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PubMed2005

Management of spontaneous perforation of esophageal cancer with covered self expanding metallic stents.

Optimal management of esophageal perforation is controversial, especially in the presence of malignancy. Esophagectomy has traditionally been employed for patients with malignant perforations. However, in patients with advanced disease, other less invasive treatment options may be of benefit. We present two cases of spontaneous perforation of advanced esophageal cancer successfully managed by insertion of covered self-expanding metallic stents and a review of the literature.

Aged↗
PubMed1989

The treatment of achalasia. A current perspective.

We analyzed the course of 79 adult patients treated for achalasia between 1977 and 1988. Sixty-six patients (84%) had pneumatic dilatation as the primary therapy. Fifty-three patients (80%) had immediate improvement in swallowing. Three patients required immediate redilatation, 2 developed pulmonary aspiration, and 8 (12%) suffered esophageal perforation. Esophageal perforation was treated by closure plus Heller's myotomy in 3 patients, closure only in 3, chest tube in 1, and antibiotics and nasogastric suction in 1. At 4 years' follow-up, 50% of patients who had dilatation remained asymptomatic, 30% had symptoms of gastroesophageal reflux, and 20% had persistent dysphagia. Eight Heller myotomies were performed, with excellent results in 7 and 1 postoperative death from respiratory failure. Seven additional patients with disabling esophageal symptoms after multiple operations for achalasia were ultimately treated by esophagectomy (n = 5), hemigastrectomy and Roux-en-Y gastrojejunostomy (n = 1), and repeated myotomy (n = 1). All recovered and are able to eat solid food. Thus, our experience indicates that pneumatic dilatation remains unperfected (ie, the line between undertreatment and overtreatment is finer than generally recognized), and unless improvements can be made, the role for surgery may need to be reexpanded.

Adult↗
PubMed1996

The leaking esophagus: CT patterns of esophageal rupture, perforation, and fistulization.

Esophageal perforation can be a catastrophic event for a patient regardless of the etiology of the perforation. Contrast esophagrams can typically diagnose an esophageal perforation if the clinical symptoms or history suggest the diagnosis. Often, however, the clinical features are atypical and a CT scan is performed early in the patient's workup. It is, therefore, essential to recognize the CT features seen in esophageal perforation. The various etiologies and CT findings of esophageal perforation are reviewed in this article. The CT abnormalities include extraluminal air, periesophageal fluid, esophageal thickening, and extraluminal contrast. These CT findings may be the first clue to the correct diagnosis of esophageal perforation.

Esophageal Fistula↗
PubMed1988

Treatment of instrumental perforation of esophageal malignancy by transhiatal esophagectomy.

Perforation of esophageal malignancy secondary to instrumentation is an uncommon but catastrophic complication. Esophageal perforation at the site of an obstructing esophageal malignancy precludes simple operative repair and mandates esophageal resection with reestablishment of gastro-intestinal tract continuity. In the past the standard surgical approach has involved transthoracic esophageal resection via thoracotomy. We have successfully treated four patients with perforated esophageal neoplasms by transhiatal esophagectomy and cervical esophagogastrostomy, thus avoiding thoracotomy in high-risk patients. We consider transhiatal esophagectomy an advantageous alternative in the management of selected cases of instrumental esophageal perforation adjacent to an esophageal malignancy.

Adult↗
PubMed1979

Esophageal-atrial perforation due to recurrent esophagitis 18 years after esophageal bypass surgery.

A 62-year-old man presented with a grand mal seizure, progressive abdominal distention, and refractory hypotension 18 years after colonic bypass of a benign stricture of the low middle third of the esophagus. He died 3 hours after admission to the hospital. The patient had a history of liniment ingestion in childhood plus a long history of dysphagia and substernal pain. Autopsy disclosed a large ulcer of the anterior wall of the distal esophagus, which had eroded through the posterior wall of the left atrium. Histologic examination revealed chronic esophagitis with fibrous obliteration of the esophageal wall, pericardium, and left atrial myocardium near the site of perforation. Foreign material was present within small arteries of multiple viscera, and in several of these fragments transverse striations were demonstrated. Esophageal-atrial perforation is a rare but fatal complication of chronic esophageal ulceration. The clinical and pathological features of this and previously reported cases of nontraumatic esophageal-atrial perforation are reviewed.

Esophageal Fistula↗
PubMed1993

Perforation complicating balloon dilation of esophageal strictures in infants and children.

PURPOSE: The authors retrospectively reviewed their experience with balloon dilation of esophageal strictures in infants and children to determine the prevalence of esophageal perforation during this procedure. MATERIALS AND METHODS: Balloon dilation was performed in 32 patients with esophageal stricture due to either congenital or postoperative stenosis. The total number of procedures was 141; each patient underwent one to 12 procedures. RESULTS: Four cases of esophageal perforation occurred during balloon dilation and were detected immediately after the procedure. Perforation in three of these patients was treated nonoperatively with parenteral fluid and antibiotics, and one patient was treated surgically with resection and creation of an anastomosis. The clinical course after treatment was favorable in all cases. CONCLUSION: Although esophageal perforation during balloon dilation of benign strictures has been reported as a rare complication, four perforations were observed in 32 patients. Esophageal perforation can occur in infants and children more frequently than previously reported.

Catheterization↗
PubMed1999

The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas.

Esophageal perforations, Mallory-Weiss tears, and esophageal hematoma involve traumatic injury to the esophagus. These can be iatrogenic, in particular due to esophageal instrumentation, but can also occur spontaneously. The remarkable increase in diagnostic and therapeutic endoscopy as well as esophageal surgery has made instrumentation the most common cause of esophageal perforation. In many instances, spontaneous perforations are associated with retching and vomiting, which causes a sudden increase in intraesophageal pressure. A high index of suspicion leading to rapid diagnosis and appropriate therapy are needed to optimize clinical outcomes. This article focuses on esophageal perforations, Mallory-Weiss tears, and esophageal hematomas, with emphasis on etiology, pathogenesis, clinical presentation, diagnosis, management, and prevention.

Esophageal Diseases↗
PubMed1987

Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis.

Perforation of the newborn child's esophagus or pharynx can mimic esophageal atresia clinically. Fourteen cases of newborn hypopharyngeal or esophageal perforation are presented. In nine cases, esophageal atresia was the initial diagnosis entertained; seven of these on the first day of life. In four others, the diagnosis of a perforated pharynx or esophagus was evident on plain x-ray. Six patients had esophagograms. Two newborns underwent thoracotomies for repair of their initially diagnosed esophageal atresia. Subsequently, esophageal perforation was diagnosed intraoperatively on each and suture repair was undertaken. The 12 remaining neonates were treated nonoperatively. There were four deaths, all in the nonoperative group and three weighing less than 1,000 g. None of the deaths were directly attributable to the perforations. In retrospect, each child presented with one or more early clues to the diagnosis of pharyngoesophageal perforation, which included a history of difficult tracheal or nasogastric intubation, blood in the nasogastric tube, length and course of nasogastric tube inserted, and subtle chest x-ray changes. In these cases, nonoperative treatment is usually successful.

Diagnosis, Differential↗
PubMedDate not supplied

Expandable stents for iatrogenic perforation of esophageal malignancies.

The management of patients with iatrogenic perforation of esophageal cancers is controversial. We reviewed the management of perforated esophageal malignancies at a single institution with a large volume of patients with esophageal cancer. Cases of iatrogenic perforation of the esophagus occurring during a 3-year period were identified from the hospital endoscopy database. Inpatient and outpatient records were reviewed, and subjects were visited to obtain follow-up information. Perforation was suspected after 10 of 492 endoscopic dilatation procedures done in patients with obstructing esophageal malignancies. All patients were diagnosed immediately. One patient with pneumomediastinum and pneumoperitoneum died 7 days after laparotomy. Nine patients with pneumomediastinum were managed endoscopically with delayed (n=1) or immediate (n=8) placement of a self-expanding metal stent. Patients were treated in the hospital for an average of 5.4 days. No patients developed clinical signs of sepsis, and all were discharged tolerating a soft diet. Follow-up data were obtained for seven of nine discharged patients (range 152 to 263 days). None developed signs or symptoms of infection or recurrent dysphagia. Immediate placement of a coated self-expanding metal stent is an effective treatment for iatrogenic perforation of an obstructing esophageal malignancy.

Adult↗
PubMed2000

Incidence and significance of pneumomediastinum after laparoscopic esophageal surgery.

BACKGROUND: Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. METHODS: Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean +/- SEM. RESULTS: Twenty-five men (56%)and 20 women (44%) aged 33.0 +/- 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. CONCLUSION: Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients.

Adolescent↗
PubMedDate not supplied

[Perforation of esophageal cancer (author's transl)].

Perforation of an esophageal cancer can occur spontaneously or during radiotherapy. If the perforation is the first manifestation of the cancer, the diagnosis depends on X-ray and endoscopy. During radiotherapy, the intending perforation must be carefully watched for. We have treated two perforations appearing as first manifestation of the cancer and 3 developed during evolution, 2 of them during radiotherapy. Various treatments have been applied. In 2 cases, resection was possible, curative in one, palliative in the other. In the other 3 cases, retrosternal by-pass has allowed feeding and radiotherapy. Such a complication generally condemns the patient to a gastrostomy. However, a more aggressive surgical attitude can be adopted if the general status of the patient permits. An esophageal endo-prosthesis can also be used.

Esophageal Neoplasms↗
PubMedDate not supplied

New approach to surgical management of early esophageal thoracic perforation: primary suture repair reinforced with absorbable mesh and fibrin glue.

Esophageal perforation is a life-threatening situation and represents a major therapeutic challenge. Results have improved in recent years particularly as a result of progress in antibiotic therapy and the use of total parenteral nutrition. Surgical management retains a predominant role, involving early primary closure and thoracic drainage. We have made an addition to the surgical management by applying an absorbable mesh and fibrin glue to the repaired site. Seven patients (ages 38-79 years) were treated as described. The mean interval from leak to surgery was 28 hours. Six patients had an uneventful postoperative course with a mean hospital stay of 34 days (range 26-45 days). In one case the technique failed and the patient required an exclusion-diversion procedure. All 7 patients recovered without mortality. We believe that this technique provides a real improvement for this precarious esophageal repair.

Adult↗