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PubMed1993

The use of thoracoscopy in the treatment of iatrogenic esophageal perforations.

Treatment options for patients with iatrogenic esophageal perforations are multiple and remain a source of controversy. Therapeutic options range from conservative, non-operative treatment to esophageal exclusion or esophagectomy. We present herein what we believe to be the first described repair of an esophageal perforation using thoracoscopic surgical techniques. We believe this approach offers several advantages over open thoracic surgery and has a role in minimizing postoperative morbidity in an already potentially life-threatening condition.

Aged↗
PubMedDate not supplied

Successful closure of spontaneous esophageal perforation (Boerhaave's syndrome) by endoscopic clipping.

Endoscopic clips have been used mainly for control of gastrointestinal (GI) bleeding and occasionally for closure of GI perforations. However, closure of spontaneous esophageal perforation (Boerhaave's syndrome) by clipping has not been reported. We described successful non-surgical closure of spontaneous esophageal perforation by endoscopic clipping in a patient with bilateral pyopneumothorax and septicemia.

Diagnosis, Differential↗
PubMed1982

Esophageal perforations: a 15 year experience.

A review of 44 patients with 50 esophageal perforations from 1966 through 1980 is presented. The age span was 15 months to 94 years and the male to female ratio was 1 to 1. Each case was studied with regard to presentation, etiology, treatment and complications. Twenty-two cases of esophageal perforation followed instrumentation, including 6 secondary to Mosher bag dilatation for achalasia. Of the remainder, seven patients had spontaneous perforation, five had external trauma, five had intraoperative injury, two had caustic ingestion, and one each had foreign body ingestion, Zollinger-Ellison syndrome and an incarcerated paraesophageal hiatal hernia. Management was nonoperative in 12 patients, primary repair and drainage was performed in 23 patients, and 9 patients underwent drainage and diversion. This series plus 824 patients with esophageal perforation accumulated from a review of the literature emphasizes the importance of the influence of different methods of treatment and time lapse between occurrence and therapy. The type of perforation had no significance on this series. As a result of the experience gained from this series, a treatment protocol is proposed for the management of esophageal perforation.

Adolescent↗
PubMed1996

Successful application of an omental pedicle flap in delayed repair of a perforated esophageal diverticulum: report of a case.

Mediastinitis resulting from a perforated esophageal diverticulum is a potentially fatal complication and the surgical treatment of persistent esophagomediastinal fistula may be difficult. In this report, we describe the successful application of an omental pedicle flap in the delayed repair of a perforated esophageal diverticulum. A 53-year-old man presented with chest and back pain and a diagnosis of perforated esophageal diverticulum was subsequently confirmed. After receiving conservative treatment, he was referred to our department and underwent surgical repair 6 months following the onset of the perforation. Through a right thoracotomy, the mucosal layer of the esophagus around the diverticulum was sutured, and an omental pedicle flap was used to cover the suture line and obliterate the fistulous tract. His postoperative course was uneventful and the suture line healed well. The successful treatment of this patient reinforces our belief that wider application of the omental pedicle flap can be expected in the field of thoracic surgery.

Diverticulum, Esophageal↗
PubMed2002

Surgery in thoracic esophageal perforation: primary repair is feasible.

Prompt diagnosis and effective treatment are important for thoracic esophageal perforations. The decision for proper management is difficult especially when diagnosed late. However, there is an increasing consensus that primary repair provides good results for repair of thoracic esophageal perforations, which are not diagnosed on time. Primary repair for thoracic esophageal perforations was applied in 20 out of 25 consecutive patients. The time interval between perforation and repair was less than 24 h in six patients (group I), and more than 24 h in 14 patients (group II). The remaining five patients underwent esophagectomy with simultaneous or staged reconstruction because of incorrectable underlying esophageal pathology. Group I had much more iatrogenic causes (P < 0.05). Preoperative sepsis occurred only in group II (P=0.05) and was highly associated with Boerhaave syndrome (P=0.001). Regional viable tissue was used to reinforce the sites of primary repair (n=15, 75%). All of the postoperative morbidity (n=9, 45%) including esophageal leaks (n=6, 30%) and operative death (n=1, 5%) occurred in group II. In patients with postoperative leaks, five eventually healed, but one became a fistula that required reoperation. Primary healing with preservation of the native esophagus was achieved in all 19 patients except one operative death. In addition, the increased incidence of leak and morbidity did not lead to an increase in mortality. In the esophagectomy group, there was no mortality, but one minor suture leak. Regardless of the time interval between the injury and the operation, primary repair is recommended for non-malignant, thoracic, esophageal perforations, but not for anastomotic leaks. Reinforcement that may change the nature of a possible leak is also useful. For incorrectable underlying esophageal pathology, esophagectomy with simultaneous or staged reconstruction is indicated.

Adolescent↗
PubMed2004

Endoscopic clip application for closure of esophageal perforations caused by EMR.

BACKGROUND: With increasing use of EMR for early stage esophageal carcinoma, the number of cases of iatrogenic esophageal perforation is likely to increase. This study evaluated the results of endoscopic clip application for treatment of perforations caused by EMR in patients with esophageal carcinoma. METHODS: Among 185 patients who underwent EMR for esophageal carcinoma, esophageal perforation occurred in 3 patients (1.6%). Metallic clips were immediately applied endoscopically to close the perforations. OBSERVATIONS: All 3 patients were observed closely and were managed conservatively (intravenous hyperalimentation, antibiotics) after closure of the perforation. They were discharged without any further serious complication. CONCLUSIONS: When esophageal perforation caused by EMR is immediately recognized, endoscopic application of metallic clips is appropriate therapy. However, patients must be carefully monitored for the development of generalized mediastinitis.

Aged↗
PubMed2004

Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.

BACKGROUND AND STUDY AIMS: Extensive anastomotic leaks after esophageal resection and esophageal perforations are a therapeutic challenge. The aim of the present study was to assess the potential of the self-expandable Polyflex plastic stent for the treatment of these conditions. PATIENTS AND METHODS: Between January 2002 and March 2003, nine patients were treated with a self-expandable Polyflex plastic stent for sealing of thoracic esophagoenteric anastomotic leaks following surgical resection (n = 5) or esophageal perforation (n = 4). RESULTS: In all patients the stents were inserted successfully without technical problems. In all but two patients complete sealing of the leak was achieved as demonstrated by radiography with water-soluble contrast media. The stent migration rate was 30 % and repositioning of the migrated stents was possible in all cases. Complete mucosal healing of the esophageal leaks and stent extraction was achieved in six patients. The stents were in situ for an average period of 135 +/- 78 days. Two critically ill patients with anastomotic leaks died in spite of stent insertion due to sepsis and one patient with esophageal perforation died due to the underlying malignant disease. CONCLUSIONS: Our preliminary experience with the self-expanding and removable Polyflex plastic stent for the sealing of anastomotic leaks and esophageal perforations suggests that this stent is a feasible treatment option, in particular, for more extensive esophageal defects, patients with co-morbid conditions, and critically ill patients.

Aged↗
PubMed1994

Near-total esophageal exclusion in the treatment of late-diagnosed esophageal perforation.

Two cases of late-diagnosed esophageal perforation were successfully treated with near-total esophageal exclusion, using cervical T-tube esophagostomy with circumferential suture fixation of the lower arm of the T-tube. Esophageal stricture developed at the site of catgut or dexon tie. This complication can be managed with esophageal dilation. Drainage-tube gastrostomy proved to be unnecessary.

Adult↗
PubMed1990

Esophageal perforation due to nasogastric intubation.

Esophageal perforation is a rare but catastrophic complication of nasogastric intubation. Diagnosis is frequently delayed, resulting in high mortality. We report a case of perforation due to nasogastric intubation in an otherwise normal esophagus. Patients at high risk of this complication can be identified, and special techniques can be used to avoid perforation. Percutaneous endoscopic gastrostomy is an alternative to nasogastric intubation for long-term enteral feeding. When nasogastric intubation is performed, clinical tests of tube position are not sufficient to guarantee proper tube position. The tip of the tube must be visualized radiographically in the stomach prior to initiation of tube feeding. When perforation does occur, proper management is often controversial. Therapy must be tailored to each individual case for the best possible outcome.

Aged↗
PubMed1979

Delayed esophageal perforation after pneumatic dilatation for the treatment of achalasia.

Two cases of delayed esophageal perforation following a pneumatic dilatation for the treatment of achalasia are presented. Esophagrams obtained immediately after pneumatic dilatation failed to reveal a perforation. Increasing symptoms prompted repeat contrast studies, at which time an esophageal perforation was demonstrated. The occurrence of delayed esophageal perforation after pneumatic intrumentation is emphasized. An ischemic etiology for this delayed perforation is postulated.

Dilatation↗
PubMed2001

Successful primary reinforced repair of esophageal perforation using a pedicled omental graft through a transhiatal approach.

Esophageal perforation is potentially lethal if untreated. We report a case of distal esophageal perforation probably caused by swallowing a fish bone. The patient initially received conservative treatment 4 days after the esophageal injury. The treatment was promptly changed from conservative to operative treatment owing to rapid manifestation of suppurative mediastinitis followed by peritonitis. The patient successfully underwent primary repair of the perforation buttressed with a pedicled omental graft pulled up through the esophageal hiatus following a laparotomy. We discuss the validity of this method of transhiatal approach without thoracotomy for primary repair of distal esophageal perforation.

Aged↗
PubMedDate not supplied

[Esophageal perforation caused by tracheal intubation].

Esophageal perforation is an unusual complication of tracheal intubation caused by technical error. Its diagnosis is easily made which is very important since it requires prompt treatment. A case observed in the emergency room of our training hospital is reported. The patient recovered with adequate measures.

Esophageal Perforation↗
PubMed2005

Management of esophageal perforations: the value of aggressive surgical treatment.

BACKGROUND: The treatment of esophageal perforation remains controversial, particularly in terms of the type of operative therapy. This report analyzed results of an aggressive treatment protocol. METHODS: Patients with esophageal perforations in a normal esophagus or those with a motor disorder were treated by operative closure. All defects were buttressed or closed by either muscle or pleura. Sternocleidomastoid muscle was used to buttress or primarily close the defects in the neck, and a flap of diaphragm was often used for thoracic perforation. Patients with perforated cancer or severe underlying disease had an esophagectomy. RESULTS: Sixty-four patients had operation: 50 underwent preservation of the esophagus after closure of the perforation and 14 underwent resection. The leak rate was 17%, but all healed. One patient treated with primary closure died (1.5% mortality); only 1 patient required subsequent esophagectomy. Thirteen of 14 patients treated with esophagectomy had an excellent result. CONCLUSION: The aggressive approach to esophageal perforations with attempt at uniform closure or resection of severe disease produced excellent results with reduced morbidity and low mortality.

Digestive System Surgical Procedures↗
PubMed2001

[Esophageal perforation by osteosynthesis material after ventral spondylodesis of the cervical spine].

Esophageal perforation after cervical spine surgery is a rare complication. Based on the case of a 77-year-old female patient with a late, asymptomatic esophageal perforation after a ventral spondylodesis of the cervical spine, the symptoms, diagnostics, and therapy of this complication are discussed. The therapy of choice is the operation. Nonoperative therapy should only be chosen--like in our case--for special indications. An esophageal perforation with symptoms should be treated operatively. Our patient was treated conservatively in consideration of her age and missing symptoms.

Aged↗
PubMed1989

[Esophageal perforation: prognostic factors].

Esophageal ruptures are amongst the severest of the digestive tract. We report a retrospective study of 30 cases (15 men and 15 women) aged 17 to 85, collected between 1976 and 1987. The group of risk is constituted by patients aged 60 and up, presenting an underlying esophageal illness. The endoscopic etiology of the perforation is as severe as the one of surgical or spontaneous origins. Medical treatment is considered only if the perforation is inferior to 2 cm, extra-thoracic, without an associated pleural effusion and without an associated esophageal illness. When surgical treatment of a primary suture is done, it is the most important factor to protect the suture by a patch.

Adolescent↗
PubMed1977

Esophageal perforation. An unusual presentation with a benign clinical course.

A case of esophageal perforation occurring in a 75-year-old man is presented. The clinical presentation was benign and the diagnosis of esophageal perforation was made incidental to an upper gastrointestinal barium examination. Conservative management consisting of nasogastric suctioning, antibiotics and antacids was effective in minimizing the clinical course. This represents a rare instance of a successful nonsurgical approach to esophageal perforation.

Aged↗
PubMed1993

[Esophageal perforation in a fruitless attempt at endotracheal intubation].

Esophageal perforation is a rare but potentially serious complication of endotracheal intubation, often leading to mediastinitis. The diagnosis should be performed rapidly, based on suggestive clinical signs as well as on plain chest roentgenograms and contrast esophagogram. The usual treatment consists of broad spectrum antibiotherapy, prompt surgical closure of the perforation and adequate drainage of the area. The overall mortality rate of about 50% is significantly reduced if therapy is begun within the first 12 hours. A number of ancillary tests and clinical criteria have been proposed in order to assess difficult intubations. The authors report a case of esophageal perforation following a difficult intubation, resulting in acute respiratory distress, subcutaneous emphysema and bilateral pneumothorax. An early diagnosis and prompt surgical treatment facilitated a successful outcome.

Esophageal Perforation↗