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A report is given on three patients with a perforation of the oesophagus. The treatment was carried out without operative intervention. Also extended non-transmural openings of the perforation close under conservative therapy. The profound diagnosis important for therapeutic considerations is emphasized.
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The authors showed the case of oesophageal perforation during an attempt to remove of foreign body at 37-year-old man. The foreign body (bone) was removed by right thoracotomy.
Oesophageal perforations are a catastrophic event with a 10-40% mortality rate. The decisive prognostic factor is the time from the event to the diagnosis, while there is no agreement as to the therapeutic options. The aim of this study was to present our ten-year experience in the treatment of oesophageal perforations together with an evaluation of the prognostic factors. From January 1995 to January 2005, 18 patients (11 M, 7 F), mean age 49.3 years (range: 22-79), with oesophageal perforations were treated in our department. They were classified according to the cause and localization of the perforation and the time elapsing since the event. The perforation was localised in the cervical oesophagus in 4 patients (22.2%), in the abdominal oesophagus in 4 patients (22.2%) and in the thoracic oesophagus in 10 patients (55.5%). It was spontaneous in 4 patients (22.2%), traumatic in 4 (22.2%) and iatrogenic in the remaining 10 (55.5%). In 7 patients (38.9%), the treatment was started during the first 24 hours from the event, while the remaining 11 (61.1 %) were referred to us more than 24 hours after the perforation occurred. The overall mortality was 27.8% (5 patients). The only decisive prognostic factor was the time of observation: only 1 patient (14.3%) died in the group observed in the first 24 hours, while the remaining 4 who died (36.4%) were in the group treated more than 24 hours after the event (p < 0.05). Our series confirms that the time elapsing from the event to the diagnosis is the only decisive prognostic factor in the treatment of oesophageal perforations. There is no therapeutic option of choice since there is no significant influence of either cause or localisation of the perforation on outcome.
Perforation of the esophagus is life-threatening and requires prompt diagnosis. Immediate surgery with primary suture of the perforation is the treatment of choice. Any delay in diagnosis or treatment results in a sharp increase in mortality due to the combination of rapid development of necrotizing mediastinitis and inability to close the perforation surgically. To avoid leaks from the anastomosis the suture line can be buttressed with adjacent structures. The fundus of the stomach, parietal pleura and muscular flaps have been used to cover the perforation. We describe 2 patients with perforation of the lower esophagus. Both were operated on within 8 hours, the perforation was closed primarily and a diaphragmatic flap was formed to cover the suture line. There were no postoperative leaks and recovery was uneventful.
A case of oesophageal perforation in a newborn is reported. Authors describe the different clinical pictures due to the various sites of perforation. Authors believe that conservative treatment is satisfactory when applied to most oesophageal perforations and operative approach should be employed only in selected cases and after failure of a trial of non-operative treatment.
During 7336 diagnostic and therapeutic endoscopies of the upper gastrointestinal tract 10 perforations of the esophagus were seen (0.14%). After diagnostic X-ray 5 patients were operated and 5 treated conservatively. The precondition for conservative treatment were immediate diagnosis and a covered perforation of the intrathoracal esophagus without communication to pleura or trachea. Treatment consisted in alimentary restriction, parenteral nutrition and high antibiotic therapy. One patient with a esophagotracheal fistula died under conservative treatment. He could not be operated because of advanced tumour disease. The others had an uncomplicated course and, after healing of the perforation, between the 5. and 15. day oral nutrition could be started. It is proved, that the conservative treatment of iatrogenic perforation of the esophagus is a minimal stressing and very successful therapy, if the above-mentioned conditions are followed exactly.
Right empyema developed, apparently secondary to anterior perforation of the esophagus into the right pleural cavity, in a neonate. Pathogenetic factors and management are discussed.
Oesophageal perforation after vagotomy is a quite rare complication. We know figures between 0.4 and 0.8%. The radiodiagnostic verification has central significance for a possibly necessary reoperation, and hence the prognosis of the patient, if this perforation is not recognized under the operation, or necrosis of the wall should happen in the early post-operative phase. We give information about four own observations.
Candidal mediastinitis, like Boerhaave's syndrome, is uncommon, and both, if treated late or incompletely, frequently result in death. Early recognition and aggressive medical and surgical intervention are the best means to convalescence and cure in both conditions.
A newborn infant with traumatic perforation of the esophagus is described. Etiologic factors, clinical presentation, diagnosis and treatment are discussed. The limitation of negative suction pressure used in neonatal resuscitation is emphasized.
Pharyngoesophageal perforation due to blunt external trauma is a relatively rare and unreported injury. A patient is presented with such an injury secondary to assault, and the modes of diagnosis and management are discussed.
Two patients suffered from superior mediastinal masses producing pain and dysphagia. They were investigated using imagery and endoscopy without a definite diagnosis being made. It was finally decided to perform a cervical exploration in both cases and this enabled a diagnosis of perforation of the oesophagus and pseudo-tumoral abscess to be made. The foreign body responsible was found in one case. The symptoms and signs of oesophageal perforation by foreign body may be misleading when they are chronic or delayed. There remains a place for surgical exploration when other methods have failed.
Oesophageal perforations due to foreign bodies are a rare pathology with an increased index of complications. Early diagnosis and treatment can reduce the mortality, which accounts for 28 percent. We report 3 cases of oesophageal perforations due to foreign bodies, 2 of them localized at the cervical level and the 3rd, at the end of the thoracic oesophagus, the later ending ominously.
Transoesophageal echocardiography (TOE) is increasingly used in cardiology, cardiac surgery and intensive care. Its complications are rare. We report a case of perforation of the oesophagus after TOE in a 71-year-old woman, scheduled for an elective aortic valve replacement. Her medical history included arterial hypertension but no pre-existing oesophageal disease. A Hewlett Packard ultrasound imaging system was used, with a 5 MHz single plane probe. After local anaesthesia, the transducer probe was inserted into the distal oesophagus, after three attempts, without any apparent incident. A few hours later, the patient complained of acute cervical and dorsal pain. Examination showed severe skin emphysema in of neck, but neither breathing difficulties, nor haemodynamic modifications. The EKG was normal and body temperature at 38.8 degrees C. The opacification of the oesophagus showed a passage of the contrast medium into the mediastinum. Emergency surgical exploration by left cervicotomy showed a perforation of 2 to 3 cm of the posterior wall of oesophagus, treated with terminal oesophagostomy and drainage. The pressure by the TOE probe on the oesophagus may explain this perforation. The outcome was uneventful. Although TOE is a semi-invasive technique with a low risks its benefit/risk ratio should be considered in each patients before using it.
Perforations of the esophagus require prompt treatment. We have described a patient in whom extrapleural exclusion of a primary repair was used. This procedure, which has not been previously reported, is not technically difficult and is similar to the approach used in the treatment of tracheoesophageal fistula. It allows good mediastinal drainage and prevents pleural soilage by providing an effective buttress to the esophageal repair.
The authors report unusual complications arising from the ingestion of a small fish bone by a 68-year-old man. These included mediastinitis, empyema, pericarditis and septic shock, probably secondary to a small perforation of the esophagus. After appropriate surgical drainage, antibiotic therapy and supportive therapy the patient made a good recovery.
Spontaneous perforation of the esophagus (Boerhaave's syndrome) is an emergency that requires early diagnosis if death or serious prolonged illness is to be averted. The literature is reviewed and the causes of delay in diagnosis are analyzed.