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The eighth case of spontaneous intramural esophageal perforation (or intramural hemorrhage) is reported. Previous cases are reviewed. The fact that patients with this injury can be managed conservatively is documented. Diagnostic and therapeutic modalities are discussed.
Esophageal perforation may occur spontaneously or as a complication of esophageal operations. Treatment often mandates emergency operative intervention to close the leak or to provide adequate drainage. Recurrent or persistent leak can lead to prolonged drainage before final healing. We describe herein a minimally invasive and inexpensive technique using fluorescein dye that can confirm the persistence of esophageal leak drained by tube thoracostomy without requiring expensive and potentially morbid invasive or radiological techniques. Application of this technique assists in diagnosis when previously described minimally invasive techniques are impractical or yield inconclusive results.
A study of 90 cases of esophageal perforation in the antibiotic era emphasizes individualized treatment and options of therapy based on a fundamental understanding of modifying pathophysiologic factors. If the patient is seen during the first 24 hours, surgical repair and irrigating tube drainage continue to be the treatment of choice in the thoracic and abdominal regions, with certain exceptions. The exceptions include small perforations proved by a thin media esophagram or esophagoscopy without pleural involvement or constitutional symptoms. Such patients may be treated nonoperatively, with gastric drainage, antibiotics, and parenteral alimentation. However, for large perforations with extensive contamination of the mediastinum and pleura, an esophageal exclusion operation may be life saving. In the cervical region, irrigating tube drainage may be just as effectual as repair and drainage. In patients seen after 24 hours, size of the perforation and the amount of mediastinopleural infection, rather than the time that has elapsed, dictate optimal treatment.
Photodynamic therapy is an effective palliative treatment of esophageal cancer. Minor complications associated with this therapy include pleural effusions, fever or esophageal strictures. In addition to this major complications such as respiratory-esophageal fistula and bronchus perforation have been described. We report here our experience with a patient who developed a complete esophageal necrosis and perforation of the left main bronchus following photodynamic therapy. The surgical and intensive care management of the patient is described and the literature discussed.
The experience on perforation of the esophagus at the Hospital Infantil de México is reviewed. Between 1961 and 1975, 20 cases were attended. The most frequent perforation is the iatrogenic subsequent to dilatations or to esophagoscopy. Esophageal perforation is the most serious of the digestive tube perforations and must be considered as a real medicosurgical emergency. The clinical picture is analyzed and the necessity to take chest x-rays and esophagogram as urgent measures is emphasized at the slightest clinical doubt. The different treatment methods are mentioned and it is stressed that the best results are obtained with an urgent thoracotomy, closure of the perforation, full canalization and antibiotic therapy at high doses. According to the literature referred and to the results obtained from the present study, mortality is higher in cases where treatment is delayed. The clinical and radiological pictures are described together with the therapeutic behavior in spontaneous perforation in the newborn. The theories to explain this etiology are set forth. At present, mortality is still high; therefore, in order to bring down this high percentage, it is concluded that an early diagnosis together with an agressive surgical treatment are necessary.
Pharyngeal and upper esophagus substitution is an ordinary procedure in adults, performed mainly for oncologic purposes, but it is rarely done in children. The authors present a case report of a free jejunal graft pharyngo/esophageal reconstruction with microvascular anastomosis to the primitive carotid artery and the internal jugular vein in a a 10-year-old girl who had a loss of lower pharynx and cervical esophagus secondary to esophageal perforation by foreign body. Other surgical approaches for pharyngo-esophageal reconstruction in children are revisited.
We present a 63-year old female with mediastinitis following an esophageal perforation, possibly favoured by an oesophageal motility-disorder and the use of non-steroidal anti-inflammatory drugs, who developed a broncho-mediastinal fistula in the left main bronchus. She was successfully treated with intravenous antibiotics, a cervical oesophagostomy and secondary isoperistaltic coloplasty.
Perforation of the esophagus is a very rare complication of metallic esophageal stent insertion. Two cases are presented in which esophageal perforations were caused by the sharp ends of metallic stents impinging on the esophageal wall. In retrospect, both perforations might have been prevented by additional stent insertion.
Surgery is considered mandatory for major oesophageal perforations but the operative risk in cirrhotic patients is very high. The best treatment of these perforations is unknown as these have been always analyzed together with all other kinds of oesophageal perforations. A case is reported of spontaneous healing of severe postsclerosal perforation in an aged cirrhotic patient treated conservatively who otherwise should have been treated surgically. Conclusions are that due to the rarity and the cirrhosis, the common guidelines for the treatment of major esophageal perforations are not to be automatically extended to these perforations as postsclerosal perforation is clinically particular, etiologically and prognostically different than all other oesophageal perforations. Conservative but active treatment is to be tried first also with major postsclerosal oesophageal perforations.
Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).
Surgical treatment of corrosive esophagitis with gastric perforation is a high risk operation. Nonthoracotomy esophagectomy plus total gastrectomy was performed upon seven patients and compared with cervical esophagostomy plus total gastrectomy performed upon five patients. Two patients in the first group and all of the patients in the second group died. Transpleural esophagectomy for these critically ill patients is usually dangerous with high morbidity rates, while nonthoracotomy esophagectomy is a procedure which has lower risks and more advantages for removing the damaged esophagus of the patient with corrosive esophagitis.
OBJECTIVE: To explore the countermeasure to reduce fatality in patients with intrathoracic oesophageal perforation caused by foreign body. METHOD: Exploratory pleuracotomy were operated on all the 12 cases with intrathoracic esophageal perforation caused by foreign body. According to the different pathological morbids, one of following surgical procedures was operated: 1. esophagoscopy was used to fetch the foreign body and the oesophageal perforation was repaired (3 cases), 2. esophagotomy was adopted to fetch the foreign body and to had the oesophageal a drainage using "T" tube (5 cases), 3. esophagotomy was adopted to fetch the foreign body and to had the oesophageal a drainage using "T" tube as well jejunostomy (3 cases). Occlusive drainage were used on all the cases and pleuroclysis with flagyl soloution and normal saline were used on some cases. RESULT: Four of 12 cases (33.3%) were cured, the others (66.7%) died, among them 7 cases died of breaks of thoracaorta and hematorrhoea afterwards. CONCLUSION: An esophagoscopy to fetch the foreign body, the pleuracotomy to protect thoracaorta in time, preventing infection and hematorrhoea post-operation are keys in reduce the fatality in patients with intrathoracic oesophageal perforation caused by foreign body.
In 18 dogs esophagocardioplasty was performed through an abdominal incision with a gastric patch taken from the minor curvature of the stomach. In four dogs the mucosa was removed from the gastric patch and in six dogs a Nissen fundoplication was done. The dogs were observed for 1 year. All dogs showed macroscopic and microscopic signs of esophagitis with ulcers; three had esophageal perforation and two dogs had esophageal stenosis. We found that gastric patches with peptic acid secretory mucosa in dogs cause grave esophageal lesions.
OBJECTIVE: The aim of this study was to present a new technique of secondary vocal prosthesis placement on an outpatient basis without general anesthesia by means of digestive endoscopy. METHODS: It is a prospective study, 35 laryngectomized patients were sedated with midazolam and underwent digestive endoscopy and tracheoesophageal punch with vocal prosthesis insertion. RESULTS: A success rate of 94.2% was achieved with this surgical technique. The mean procedure time was estimated at 12 minutes, and no serious complications due to the prosthesis insertion were observed. CONCLUSION: The advantages of this new technique over the classic technique are lack of use of general anesthesia, performance of procedure on an outpatient basis, lower complication risks (including hemorrhage, mediastinitis, vertebral fracture, esophageal perforation; and minor oropharyngeal, and esophageal mucosal trauma), and direct visualization of the prosthesis in the esophageal lumen.
OBJECTIVE: To study the long-term treatment results and acute irradiation response as well as complications following external irradiation combined with intracavitary brachytherapy. METHODS: After loading intracavitary brachytherapy was used for patients with esophageal cancer. In 92 patients with esophageal cancer, 47 (group A) were treated with external irradiation only, and 45 (group B) with external irradiation and brachytherapy. The doses were 60.0 Gy - 70.0 Gy per 6-7 week for external irradiation, using 8 or 10 MV liner accelerator, and 5.0-8.0 Gy per fraction for intracavitary therapy. RESULTS: There was a significant difference in acute response and complications as well as local recurrence rate between the two groups (P < 0.05). The survival rates of groups A and B at 1,3 and 5 years were 59.6%, 25.6%, 10.6% and 80.0%, 46.7%, 26.7% respectively (P < 0.05 respectively, using chi2 test). The complications related to intracavitary irradiation were esophageal perforation, esophagorrhagia, esophagotracheal fistula and esophageal narrowing. 66 patients died and 9 lost follow-up, giving a follow up rate of 90.2%. CONCLUSION: External irradiation combined with afterloading intracavitary brachytherapy for esophageal cancer can reduce the local recurrence and enhance the long-term survival but with an increase of complications compared with the patients treated with external irradiation alone.
Barium and conventional hypertonic water-soluble contrast media (e.g., Gastrografin) are not ideal contrast agents in the evaluation of the esophagus when leakage into the mediastinum or aspiration into the lung is possible. Metrizamide (Amipaque) is water-soluble and can be well visualized in isotonic solution. Three cases are presented where metrizamide was used successfully in the evaluation of suspected esophageal perforation or tracheoesophageal fistula.
Esophageal ulcers are a rare cause of upper gastrointestinal bleeding. This report describes the etiology, treatment, complications, and outcome of esophageal ulcers. An esophageal ulcer is defined as a discrete break in the esophageal mucosa with a clearly circumscribed margin; esophageal ulcers were seen in 88 patients from a total of 7,564 esophagogastroduodenoscopies done by one surgeon at an urban hospital from 1991 to 2001. All hospital reports were reviewed. The etiology of esophageal ulcers included the following: gastrointestinal reflux disease (GERD) (n=58, 65.9%), drug induced (n=20, 22.7%), candidal (n=3, 3.4%), caustic injury (n=2, 2.3%), and herpes simplex virus (HSV), human immunodeficiency virus (HIV), marginal ulcer, foreign body, and unknown etiology (n=1 of each, 1.1%). The mean size of GERD-induced esophageal ulcers and drug-induced esophageal ulcers was 2.78 and 2.92 cm, respectively; 80.3% of GERD-induced esophageal ulcers and 13.8% of drug-induced esophageal ulcers were located in the lower thoracic esophagus. Morbidity (n=44, 50%) included hemorrhage (n=30, 34%), esophageal stricture (n=11, 12.5%), and esophageal perforation (n=3, 3.4%). Nonoperative therapy sufficed in 81 patients (92%). Three patients (3.4%) had a recurrence of esophageal ulcers. Fifteen patients (17.0%) required endoscopic intervention including esophageal dilatation for stricture in 11 patients and endoscopic hemostasis for esophageal bleeding in four patients. Surgery (n=7, 8.0%) was reserved for esophageal stricture and perforation. Two patients (2.3%) died from complications of esophageal ulcers: hemorrhage in one and perforation in one. Three patients died of their primary disease. GERD and drug ingestion are common causes of esophageal ulcers. Midesophageal ulcers have a greater tendency to hemorrhage compared with ulcers at the gastroesophageal junction; this may reflect the etiology. Strictures complicate GERD-induced esophageal ulcers but not drug-induced esophageal ulcers. Esophageal dilatation is an effective treatment for most strictures associated with esophageal ulcers. Esophageal ulcers rarely cause death.
Two cases of unsuspected esophageal foreign body ingestion with chest pain as the main symptom are reported. Both patients had extensive cardiac evaluation to rule out myocardial ischemia. They were discharged home with continuing chest pain and odynophagia. Both patients were denture wearers, and further questioning revealed the coincidence of chest pain with taking meals. Further evaluation revealed an impacted esophageal foreign body in one patient and an esophageal perforation with a mediastinal abscess in the other. These cases illustrate the importance of considering esophageal foreign bodies as factors in chest pain.