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PubMed1999

[Esophageal perforation. A rare complication after operation of degenerative and traumatic pathology of the cervical spine].

Esophageal perforation is a rare complication in the surgical treatment of diseases of the cervical spine. Following cervical discectomy for degenerative arthritis at the C6/C7 level, a 42-year-old male patient experienced a progressive dislocation of a PMMA-implant with impending esophageal perforation. Neurological symptoms including dysphagia worsened and a new fusion had to be performed 3.5 months after initial surgery. On the 2nd postoperative day, a laceration of the esophagus was diagnosed clinically and on esophagogram. After drainage, the perforation healed under antibiotic treatment and enteral nutrition through a percutaneous endoscopic gastrostomy within 5 weeks.

Adult↗
PubMed1993

[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)

Animals↗
PubMed2000

[Esophageal perforation and postoperative fistulae of the upper digestive tract treated endoscopically with the application of Tissucol].

We present three patients with serious gastro-esophageal complications which were treated with Tissucol. The first patient developed a rare postoperative oesophago-pleural fistula. The second suffered a traumatic esophageal perforation (possibly iatrogenic) that was discovered at the end of the removal procedure of an alimentary bolus impacted in the distal esophagus. Attempts to close the high output oesophago-pleural fistula with standard treatment were unsuccessful. It was closed with Tissucol at the third attempt, in conjunction with oesophago-jejunal stenosis by means of endoscopic dilatation. In the second patient, early Tissucol application after detection of pneumomediastinum was an effective complementary treatment to the conservative approach and rapidly closed the perforation. The third patient developed a low debit postoperative gastro-cutaneous fistula that did not resolve with conservative treatment. It was closed with only one session of Tissucol sealing. We consider that the endoscopic application of fibrin glue should become the first step in the conservative treatment of small esophageal perforations or postoperative esophageal pleural fistulae, especially in cases of high output fistulae. The success of this technique depends on the localization and selective catheterization of the fistula and on brushing the fistular opening. Total resolution of any distal stenosis is necessary to prevent reopening of the fistula.

Adult↗
PubMed1991

New technique of esophageal exclusion for chronic esophageal perforation.

A new technique of near-total esophageal exclusion was used successfully in the treatment of 2 patients with chronic thoracic esophageal perforation and continuing sepsis. The most striking point of this technique is the use of cervical T-tube esophagostomy with the lower arm of the T tube circumfixed by chromic catgut tie to prevent swallowing of saliva. Whereas most of the previously reported procedures of cervical esophageal diversion require subsequent esophageal reconstruction, this technique is simple and effective and does not require a second operation.

Child↗
PubMed2006

Esophageal perforation: principles of diagnosis and surgical management.

PURPOSE: Esophageal perforation (EP) is still associated with a high mortality rate, even after surgical repair. We reviewed 17 cases of EP to evaluate the management of this major surgical problem. METHODS: We reviewed the medical records of all patients treated for EP in our department between November 2001 and November 2004. Therapy was based on various patient-related factors. RESULTS: Seventeen patients, with a mean age of 63 years, presented with EP mostly caused by iatrogenic incidents (11/17). In nine patients, the perforation was located in the thoracic segment, with a mean size of 2.5 +/- 0.6 cm. Thoracic computed tomography (CT) was performed in all patients to assess the periesophageal inflammation precisely. More than 50% showed signs of systemic inflammation indicative of sepsis, reflected by a dramatic increase in serum C-reactive protein and leukocytosis. Treatment consisted of debridement and drainage (n = 3), primary repair (n = 3), reinforced repair (n = 4), esophageal resection (n = 5), and conservative measures (n = 2). All patients, except for three with pre-existing liver dysfunction and other comorbidities, survived, representing a mortality rate of 17.6% (14/17). An analysis of the literature (2000-2005) revealed an overall mortality rate of 19.7% (101/521), ranging from 3% to 67%. CONCLUSION: Our data support the individualized surgical management of EP, based on careful evaluation of various patient-related factors, including CT findings.

Adult↗
PubMed2000

Boerhaave-mimicking esophageal perforation with subsequent esophagobronchial fistula formation as the primary manifestation of Crohn's disease.

BACKGROUND: Spontaneous ruptures of the esophagus are rare, but may lead to deleterious courses, even if diagnosed early. CASE REPORT: We report a case of Boerhaave's syndrome-mimicking esophageal perforation due to a stricture of the distal esophagus as the primary manifestation of Crohn's disease. Diagnosis was delayed resulting in a complicated clinical course. The presented patient is the first case in the literature with esophageal perforation related to a previously undiagnosed Crohn's disease that lead to stenosis of the distal esophagus before becoming clinically apparent. CONCLUSION: Difficulties in differential diagnosis, problems related to initial misdiagnosis and consecutive mismanagment of spontaneous esophageal perforation, and treatment options including nonsurgical approaches are discussed.

Aged↗
PubMed2006

Conservative management of a three-day-old esophageal perforation with feeding jejunostomy and prokinetic drug.

Spontaneous esophageal perforation is a well-recognized, life-threatening emergency. The spectrum of presentation is a major reason for errors in diagnosis and the failure to institute prompt and imminent management. A case of Boerhaave's syndrome, diagnosed and managed non-operatively in a tertiary center three days after tear, is described. The diagnosis was confirmed with a series of gastrograffin esophagograms which revealed a leak in the lower part of the esophagus, with hydropneumothorax.

Enteral Nutrition↗
PubMed2006

Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures.

BACKGROUND: Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. CASE: A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. CONCLUSION: Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.

Atrial Fibrillation↗
PubMed1999

Pleural empyema: An unusual presentation of esophageal perforation.

A 67-year-old patient presented with pleural empyema as the sole manifestation of thoracic esophageal perforation, 2 weeks after accidental fish bone ingestion. Nonspecific chest pain and general deterioration, unusual presenting symptoms in themselves, accounted for the extreme delay in the diagnosis. The empyema was treated surgically, and the esophageal perforation conservatively. Despite the poor prognostic factors, the patient recovered completely after 50 days in hospital.

Aged↗
PubMed1981

["Spontaneous" esophageal perforation. A rare emergency for surgical treatment].

Spontaneous esophageal perforation is a rare but not-exceptional occurrence. Its polymorphous symptomatology often prevents the early diagnosis. Surgery is the therapy of choice. The treatment is variable according to early or late diagnosis, severity of the lesion and associated conditions such as mediastinal sepsis, hydropneumothorax and loss of water, electrolytes and proteins. The mortality rate among the untreated patients is highest when compared with the treated ones (90-100% versus 28-65%). A conservative approach is justified only in the case of bad general conditions, contraindicating thoracotomy. A wide review of the surgical managements is given.

Emergencies↗
PubMed2003

Aggressive conservative treatment of esophageal perforations in children.

BACKGROUND/PURPOSE: In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has been the usual approach for esophageal perforation (EP) in children. This report aims to assess whether this strategy stands the passage of time. METHODS: We reviewed retrospectively the charts of 17 patients aged 5.3 +/- 0.9 years (mean +/- SD) treated at our institution for EP between 1991 and 2001. RESULTS: Nineteen episodes of EP were caused by stricture dilation in 9 cases, foreign body extraction in 3, and blunt trauma and sclerosis of varices in 2 cases each. The remaining child had multiple gastrointestinal perforations in the course of chemotherapy for leukemia. Vigorous treatment, consisting of nasopharyngeal aspiration, wide spectrum antibiotics, prompt drainage of effusions and either parenteral or infraesophageal nutritition, was implemented immediately after diagnosis. Perforations were closed without direct surgery in 18 of 19 episodes (16 of 17 children). One or more pleural drains were inserted in 12 cases, and pericardial drainage was required once. Seven gastrostomies, 2 jejunostomies, and one esophagostomy were performed. Several major abdominal operations were necessary to repair concomitant lesions in a child who sustained severe blunt abdominal trauma and in the patient with leukemic perforations. All patients survived, and all recovered esophageal function. However, 2 with intractable lye strictures ultimately required esophageal replacement. The only patient in whom a direct approach for esophageal necrosis due to variceal endosclerosis was unavoidable, lost her organ and had a retrosternal colonic interposition after a successful portosystemic shunt. Excluding patients with other concomitant lesions and the patient who underwent surgery, median length of stay was 11 days (range, 6 to 47). CONCLUSIONS: Prompt and aggressive nonoperative treatment of esophageal perforations in children allows survival with conservation of the organ in most cases and remains, in the authors' hands, the first therapeutic choice at this age.

Abdominal Injuries↗
PubMed1991

[Esophageal perforation--indications for surgical therapy].

From January 1, 1970 to April 1, 1990, we treated 32 patients with esophageal perforations. 19 patients underwent surgical repair by bilateral closing suture (n = 10), mucosal suture, extramyotomy and semifundoplication in the presence of achalasia (n = 6). Three patients had subtotal esophagus resection with esophageal graft. Four of these patients died postoperatively, the site of intervention being unremarkable. We lost 7 out of 13 patients from the group subjected to conservative therapy. These results suggest a low risk in the surgical treatment of esophageal perforations when carried out at early stage. The conservative approach on the other hand constitutes an uncalculable risk factor. It should be thus be employed with utmost precaution, e.g. in case of minor perforation only, or in patients with incurable carcinoma.

Adult↗
PubMed2001

Esophageal perforation: a rare complication of Zollinger-Ellison syndrome.

Spontaneous perforation of the esophagus is a rare manifestation of Zollinger-Ellison syndrome (ZES). Failure to recognize its existence can lead to an unsuccessful treatment of the esophageal perforation. We present a rare case of reflux esophagitis-induced esophageal perforation in a patient with ZES. Presence of a gastrinoma should be considered when recurrent or complicated reflux esophagitis is encountered.

Barium Sulfate↗
PubMed2004

Esophageal perforation preceding fatal closed head injury in a child abuse case.

This is a case describing an extensive esophageal perforation in a 15-day-old infant with an unclear mechanism of injury, who at 3 months of age presented as the victim of child abuse from a fatal closed head injury. Extensive esophageal perforation in a neonate or infant is usually induced by trauma, either accidental or non-accidental. When the given history does not correlate with the degree of injury, child abuse must be strongly suspected and a thorough social investigation must be undertaken.

Child Abuse↗
PubMed1996

Mechanisms of gastric and esophageal perforations during laparoscopic Nissen fundoplication.

OBJECTIVE: The purpose of this study was to determine possible mechanisms of 17 gastric and esophageal perforations that occurred during laparoscopic Nissen fundoplication. METHODS: Specific details of each perforation relating to mechanism of injury, surgeon experience, diagnosis, treatment, and outcome were obtained. For each perforation, an attempt was made to accurately determine the mechanism of perforation. RESULTS: Three mechanisms accounted for the 17 perforations, the majority of which occurred within the first ten laparoscopic Nissen fundoplications performed by the surgeon. Ten perforations resulted from injuries related to improper retroesophageal dissection, five occurred during passage of the bougie dilator or nasogastric tube, and two occurred after surgery secondary to suture pullthrough. Six patients received a delayed diagnosis, which adversely affected outcome. Most of the perforations were successfully managed by primary closure and wrap to include the repair. Morbidity was significantly increased for perforations recognized late. One death, attributed to sepsis, occurred in association with a delay in diagnosis. CONCLUSIONS: Gastric and esophageal perforations are serious complications of the new laparoscopic method of Nissen fundoplication. The mechanisms of these complications are specifically related to limitations of the laparoscopic technique. Prevention of these potentially lethal complications requires a full understanding of the detailed anatomy of the gastroesophageal region and awareness of the recognized mechanisms of perforation.

Adult↗