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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↗
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↗
PubMed1991

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.

Aged↗
PubMed2000

[Esophageal perforations. Presentation of 23 cases].

AIM: Esophageal perforations are the most serious perforations of the digestive tract and their treatment remains controversial. The aim of this study was to analyse the outcome of patients with esophageal perforations given surgical and conservative treatment. PATIENTS AND METHODS: Retrospective study of 23 patients with esophageal perforations, 8 cervical (35%) and 15 thoracic (65%). Medical treatment was indicated in patients who fulfilled Cameron's criteria (minimal signs of clinical sepsis; disruption contained in the mediastinum; drainage of the cavity back into the esophagus; minimal symptoms). The remaining patients underwent surgery. RESULTS: Two patients with cervical perforations (25%) met Cameron's criteria. Evolution after conservative treatment was favourable. The remaining patients (75%) were surgically treated: simple closure of the perforation was performed in four and drainage of the cervical abscess in two. Two of the patients who underwent surgery presented pleural hemorrhage, one of which was associated with pneumonia. Four patients with thoracic perforation (27%) met the criteria for conservative treatment. One presented respiratory distress syndrome during treatment and required intensive care. Evolution was favorable in all. The remaining 11 patients (73%) received surgical treatment: in five (46%) simple closure of the perforation was performed, in three (27%) bipolar exclusion was performed and in the remaining patients, other techniques were used. Morbidity was 82% (nine patients) mainly due to pneumonia and mortality was 46% (five patients). CONCLUSIONS: Treatment of esophageal perforation should be individualized. Conservative treatment should be considered in patients meeting Cameron's criteria as their evolution is favorable, with low morbidity and mortality and surgery is not necessary.

Abscess↗
PubMed1980

The management of nonmalignant intrathoracic esophageal perforations.

Eight patients with nonmalignant intrathoracic esophageal perforations recognized more than 48 hours (48 hours to 14 days) after rupture were treated at Toronto General Hospital between 1973 and 1978. Perforation was due to postemetic rupture in 7 patients and to instrumentation in 1. The patients were seen with pain (8), vomiting (7), fever (7), shock (4), respiratory insufficiency (5), pleural effusion (7), pulmonary infiltrates (7), and leukocytosis (6). All patients were managed with thoracotomy. Direct suture closure of the perforation was carried out in 4 patients with midesophageal perforations. Postoperative localized leaks developed in 2 of these patients but healed with conservative management. Cervical esophagostomy and esophageal diversion were used in 1 patient in whom a severe empyema developed in the postoperative period. Direct suture closure, reinforced with a gastric patch, was used to close three lower esophageal perforations. None of these patients had a postoperative leak but all developed subsequent reflux esophagitis. All 8 patients survived. In patients with delayed recognition of a nonmalignant intrathoracic esophageal perforation, elimination of continued chemical and bacterial contamination can be achieved by a clear definition and closure of the esophageal mucosal margins. The obliteration of potential pleural spaces by good tube drainage, lung decortication, and the elective use of mechanical ventilation with positive end-expiratory pressure decreases the incidence of uncontrolled intrapleural sepsis.

Adult↗
PubMed1997

Management of esophageal perforations after therapeutic upper gastrointestinal endoscopy.

BACKGROUND: Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management. METHODS: From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed. RESULTS: Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82%; only two patients died, both of whom had underlying malignant disease. CONCLUSIONS: The current concept in management of esophageal perforations comprises surgical as well as medical treatment. In well-selected cases, non-operative treatment can be considered with favorable results.

Aged↗