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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↗
PubMed2006

Detection of esophageal perforation using intraesophageal dye injection.

OBJECTIVES: Esophageal perforation complicating anterior cervical spine surgery is a potentially fatal complication. Early identification and immediate treatment may lower adverse effects for the patient. The purpose of this study is to assess the efficacy of intraesophageal dye injection to detect an esophageal injury and to test two novel techniques. METHOD: Ten cadaveric specimens were dissected using an anteromedial Smith-Robinson approach. Each was sequentially tested by a control and three dye injection techniques: technique A: nasogastric tube alone; technique B: nasogastric tube plus a distally placed Foley catheter; technique C: proximal plus a distally placed Foley catheter. Each technique was tested against esophageal perforations created by needle puncture (21-gauge, 18-gauge, and 14-gauge) and by a 2-mm high-speed burr. Dye visualization was independently graded as present or absent by two authors. RESULTS: In the control trial, no dye leak was visualized in any of the 10 specimens. In technique A, 0 of 10 21-gauge perforations, 1 of 10 18-gauge perforations, 2 of 10 14-gauge perforations, and 6 of 10 burr perforations were visualized. In technique B, 1 of 10 21-gauge perforations, 8 of 10 18-gauge perforations, 9 of 10 14-gauge perforations, and 9 of 10 burr perforations were visualized. In technique C, 0 of 10 21-gauge perforations, 9 of 10 18-gauge perforations, 10 of 10 14-gauge perforations, and 7 of 10 burr perforations were visualized. CONCLUSIONS: The study suggests that intraesophageal dye injection via nasogastric tube alone should not be relied upon to exclude the presence of esophageal perforation. Two novel techniques showed an improved, though limited, capability of detecting esophageal perforations.

Cadaver↗
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↗
PubMed1999

[Management of thoracic esophageal perforation].

OBJECTIVE: To compare surgical management of esophageal perforation on thoracic portion with nonoperative management. METHODS: Seventeen patients were treated for thoracic esophageal perforation at our department between 1962 and 1996. Among them, seven patients underwent nonoperative management. The remaining 10 had operative procedures (primary repair in 5, esophagostomy in 3, and drainage alone in 2 cases). RESULTS: Postoperative leakage occurred in 2 patients; among the two leakages, 1 required cervical esophagostomy, and 1 became a controlled fistula needed pleural drainage and feeding jejunostomy. One patient had anastomotic narrowing after esophagostomy. Of patients with nonoperative management, five survived (with 28% in-hospital mortality rate), Whereas only one patient, who was treated by surgical procedure, died (with 10% inhospital mortality rate). The mean hospital stay in nonoperative and operative group were (28.3 +/- 12.9) days and (57.6 +/- 52.7) days respectively. CONCLUSIONS: The clinical observation suggested that rapid diagnosis of thoracic esophageal perforations is essential and once the diagnosis of esophageal perforation is established, a appropriate management must be selected promptly.

Adult↗
PubMed1987

Surgical management of esophageal perforation.

The recognition and management of esophageal perforation remain a problem. Diagnostic and treatment delays are common, and controversy continues regarding approaches to surgical intervention. Overall survival has increased with improved adjunctive modalities; however, morbidity and mortality remain high. A total of 115 consecutive cases of nonmalignant esophageal perforation were reviewed. There were 69 thoracic, 27 cervical, and 19 abdominal perforations. Etiology of the perforations was iatrogenic in 65 patients, traumatic in 28, and spontaneous perforation in 22. Symptoms included pain (71%), fever (51%), dyspnea (24%), and crepitus (22%). Contrast roentgenography was used in 78 patients and demonstrated the perforation in all but two patients. All but 20 patients had operations. In the last decade, the survival rate was 11.4 per cent for patients treated within 24 hours of perforation. Survival significantly improved in the last 10 years because of hyperalimentation, cardiopulmonary monitoring, and better antibiotic coverage. Treatment of choice is primary closure with drainage, regardless of the duration of the perforation. In selected patients who have cervical esophageal perforation, nonoperative management has a role.

Esophageal Diseases↗
PubMed2000

Esophageal perforations after anterior cervical surgery.

An esophageal perforation after anterior cervical surgery is an uncommon but well recognized complication. During the past 25 years, 44 patients have presented to Craig Hospital (Rocky Mountain Regional Spinal Injury Center) with esophageal perforations; this is the largest series reported to date. There were 34 patients whose esophageal injury was related to the operations performed for cervical fractures, of which 28 patients had plate and screw fixation. The most frequently occurring clinical symptoms were that of neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. The most common clinical findings were an elevated temperature, localized induration and neck tenderness, crepitus or subcutaneous air in the neck and anterior chest wall, an unexplained tachycardia, and blood in the nasogastric tube. Imaging studies indicated an esophageal injury in only 32 (72.7%) patients. Twenty-two patients experienced cervical osteomyelitis or an abscess of the neck. Nonoperative treatment is fraught with a high mortality, and 42 patients required surgical repair of their esophageal injury. The length of hospital stay averaged 253 days. Successful management of esophageal perforations depends on the physicians' awareness of the causes, prompt recognition of the symptoms and clinical findings, and immediate institution of treatment.

Adolescent↗
PubMed2003

Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae.

BACKGROUND AND AIMS: Esophageal perforation is associated with high morbidity and mortality. Surgery and drainage are considered primary management. Conservative management is an option in a select group. Conservative treatment requires drainage, control of infection, nutritional support, and considerable patience. METHODS: We describe 3 cases in which endoscopic metallic clips were placed to close mature perforations with associated fistulae. All 3 patients underwent mucosal approximation of the defects under direct endoscopic visualization. RESULTS: A review of the literature revealed only 4 other reports of the use of endoclipping for esophageal perforation, one diagnosed immediately, a second within 24 hours, a third diagnosed after 2 days and endoclipped after prolonged mediastinal drainage, and a fourth believed to be chronic. The cases presented here represent well-established, mature defects. CONCLUSIONS: Endoscopic treatment of mature esophageal perforation with metallic clips can be performed to promote closure. In combination with other conservative medical efforts, this method can be used safely and effectively for selected patients.

Aged↗
PubMed1977

Pericarditis with effusion complicating esophageal perforation.

Among 24 patients with esophageal perforation treated during the past 6 years, 3 patients developed pericarditis with effusion as a life-threatening complication. In the first patient pericarditis was found at autopsy, the diagnosis having been suspected but not proved during life. In the other 2 patients pericardial decompression was performed and both survived. Common denominators in the 3 patients were delayed diagnosis and treatment of the perforation, with resultant empyema. Further, the diagnosis of pericarditis with effusion was difficult and delayed, because mediastinitis and associated pleuritis and pneumonia obscured the cardiac silhouette on chest roentgenogram. It is recommended that a high index of suspicion of pericarditis be maintained in patients with esophageal perforation, especially in those in whom the perforation is diagnosed late.

Adult↗
PubMed1983

Esophageal perforation. An unusual presentation of esophageal lymphoma.

A primary histiocytic lymphoma arising in the esophagus and its resultant spontaneous perforation is reported in a 69-year-old female. To our knowledge esophageal perforation occurring as a complication of a primary non-Hodgkin's lymphoma of the esophagus has not been previously reported.

Aged↗
PubMed1994

Esophageal perforation caused by coin ingestion.

Esophageal perforation and acquired tracheoesophageal fistulae (ATEF) are rare sequelae of foreign body ingestion in the pediatric population. Here we discuss the cases of two patients with esophageal perforation caused by prolonged impaction of a coin; in one case, a tracheoesophageal fistula developed. The presence of aerodigestive symptoms and signs in infants and small children should prompt physicians to consider foreign body ingestion and the presence of an ATEF. Clinical presentation, diagnostic modalities, and technical considerations for surgical management are outlined.

Child, Preschool↗
PubMed2004

Esophageal perforation: the importance of early diagnosis and primary repair.

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.

Adolescent↗
PubMedDate not supplied

A rational surgical approach for intra-thoracic esophageal perforation.

The surgical experiences of intrathoracic esophageal perforation in 17 consecutive cases seen during the last eight years are reviewed. Using a rational approach to this critical condition, the mortality and morbidity rates were lower than before. For acute perforation in a corrosive-injured esophagus, subtotal esophagectomy by eversion stripping was an effective procedure for life saving. For acute perforation of a normal or chronic fibrotic but functional esophagus, early primary repair was usually successful for healing. For chronic esophageal perforation, usually complicated by mediastinal abscess or purulent pleural effusion, an adequate local drainage or supplemented with a newly designed, temporary diversion procedure for drainage of saliva and gastric acid was recommended.

Adult↗
PubMed1997

Functional outcome after surgical treatment of esophageal perforation.

BACKGROUND: The functional results after treatment of intrathoracic esophageal perforations have been poorly documented. METHODS: A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed. RESULTS: Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%). CONCLUSIONS: In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a "normal" esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.

Adult↗
PubMed1983

Esophageal perforation associated with combined use of the Thumper Resuscitator and esophageal airway.

Esophageal perforation is an uncommon but catastrophic complication of resuscitation with the esophageal obturator airway. Three cases of esophageal perforation are reported associated with combined use of an obturator airway and Thumper mechanical resuscitator. The possibility of increased risk when these devices are used together has not been previously discussed in the literature. This risk may be reduced by using lower balloon volumes, less aggressive compressor settings, and obturator airways modified for nasogastric drainage.

Aged↗
PubMed1987

[Spontaneous and other non-tumor-induced esophageal perforations].

The outcome of esophageal perforation is determined by the cause and localisation, but mainly by the time lapse between trauma and therapy. Spontaneous and intraoperative ruptures are most dangerous. Treatment of choice is direct closure and drainage. If this is not possible, esophagectomy or exclusion and diversion in continuity should be considered. The injury may present itself with rather unspecific symptoms. Pathological findings in the plain chest roentgenogram and gastrographin study will confirm diagnosis in nearly all cases.

Adolescent↗
PubMed2003

Esophageal perforation and mediastinitis from fish bone ingestion.

Esophageal perforation is a serious condition with a high mortality rate. Successful therapy depends on the size of the rupture, the time elapsed between rupture and diagnosis, and the underlying health of the patient. Common causes of esophageal perforation include medical instrumentation, foreign-body ingestion, and trauma. A case of esophageal perforation due to fish bone ingestion in a 70-year-old diabetic male is described here, with a review of the pertinent literature. The patient presented with odynophagia after a meal that included fish. Initial evaluation was nondiagnostic and the patient was discharged home. The patient returned 12 days later with fever, generalized weakness, and persistent dysphagia. Esophageal biopsy of a necrotic ulcer revealed foreign material with acute inflammatory changes. Computed tomography scan demonstrated a pneumomediastinum. The patient became hemodynamically unstable and died on the third hospital day.

Aged↗
PubMed2005

Treatment of esophageal perforation in a referral center in taiwan.

PURPOSE: The high mortality associated with esophageal perforation can be reduced by aggressive surgery and good critical care. We report our experience of treating esophageal perforation in a clinic in Taiwan. METHODS: The subjects were 28 patients who underwent surgery for a benign esophageal perforation. RESULTS: The esophageal perforation was iatrogenic in 11 patients, spontaneous in 8, and caused by foreign body injury in 9. Most (22/28) of the patients were seen longer than 24 h after perforation, and 77% had empyema preoperatively. The perforation was located in the cervical area in 5 patients and in the thoracic esophagus in 23. We performed primary repair in 24 patients, esophagectomy in 3, and drainage in 1. Leakage occurred after primary repair in ten (41%) patients, resulting in one death, and two patients died of other diseases. Postoperative leakage prolonged the hospital stay but had no impact on mortality. Overall survival was 90%. Univariate analysis revealed that age, timing of treatment, and cause and location of the perforation influenced outcome, but multivariate analysis failed to identify a predictor of mortality. CONCLUSIONS: Early diagnosis and intervention are crucial to prevent morbidity and mortality in patients with esophageal perforation. Primary repair is feasible even if the diagnosis is delayed.

Adult↗