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PubMed1989

[Boerhaave syndrome, as a cause of acute abdomen].

Boerhaave's syndrome, or spontaneous esophageal perforation, is an infrequent entity with an elevated morbidity and mortality. Its clinical manifestations are such that an extensive differential diagnosis with other entities in necessary, but diagnostic delay worsens the prognosis. We present a new case of Boerhaave's syndrome, that debuted as a picture of acute abdomen which led to the realization of an exploratory laparotomy that failed to evidence the esophageal perforation.

Abdomen, Acute↗
PubMed2001

Evaluation of minimally invasive approaches to achalasia in children.

BACKGROUND: Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical intervention. This report describes the authors' experience with thoracoscopic (TH) and later laparoscopic Heller (LH) myotomy for definitive treatment of this disease. METHODS: Nine patients with achalasia were referred for surgical therapy. Ages ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergone at least one dilatation with recurrence of symptoms. The first 4 were treated by TH and the last five by LH. The 5 LH procedures also included a partial fundoplication. RESULTS: All procedures were completed successfully using minimally invasive techniques. Operating times averaged 95 minutes for TH and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 day and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after operation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophageal reflux (GER). CONCLUSIONS: Minimally invasive Heller myotomy is a safe and effective procedure in children. TH results in a slightly longer operating time and hospital stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children.

Adolescent↗
PubMedDate not supplied

Dilation of esophageal strictures: comparative morbidity of antegrade and retrograde methods.

A total of 687 dilations of esophageal strictures were performed on 59 patients in the operating room over a 17-year period. Seventy-nine percent of the strictures were secondary to caustic ingestion and 89% of the dilations were in these patients. Antegrade dilations were performed 389 times and retrograde dilations were performed 298 times. Esophageal perforation occurred seven times with antegrade dilations. There were no perforations with retrograde dilations. The retrograde method using Tucker bougies is the safest and most successful method of dilating severe strictures.

Adolescent↗
PubMed2003

Endoscopic balloon dilatation of esophageal strictures in infants and children: 17 years' experience and a literature review.

PURPOSE: Whereas endoscopic balloon dilatation (EBD) of benign esophageal strictures is an established mode of therapy in adults, this has not been accepted universally in the pediatric population. The aim of this study is to report the safety, efficacy, and long-term results of EBD for children in the authors' center. METHODS: Between 1986 and 2002, a total of 77 children (median age, 1.8 years; range, 2 months to 20 years) were treated by EBD for various causes: 2 had achalasia, and 75 had esophageal strictures (postesophageal atresia repair, 63; reflux esophagitis, 7; postfundoplication, 2; caustic injury, 3). Dilatations were performed using flexible endoscopy and fluoroscopic screening under general anesthesia. RESULTS: A total of 260 dilatations were carried out with the mean number of EBD per patient being 3.4 (range, 1 to 19). A mean period of 5 months (maximum, 28 months) for each patient was required. Four complications of esophageal perforations (1.5%) were observed, but only one required surgical repair because of persistent leakage. The remaining patients have undergone long-term follow-up (median follow-up, 6.6 years), and all are asymptomatic. CONCLUSIONS: This large series has shown that EBD can provide a safe and effective mean of relieving esophageal strictures with good long-term results.

Adolescent↗
PubMed2006

Minimally invasive enucleation of esophageal leiomyoma.

BACKGROUND: Leiomyoma accounts for 70% of all benign tumors of the esophagus. Open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have recently emerged as interesting alternatives. To date, only case reports or very small series of such techniques have been reported. The authors report their experience over the past decade. METHODS: Between January 1999 and August 2005, 11 patients (6 men and 5 women; median age, 44 years) underwent surgery after presenting with dysphagia, chest pain, or heartburn. The surgical approaches included right video-assisted thoracoscopy (n = 7) for tumors of the middle lower third of the esophagus and laparoscopy (n = 4) for tumors within 4 to 5 cm of the lower esophageal sphincter or located at the gastroesophageal junction (GEJ). Intraoperative endoscopy with air insufflation during enucleation was used to confirm mucosal integrity and safeguard against esophageal perforation. Reapproximation of the muscle layers was performed after tumor enucleation to prevent the development of a pseudodiverticulum. A Nissen or Toupet fundoplication was added for patients undergoing laparoscopic enucleation of the leiomyoma. RESULTS: The median operative time was 150 min. All tumors were benign leiomyomas (median size, 4.5 cm). One leiomyoma located at the gastroesophageal junction required intraoperative mucosal repair with three stitches for an esophageal perforation (preoperative biopsies had been taken). There were no major morbidities, including deaths or postoperative leaks. The median postoperative hospital stay was 6 days. All the patients were free of dysphagia during a median followup period of 27 months. One patient had a small (< 2 cm) asymptomatic pseudodiverticulum at the 6-month follow-up endoscopy. CONCLUSIONS: Video-assisted enucleation of esophageal leiomyoma can be performed effectively and safely with no mortality and low morbidity. Thoracoscopic and laparoscopic techniques for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with minimally invasive surgery.

Adult↗
PubMed1976

Cerebral embolization resulting from esophageal-atrial fistula.

A rare but catastrophic complication of nontraumatic esophageal perforation is the formation of an esophageal-left atrial fistula. Although surgical correction of this condition should be possible, failure to recognize it antemortem has thus far prevented such intervention. A woman with long-standing severe esophagitis, was admitted with hematemesis and acute neurologic abnormalities that progressed to coma and death. A similar picture of chronic esophagitis terminating in uppergastrointestinal-tract bleeding accompanied by neurologic signs was seen in the three previously reported cases as well. Recognition of this symptom complex should permit future cases to be diagnosed clinically, and, it is hoped, corrected.

Adult↗
PubMed2004

Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia.

AIM: Achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES) has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation remains the first choice of treatment. The aims of this study were to determine the long term clinical outcome of treating achalasia initially with pneumatic dilatation and usefulness of pneumatic dilatation technique under endoscopic observation without fluoroscopy. METHODS: A total of 65 dilatations were performed in 43 patients with achalasia [23 males and 20 females, the mean age was 43 years (range, 19-73)]. All patients underwent an initial dilatation by inflating a 30 mm balloon to 15 psi under endoscopic control. The need for subsequent dilatation was based on symptom assessment. A 3.5 cm balloon was used for repeat procedures. RESULTS: The 30 mm balloon achieved a satisfactory result in 24 patients (54%) and the 35 mm ballon in 78% of the remainder (14/18). Esophageal perforation as a short-term complication was observed in one patient (2.3%). The only late complication encountered was gastroesophageal reflux in 2 (4%) patients with a good response to dilatation. The mean follow-up period was 2.4 years (6 mo - 5 years). Of the patients studied, 38 (88%) were relieved of their symptoms after only one or two sessions. Five patients were referred for surgery (one for esophageal perforation and four for persistent or recurrent symptoms). Among the patients whose follow up information was available, the percentage of patients in remission was 79% (19/24) at 1 year and 54% (7/13) at 5 years. CONCLUSION: Performing balloon dilatation under endoscopic observation as an outpatient procedure is simple, safe and efficacious for treating patients with achalasia and referral of surgical myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilatations.

Adult↗
PubMed1999

Conservative treatment of caustic esophageal injuries in children: 20 years of experience.

The authors present their experience in the medical treatment of 1, 296 caustic esophageal injuries in children over the last 20 years in two study groups, one comprising the period up to 1989 and the other 1990 to 1996, comparing the different treatments used in each group. The treatment was based fundamentally on dilatations with anterograde mercury bougies, Savary bougies, or retrograde thread-guided bougies with gastrostomy. Pneumatic balloons or stenting procedures have also been employed in the last 3 years. Early fiberendoscopy was used systematically in the second group, which provides a more accurate evaluation of the esophageal lesions. Antibiotic coverage was done systematically during the first 10 days in all serious cases, while steroids were employed routinely only in the last 3 years. The results were similar in both groups, with a dilatation average of 32 in the first and 30 in the second group and an initial dilatation interval of 3 to 4 weeks in both. Using updated exploration and dilatation techniques, we drastically reduced the number of gastrostomies needed for retrograde thread-guided dilatations from 51 in the first group to 5 in the second, consequently improving the patients' life quality. There was no mortality and only five esophageal perforations, which did not require surgical treatment.

Anti-Bacterial Agents↗
PubMed1999

Combined use of steroid, antibiotics and early bougienage against stricture formation following caustic esophageal burns.

BACKGROUND: If an esophageal burn is diagnosed, the aim is to prevent stricture formation. The combined use of steroid, antibiotics and early bougienage (SAEB) is one of the currently used treatment protocols. The effect of SAEB treatment against stricture formation following caustic esophageal burn has been evaluated retrospectively. METHODS: Forty-nine children of 282 admitted with a history of caustic substance ingestion were found to have esophageal burns. Forty-nine children underwent treatment against stricture formation. SAEB was begun within 48 hours of ingestion. RESULTS: Eight children of 12 who ingested sodium hydroxide and five children of 20 who ingested acids developed strictures in spite of the therapy. Additionally two esophageal perforations were encountered in patients who ingested sodium hydroxide. CONCLUSIONS: This protocol has been found to carry a risk of perforation without preventing stricture formation after strong alkali ingestion. Therefore other treatment modalities for preventing strictures should be evaluated especially in children who have ingested products containing strong alkalis.

Anti-Bacterial Agents↗
PubMedDate not supplied

Pharyngoesophageal intubation injuries: three case reports.

The hypopharynx and cervical esophagus are particularly vulnerable to intubation trauma. Contributing factors include hasty intubation by inexperienced personnel; the use of curved, beveled endotracheal tubes containing stylets; malpositioning of the head, and the application of cricoid pressure. Iatrogenic pharyngoesophageal perforations may go unsuspected until characteristic signs and symptoms are recognized. These include cervical pain, fever, dysphagia, leukocytosis, subcutaneous emphysema, and pneumomediastinum. We present three cases that illustrate important points in recognizing, evaluating, and treating pharyngoesophageal perforations. The third case presents a chronic cervical esophageal perforation with secondary pseudodiverticulum, requiring resection of the pseudodiverticulum and a primary sternocleidomastoid muscle flap repair of the cervical esophageal defect. To our knowledge, this technique has not previously been reported.

Adult↗
PubMedDate not supplied

Surgical management of severe peptic esophageal stricture in children.

BACKGROUND/AIMS: In spite of the well-established treatment of gastroesophageal reflux in children, the surgical management of peptic esophageal stricture remains controversial. Previous studies adopted various treatment protocols and included strictures with various degrees of severity. In this study, we selectively reviewed children with severe peptic strictures with various degrees of severity. In this study, we selectively reviewed children with severe peptic strictures treated with a specific treatment protocol of preoperative esophageal dilatation, Nissen's fundoplication and postoperative dilatation. METHODOLOGY: We reviewed medical records of all patients with severe peptic esophageal stricture treated by the above-mentioned protocol at King Khalid University Hospital, Riyadh between 1995 and 2000. Data collected included the following: presenting symptoms, methods of diagnosis and the outcome of therapy. RESULTS: Ten consecutive patients who were treated for severe reflux esophageal strictures were included. Their age at surgery ranged between 2 to 12 years (mean, 5.6 years). All patients had a trial of medical treatment which failed to give any improvement of symptoms. Subsequently, all patients underwent a protocol of preoperative esophageal dilatation, Nissen's fundoplication and finally postoperative dilatation. Two patients had esophageal perforations: one by the flexible endoscope during the preoperative assessment and the other during preoperative dilatation. There were no mortalities. Eight patients showed marked improvement in their clinical symptoms and complete resolution of strictures radiologically and the remaining two showed significant improvement clinically and radiologically. The average follow-up period was 3 years (range, 1-5 years). CONCLUSIONS: We conclude that preoperative dilatation, Nissen's fundoplication, and postoperative dilatation is an effective approach to treat severe pediatric peptic esophageal strictures. Other aggressive approaches described in the literature such as resection and/or replacement of the stricture are rarely indicated even for the most severe strictures.

Child↗
PubMed1991

[Treatment of perforation of the cervical esophagus during diagnostic endoscopy].

Early diagnosis of esophageal perforation is critical. We believe that the treatment of each case must be individualized. The management of perforation in our series has been "conservative" in two cases, for small perforations; and "operative", suture closure and drainage, in the remainder, for a large perforation with contamination of the mediastinum.

Aged↗
PubMed1995

Breast carcinoma metastatic to the esophagus: clinicopathological and management features of four cases, and literature review.

Dysphagia due to esophageal metastases from primary breast carcinoma is an unusual entity. In this series of cases, we describe the clinical features of dysphagia due to metastatic esophageal lesions in four patients (with a primary diagnosis of breast cancer made 8-22 yr previously). We provide the first endoscopic ultrasound characterization of metastatic lesions to the esophagus from breast carcinoma. Endoscopic management of these strictures with both bougienage and balloon dilation techniques resulted in esophageal perforation in three of our four patients. We believe that endoscopic ultrasound is helpful in the diagnosis of metastatic breast cancer to the esophagus. However, endoscopic dilation of these strictures should be done gently and only after other treatment options have been carefully considered.

Aged↗
PubMed1997

Indications, new surgical technique and results of colon interposition or bypass in esophageal surgery.

Over a 5-year period, 29 patients with esophageal disease underwent colon interposition or bypass. The indication was cure of cancer in 11 patients, who underwent earlier a gastric resection. Other indications was benign stricture in 7 patients, bypass for unrespectable cancer in 6, having a caustic injury in 3 and after an esophageal perforation in 2. In 14 patients the left colon, in 15 the right colon was used. The colon was transected without dividing the mesentery other than just along its mesenteric border. This preserves additional blood supply from the marginal artery, also improves the function of the graft in transporting food. Anastomosis leakage occurred in 4 cases (13.7%). Graft necrosis occurred in 2 of 29 patients, one of whom alter underwent a successful second reconstruction. The 30 day operative mortality rate was 13.7%. A colon interposition provides good quality of deglution, and is the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival, or when the stomach is unsuited for replacement or bypass.

Anastomosis, Surgical↗
PubMed2004

Spontaneous pneumomediastinum: are we overinvestigating?

BACKGROUND: Spontaneous pneumomediastinum (SPM) is uncommon in pediatrics. Because of the growing concern about the risks of radiation in children, the authors analyzed whether an extensive radiologic workup influences management and outcome. METHODS: In a retrospective study from 1991 to 2003, 53 patients were diagnosed with SPM. Charts were reviewed for demographics, predisposing factors, presentation, investigation, and evolution. Pneumomediastinum occurring in the neonatal period or related to either pneumothorax, barotrauma, or trauma were excluded. RESULTS: Of 53 cases, 26 (49%) were bronchospasm related, 11 (21%) had respiratory tract infections, and 8 (15%) were idiopathic. Four (7.5%) were caused by inhaled foreign bodies while other causes accounted for the remaining 7.5%. No esophageal perforations were identified. Presentations included dyspnea (64%), subcutaneous emphysema (60%), cough (45%), cervical or chest pain (42%), and Hamman's sign (19%). Postero-anterior chest x-rays (CXR) were diagnostic in all cases except one. Mean number of CXR per hospitalization was 3. Only 3 patients subsequently had pneumothorax, and none required pleural drainage. Of the 8 patients with idiopathic SPM, 5 underwent a barium swallow, and 2 had a chest CT scan; results of all were normal. CONCLUSIONS: More than 70% of SPMs were related to bronchospasm or respiratory tract infections. Idiopathic SPMs deserve more attention because of the concern about esophageal perforation, although most investigations will be negative. SPM usually is a self-limited condition, and prognosis is related to the underlying disorder. Consequently, with clinical improvement, aggressive investigation and follow-up x-ray rarely is warranted.

Adolescent↗
PubMed1990

Barogenic perforation of the esophagus distal to a stricture after endoscopy.

Instrumentation is the most common cause of esophageal perforation, usually at or above a stricture. We report an unusual case in which the perforation occurred distal to a proximal esophageal stricture during diagnostic endoscopy. The perforation occurred close to the gastroesophageal junction involving an apparently normal esophagus, in a manner similar to that of "spontaneous," barogenic esophageal rupture (Boerhaave's syndrome). We postulate that the abrupt rise in pressure in the intraluminal esophagus, the inlet of which was obstructed by a tightly fitting instrument, was responsible for the rupture.

Aged↗
PubMed1961

Iatrogenic perforation of the esophagus.

In three of ten cases of instrumental esophageal perforation occurring at the San Francisco Hospital in the period 1947-1959, the patient died, having received supportive therapy only. Eight of the ten perforations in this series resulted from the use of the esophagoscope. Roentgen studies of the neck and chest, including studies with an opaque medium in the esophagus, are invaluable aids in establishing the diagnosis.Close observation of all patients for twenty-four hours after instrumental procedures involving the esophagus is advisable.

Esophageal Perforation↗
PubMed1989

Frequent endoscopic variceal sclerotherapy increases risk of complications. Prospective randomized controlled study of two treatment schedules.

In an effort to determine the optimal dose and frequency of chronic endoscopic variceal sclerotherapy, a prospective randomized controlled study comparing two treatment schedules of sclerotherapy was carried out over a 21-month period. Patients with variceal hemorrhage were randomly assigned to receive sclerotherapy at weekly intervals using injection volumes of greater than 15 cc at each treatment or at mean intervals of three days using volumes of less than 10 cc per treatment. Esophageal perforation occurred in three patients (15%) in the small-dose, frequent-injection group as compared to none in the large-dose weekly treatment group (P = 0.07), leading to premature termination of the study. The mean time to rebleeding was significantly shorter in the small-dose, frequent-treatment group (P = 0.05). Variceal obliteration was achieved in a mean of 66% of patients in both groups with no difference in the time to obliteration or the frequency of other complications. Sclerotherapy offered at less than weekly intervals is less effective and is associated with an increased frequency of serious and life threatening complications.

Adult↗