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PubMed1992

Esophageal perforation: a continuing challenge.

Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.

Esophageal Perforation↗
PubMed1992

Esophageal perforation: an 8-year review of a multispecialty clinic's experience.

Esophageal perforation is the most serious perforation of the gastrointestinal tract, and despite early diagnosis and treatment, mortality remains high. Twenty-four cases of esophageal perforation seen at a large multispecialty clinic between 1983 and 1991 were retrospectively reviewed. Thirteen patients presented with acute perforation, five with subacute, and six with chronic perforation. Eighteen (75%) of 24 perforations resulted from iatrogenic causes, and the rest were spontaneous. Of the iatrogenic perforations, therapeutic endoscopy and paraesophageal surgical complications were responsible for 55% and 33%, respectively. Chest pain, fever, and dyspnea were common presenting signs and symptoms of acute perforation, whereas dysphagia and supraventricular arrhythmia were more prominent features of chronic perforation. All but seven patients had surgical intervention. An overall mortality rate of 46% was noted, and despite early diagnosis and treatment, this mortality was associated with the severity of underlying disease.

Adult↗
PubMed2006

Thoracic esophageal perforation: one surgeon's experience.

Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.

Adult↗
PubMed2004

Late esophageal perforation complicating anterior cervical plate fixation in ankylosing spondylitis: a case report and review of the literature.

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5-7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.

Cervical Vertebrae↗
PubMed1993

Surgical repair of esophageal perforation due to pneumatic dilatation for achalasia. Is myotomy really necessary?

Esophageal perforation is a rare complication of pneumatic dilatation for achalasia. The few clinical series reported in the literature recommend, under most circumstances, esophageal repair combined with esophagocardiomyotomy. However, the superiority of this technique over repair alone has never been proven. We reviewed our experience, since 1979, with six operative cases of esophageal perforation from pneumatic dilatation for achalasia. After débridement, the esophagus was repaired and, if possible, buttressed with a gastric fundal patch. There was only one late postoperative death due to sepsis and one upper gastrointestinal bleeding complication in our series. Follow-up (1 to 12 years) revealed no dysphagia in any of the five surviving patients and mild gastroesophageal reflux in two. From a review of the literature we found no reports of similarly treated patients experiencing recurrent symptoms of achalasia. In these acutely ill patients, our operative strategy is more feasible than repair and esophagocardiomyotomy and equally effective.

Abscess↗
PubMed2001

Esophageal perforation: life threatening complication of endotracheal intubation.

OBJECTIVE: To raise awareness of this complication of tracheal intubation, to emphasize the gravity due to delayed diagnosis, and to advocate a surgical treatment. METHODS: Between April 1980 and January 2000, 97 patients were treated for esophageal perforation in our department. We reviewed the cases of perforation occurring after attempted tracheal intubation. Each case is presented. Discussion is focused on diagnosis and treatment. RESULTS: Esophageal perforation occurred after attempted endotracheal intubation in five cases among 58 iatrogenic perforations. There were four women and one man (mean age 72 years). In all cases, it was for a planned operation. Intubation was performed by a single lumen tube in three cases and a double lumen tube in two cases. Presenting symptoms were acute in one case and insidious in four cases. Free interval before diagnosis and treatment was long in all but one case, with an average of 179 h (range 5--432). Two patients suffered from septic shock when they were transferred. All patients were operated on. Two patients died. CONCLUSION: Post intubation esophageal perforation is one of the most life threatening esophageal perforation. Delayed diagnosis is the first cause of gravity. Prevention of this complication begins with recognition of a potentially difficult intubation. Good outcome follows from rapid diagnosis and early surgical treatment.

Aged↗
PubMed1994

Instrumental esophageal perforation: chest film findings.

The aim of this study was to evaluate plain film findings of the chest in instrumental esophageal perforation. We hypothesized that such "clean" perforations, often detected early, would be associated with a low frequency of abnormal plain film findings. Fifteen patients with instrumental esophageal perforation were identified, and their records and radiographs were reviewed. Twelve (80%) of the patients had abnormalities suggestive of perforation. The most common (60%) abnormality seen was pneumomediastinum. The second most common (33%) finding was a density adjacent to the descending aorta in the left cardiophrenic angle, resulting in loss of contour of the descending aorta at the level of the left diaphragm. We concluded that plain films, even when taken shortly after instrumentation, provide useful information regarding the presence of esophageal perforation.

Adult↗
PubMed2003

Thoracic esophageal perforations.

BACKGROUND: Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. METHODS: We retrospectively analyzed all cases of thoracic esophageal perforation diagnosed at our hospital from September 1, 1979, through April 1, 2001. The study group consisted of 62 patients (43 men) with a mean age of 58.8 years (range, 20-92 yr). RESULTS: In the group of 39 patients with early diagnosis (< or = 24 h), hospital survival was 87%, which increased to 93% when early diagnosis was combined with aggressive surgical treatment Among the 23 patients with late diagnosis (> 24 h), survival approached 70%. Yet, in patients who were treated aggressively with surgery, survival was almost 90% despite delayed diagnosis. CONCLUSION: We recommend aggressive, definitive surgery for thoracic esophageal perforations, whether diagnosed early or late. A variety of options are discussed with regard to complicated presentations.

Adult↗
PubMed1989

Cervical esophageal perforation caused by diagnostic flexible esophagoscopy.

Two cases of iatrogenic cervical esophageal perforation caused by diagnostic flexible fiberoptic endoscopy are described. The relative risks of perforation at fiberoptic and rigid esophagoscopy are discussed and the importance of contrast radiology and early diagnosis are emphasized. Cases with a small tear and minimal contamination may be treated conservatively. Early surgical repair with drainage is otherwise the treatment of choice for cervical esophageal perforation. Even if there has been abscess formation tracking down into the mediastinum, drainage can be successfully achieved via the neck, avoiding the need for thoracotomy.

Abscess↗
PubMed2003

[Spontaneous esophageal perforation--a case report and review].

The quick diagnosis is decisive for the outcome of the treatment of patients with esophageal perforation because of the serious complications--mediastinitis, empyema and sepsis. These are the main causes for the high mortality of up to 60 per cent of the patients with esophageal perforation. The difficulties for the particular operative tactics rise from the late diagnosis. These are the most problematic moments of the spontaneous esophageal perforation (Boerhaave's syndrome) management. A review of the clinical signs, the complications, the diagnostics and the successful operative treatment on a patient with Boerhaave's syndrome performed on the 10th day after the incident is presented.

Digestive System Surgical Procedures↗
PubMedDate not supplied

Interpleural analgesia in the management of esophageal perforation.

BACKGROUND AND OBJECTIVES: Interpleural analgesia was used in a case of esophageal perforation due to surgical mishap. The medical literature cites no reference to use of this technique in this condition. METHOD: Interpleural bupivacaine analgesia was used along with conventional forms of pain relief. RESULTS: Superior analgesia was obtained, and the method proved to be safe and complication free on a general surgical ward over the period of several days that it was used. CONCLUSION: Interpleural analgesia is safe and effective for management of pain due to esophageal perforation.

Analgesia↗
PubMed2005

Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy.

BACKGROUND: Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques. METHODS: All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test. RESULTS: Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation. CONCLUSIONS: Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.

Adult↗
PubMed1996

Endoscopic management of inveterate esophageal perforations and leaks.

The endoscopic management of four selected patients with inveterate esophageal perforations or leaks is presented. One patient had a perforation of the cervical esophagus following endoscopic removal of a foreign body already treated with surgical drainage; two patients had a leak following diverticulectomy and esophagogastrostomy, respectively, persistent after multiple surgical repairs; the last patient had a spontaneous perforation of the thoracic esophagus persistent after two transthoracic repairs. The mean time elapsed between the diagnosis of perforation and the endoscopic treatment was 19 days. In one patient, transesophageal drainage of a mediastinal abscess was performed. In the other three patients, a stent was placed to seal the leak in combination with gastric and esophageal aspiration. Two of these patients underwent endoscopy in critical condition and could have not been candidates for major surgical procedures. All patients received enteral nutrition. No morbidity or mortality related to the endoscopic procedure was recorded; the treatment was effective in all patients who recovered and resumed oral feeding within 3 weeks. We conclude that endoscopic transesophageal drainage and stenting are effective procedures in the management of patients with inveterate esophageal perforations or leaks.

Aged↗
PubMed1990

Esophageal perforation: a therapeutic challenge.

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Adult↗
PubMed2006

Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases.

INTRODUCTION: The aim of the study was to identify criteria for rapid recognition and successful treatment of esophageal perforation after radiofrequency ablation for atrial fibrillation (AF). METHODS AND RESULTS: Esophageal perforation occurred in five patients after intraoperative (n = 4) or percutaneous (n = 1) AF ablation. Patients presented with high fever (n = 3) or severe chest/epigastric pain (n = 2) 8-28 days after ablation. WBC count was elevated at presentation in all patients (15,460 +/- 2,910/muL), CRP showed a delayed rise. Thoracic CT detected free air in all. Neurologic complications occurred in three cases (60%) with a delay of 5-40 hours after first symptoms. Only one (20%) developed neurologic complications within the first 24 hours. Two patients (40%) died before surgery could be performed. In both, time from symptom onset to diagnosis was significant (24 and 36 hours). Three patients (60%) underwent esophageal resection and survived. In two of them, treatment was rapid with time from symptoms to surgery of 24 hours; they had favorable outcome. In the third surviving patient, surgery was late (5 days after first symptoms); permanent neurologic residues remained. CONCLUSION: The leading symptom of esophageal perforation is high fever or severe chest/epigastric pain. Fever is not necessarily present. Leukocytosis is the earliest and most sensitive laboratory marker, thoracic CT the most valuable diagnostic examination. The dramatic neurologic complications occur with a delay of at least a few hours after first symptoms. Immediate surgery may prevent neurologic complications and could possibly result in a high survival rate without residues. Delay of treatment seems to have devastating results.

Adult↗