation from esophageal perforation may be accomplished with an acceptable mortality rate.

Adult↗
PubMed1994

[Surgical treatment of esophageal perforations].

Spontaneous and iatrogenic esophageal perforations continue to present life threatening gastroenterologic emergencies. The results in 17 patients being treated between 1986 and 1992 are presented. In respect to localisation of the perforation, the underlying nature of the disease and the condition of the patient an early suture and wrap in all patients with benign diseases and an early esophagectomy in patients with esophageal cancer was aspired. 11 patients having been treated this way survived whereas 3 of six patients with extensive tumour burden and reduced physical state who had been treated conservatively died during the hospital stay. Thus early diagnosis and operative treatment of esophageal perforations improves patients outcome significantly.

Adult↗
PubMed1997

The diagnosis and treatment of esophageal perforations resulting from nonmalignant causes.

Esophageal perforations are extremely difficult to diagnose and treat. We report herein our results of a review of 26 patients with esophageal perforation which were spontaneous in 11, iatrogenic in 11, and caused by a foreign body in 4. Surgical treatment was performed in 7 of the patients with spontaneous rupture, but the remaining 19 patients were treated conservatively. The abnormality was found by plain radiography (X-ray) in 22 (85%) of the 26 patients, and by computed tomography (CT) in all 13 patients who underwent this procedure. The detection rates by esophagography and esophagoscopy were 100%, or all of 25 patients examined, and 60%, or 9 of 15 patients examined, respectively. Of 12 patients with underlying diseases, 4 (33%) died after the perforation, whereas only 1 (7%) of 14 patients without any underlying disease died. Postoperative empyema developed in all of 3 patients treated by intraoperative unfixed intrathoracic drainage (UID), but in none of the 4 treated by fixed intrathoracic drainage (FID). Conservative treatment achieved satisfactory results for spontaneous esophageal ruptures confined to the mediastinum, and for iatrogenic perforations and esophageal perforations caused by foreign bodies, provided there was no serious underlying disease such as advanced cirrhosis. Moreover, intraoperative FID proved useful in helping to prevent postoperative empyema.

Adult↗
PubMed1995

One-stage primary repair of distal esophageal perforation using fundic wrap.

Esophageal leak following primary repair of esophageal perforation is a serious complication that can lead to severe mediastinitis and sepsis. Complete diversion with esophageal exclusion or resection is designed to minimize further mediastinal contamination. However, this approach is not necessarily associated with less morbidity or mortality. Furthermore, a second stage operation is required to restore esophageal continuity. From 1986 to 1994, we performed a one-stage primary repair of the distal esophagus in seven patients with either iatrogenic (n = 5) or spontaneous (n = 2) perforations and reinforced the repair by a fundic wrap. One patient underwent an additional modified Heller myotomy for achalasia. Delay between perforation and operation was less than 6 hours in 3 patients, 6 to 24 hours in 2 patients, and greater than 24 hours in 2 patients. Only one patient (14%) developed a small esophageal leak that spontaneously resolved with adequate mediastinal drainage, intravenous antibiotics, and aggressive nutritional support. One patient (14%), whose repair was delayed by 12 hours, died postoperatively of profound sepsis. This patient was moribund from sepsis preoperatively, and postmortem examination of the esophagus revealed no evidence of esophageal leak. Esophageal continuity was maintained in all patients. The median length of stay was 21 days (range, 15-58 days). We conclude that primary reinforced repair of esophageal perforation using a fundic wrap is an effective method of treatment for distal esophageal perforation, even when the repair is delayed by more than 24 hours.

Adult↗
PubMedDate not supplied

Nonoperative management of esophageal perforation secondary to balloon dilatation.

Esophageal perforation is usually considered a surgical emergency. However, esophageal perforation after therapeutic endoscopic manipulation is a different entity. This type of perforation occurs in a controlled environment and the perforation is usually detected early. Three documented cases of perforation during endoscopic balloon dilatation are described. They were successfully treated nonoperatively.

Aged↗