Successful management of a nonmalignant esophageal perforation with a coated stent

This case report details our experience in the management of an iatrogenic perforation that recurred after two surgical repairs. A self-expanding coated stent was eventually placed to seal the esophageal perforation with significant improvement in the clinical condition of the patient. At 1-year follow-up, the patient is tolerating an oral diet with no evidence of esophageal leak or gastroesophageal reflux. This case report and a literature review suggest that self-expanding coated stents may be a useful salvage option in the management of inveterate nonmalignant esophageal perforations.     

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

Background  Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. Methods  All esophageal stent placement procedures (174 procedures for 157 patients) at the authors’ unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave’s syndrome (n = 4), or an anastomotic leakage (n = 2). Results  The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. Conclusions  Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.     

Use of temporary esophageal stent in management of perforations after benign esophageal surgery

Successful conservative management in 3 patients with catastrophic postoperative esophageal leak after nonresection surgery is presented. In each case, the placement of removable stent played a significant role. First patient had persistent leak after primary repair of intrathoracic esophageal perforation. The second patient underwent a transthoracic redo Collis-Nissen repair and was subsequently found to have a perforation in the midesophagus. The last patient had a history of recurrent hiatal hernia repair with mesh reinforcement of the hiatus. A perforation resulted from mesh eroding into the esophagus. All the patients had endoscopic placement of removable silicone-covered polyester stent under fluoroscopic guidance. Stent placement was successful in all patients allowing immediate resumption of diet. After stent removal, contrast study showed no leak or stricture. Endoscopic stent therapy is an effective option in the management of postoperative esophageal perforation.     

Thoracic esophageal perforations: a decade of experience

BACKGROUND: Perforation of the thoracic esophagus is a formidable challenge. Treatment and outcome are largely determined by the time to presentation. We reviewed our experience with esophageal perforations to determine the overall mortality and whether the time to presentation should influence management strategy. METHODS: A retrospective chart review was performed on all patients treated for perforation of the thoracic esophagus from 1990 to 2001. There were 26 patients (14 men and 12 women; median age, 62 years; range, 36 to 89 years). Fourteen patients presented within 24 hours (early), and 12 patients presented after 24 hours (delayed). Nine of the 12 patients in the delayed group presented after 72 hours. The causes of the perforations were as follows: instrumentation (19 patients), Boerhaave's syndrome (2 patients), intraoperative injury (1 patient), and other (4 patients). In the early group, 3 patients were treated conservatively, 10 patients underwent primary repair, and 1 patient required esophagectomy for carcinoma. In the delayed group, 3 patients were treated conservatively, 6 underwent successful repair of the perforation, 1 had a T-tube placement through the perforation and eventually required an esophagectomy, and 2 had an esophagectomy as primary surgical treatment. RESULTS: Hospital mortality was 3.8% (1 of 26) and morbidity was 38% (10 of 26). Persistent leaks occurred in 3 patients, 2 after primary repair and 1 after T-tube drainage. All patients selected for conservative management successfully healed their perforation. CONCLUSIONS: Primary repair can be carried out in most cases of thoracic esophageal perforation regardless of time to presentation, with a low mortality rate. A small but carefully selected group of patients may be treated successfully without operation. Esophagectomy should be reserved for patients with carcinoma or extensive necrosis of the esophagus.     

Reduction of persistent air leak with endoscopic valve implants

The standard management of air leaks due to persistent bronchopleural fistula involves chest drainage and occasionally pleurodesis, with intractable cases requiring surgical decortication or surgical repair. However, some of these patients may be at high risk for surgery, particularly if they have already had thoracic surgery or have other medical problems; for this group there is a need for less invasive methods of stopping or reducing air leaks. Emphasys endobronchial valves (EBV) are occlusive devices designed primarily for endoscopic lung volume reduction in emphysema. Because the device is a one-way inspiratory airway blocker, it is possible that it could be used in controlling persistent air leaks while maintaining the drainage of secretions. Two cases are reported of persistent air leaks that were managed by endoscopic occlusion with EBV. In one case complete stoppage of the air leak was achieved with immediate clinical benefits. The second patient died 5 days after treatment from additional complications apparently not related to the procedure. Endobronchial blockage may be a useful salvage procedure for patients with persistent air leak for whom there is no other treatment available.     

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.     

Personal management of 57 consecutive patients with esophageal perforation

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.     

Management of esophageal gunshot wounds

The records of 20 patients with gunshot wounds of the esophagus seen from 1973 through 1985 were reviewed. Nine perforations were cervical, 10 were thoracic, and 1 was abdominal. Because physical findings and plain roentgenograms lack specificity, a high index of suspicion based on the path of the bullet tract is essential for early diagnosis. Esophageal injury should especially be suspected when the bullet wound is transcervical or transmediastinal. Perforation was diagnosed by esophagoscopy in 9 patients, esophagography in 4, and surgical exploration in 7. Mean time from admission to operation was 3.8 hours. Associated injuries occurred frequently. Eighteen patients were treated by primary closure and wide drainage, and 2 were managed by esophageal exclusion. There were 2 perioperative deaths, both in patients with associated aortic injuries, and 1 late death, for an overall mortality of 15%. There was one postoperative leak following a cervical repair. No leaks occurred in patients having a thoracic repair. The findings indicate that esophageal perforation must be sought by a variety of methods. With prompt diagnosis and early operation, primary repair can be safely accomplished. When sepsis from esophageal leak is avoided, mortality and major morbidity are related to associated injuries.     

The Use of Endoscopic Stent in Management of Leaks After Sleeve Gastrectomy

Gastric leak after sleeve gastrectomy can lead to significant morbidity and mortality. The aim of this study was to examine the safety and efficacy of endoscopic deployment of a covered esophageal stent in the management of leaks after sleeve gastrectomy. Three consecutive patients who underwent sleeve gastrectomy at outside institutions presented with leaks. All three patients underwent endoscopic placement of a covered stent. Additional procedures included laparoscopic or percutaneous drainage of abdominal collection(s). The patients were two women and one man, with a mean age of 34 years. One patient presented acutely at day 7 after the index operation and two patients presented late at 6 and 9 months, respectively. Two patients had proximal gastric leaks and one patient had a proximal gastric leak with a concomitant obstruction at the mid-aspect of the gastric sleeve. Endoscopic deployment of a covered stent was successful in all cases. There were no complications relating to the stent placement. The stent was removed at 6 weeks in two patients and at 4 months in one patient. The use of endoscopic stent was a safe and effective option in the management of leaks after sleeve gastrectomy.     

Management of esophageal perforation]

The majority of esophageal perforations is caused by endoscopic procedures, while the spontaneous rupture, also known as Boerhaave's syndrome, is rare. Regardless of the cause the esophageal perforation is an urgent surgical problem. The main diagnostic method is a water-soluble contrast study of the esophagus, probably supplemented by a CT-scan. In case of uncertain diagnosis or localisation eosophagoscopy should be performed. We believe that esophageal perforation should be operated, the factor "time" seems to be important for prognosis. In case of early surgical treatment (within 24 hours) a primary suture is sufficient and safe. Only after a delay in diagnosis with extended mediastinal spillage and necrosis of the esophageal wall the use of autogenous tissue to buttress the esophageal repair may be necessary. Esophagectomy should only be performed for perforated carcinomas. We treated 10 patients in a 4-years-period by primary surgical repair combined with drainage. Nine of them survived, only a 82-years old patient died because of an unresectable perforated esophageal carcinoma.     

Esophageal perforation during laparoscopic adjustable gastric band: conversion to open sleeve gastrectomy and endoscopic stent placement

Laparoscopic adjustable gastric band (LAGB) is one of the most popular bariatric surgical procedures both in Europe and United States, because it is considered to be a safe and effective way of treating morbid obesity. This minimally invasive frequently employed bariatric procedure has many reported complications, but only a few cases of esophageal perforation have been reported. We present a case of iatrogenic esophageal perforation in an 18-year-old patient occurring during attempt to place an adjustable gastric band laparoscopically, which was diagnosed intraoperatively. Conversion to open sleeve gastrectomy with primary suturing of the perforation and drainage were performed. On the early postoperative period leak from the intra-abdominal part of the esophagus was diagnosed and treated with endoscopic placement of a self-expandable metal stent.After 2-years of follow-up the patient continues to have no sequelae from the perforation or symptoms of dysphagia, while Excess Weight Loss is 74%.     

Selective nonoperative management of contained intrathoracic esophageal disruptions.

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).     

胸段食管骨性异物穿孔的分类与外科治疗

目的 探讨骨性异物所致胸段食管破裂穿孔的分类及其治疗方法.方法 对57例胸段食管骨性异物破裂穿孔患者根据食管损伤性质和继发感染程度进行分类,分别采取不同手术方式并总结其疗效.结果 Ⅰ类为食管破裂、纵隔无脓肿形成,共计17例;其中直接食管破口连续缝合修补7例,直接缝合修补后,外穿孔部位用肋间肌加强6例,心包和带蒂大网膜加强各2例.Ⅱ类为纵膈脓肿期,共计13例;其中食管穿孔切除、胃代食管10例,纵隔脓肿清除胸腔引流3例.Ⅲ类为脓胸期,即骨性异物穿破食管后感染波及胸腔而形成脓胸,共计21例;其中食管穿孔切除、一期胃带食管12例,食管穿孔切除、二期胃或结肠带食管9例.Ⅳ类为脓肿侵犯周围器官并形成主动脉-食管瘘或气管食管瘘,共计6例;气管瘘修补、大网膜填塞、二期胃或结肠代食管术4例,病变段血管切除、人工血管置换、二期胃或结肠代食管2例.Ⅰ、Ⅱ、Ⅲ类的51例患者50例获治愈,1例死于脓毒症引起的多脏器功能衰竭综合征.Ⅳ类的6例患者术前准备时麻醉诱导过程死亡1例,手术死亡1例,死因皆为食管-主动脉瘘导致的大出血,其余4例治愈.结论 对骨性异物所致胸段食管损伤病变进行分类,并采取相应方法治疗有助于提高疗效;一旦确诊均应采取积极的手术方式.     

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.     

Iatrogenic Injury of the Intrathoracic Esophagus Sustained During a Gastric Banding Procedure

The wide diffusion of laparoscopic adjustable gastric banding as a common surgical procedure for the treatment of morbidly obese patients can be attributed not only to the easy surgical technique, the ability to caliber the stoma, and the potential for reversibility, but also to the fact that this procedure is associated with a low rate of immediate postoperative complications compared to other more complex bariatric procedures. Herein reported is the case of a 63-year-old morbidly obese woman who sustained an iatrogenic injury of the intrathoracic esophagus during a laparoscopic adjustable gastric banding procedure. The putative mechanism of this previously unreported complication of laparoscopic adjustable gastric banding and the therapeutic options are discussed. The patient was initially treated with left pleural cavity drainage, antibiotics and the placement of an endoscopic silicone covered stent to cover the esophageal tear. Nine days later she underwent surgery through left thoracotomy due to the persistence of the esophageal leak. Esophageal perforation is a potentially life- threatening complication that may occur during a laparoscopic gastric banding procedure. The conservative treatment with an endoscopic stent should be reserved to patients with no signs of progressive systemic inflammation and include the drainage of the pleural cavity and the mediastinum, the endoscopic lavage and debridement. Standard surgical treatment with direct repair should not be retarded in case of persistence of the leak.     

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.     

Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.     

Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management

Abstract Objective: The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). Methods: A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome. Results: Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality. Conclusions: The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.     

Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus.

Perforation of the thoracic esophagus may be fatal unless diagnosed promptly and treated with an effective operation. The wide mortality range in different reports reflects the importance of these two factors. This range spans from as low as 11%, if operation is within 24 hours, to greater than 50% after two to three days. The high mortality with delayed treatment is principally due to inability to surgically close the perforation. Eighteen patients (aged from 31 to 78 years) were treated four hours to 14 days after thoracic esophageal perforation (less than 24 hours: 7 patients; 24 to 72 hours: 7 patients; greater than 72 hours: 4 patients). In 14 patients the perforation was sutured, after which the suture line was buttressed with a circumferential wrap of parietal pleura, originally described by Grillo. Underlying esophageal pathology was corrected and wide mediastinal drainage was instituted. All 14 patients recovered and were discharged from the hospital after a median stay of 20 days. Two patients had minor leaks at the suture line that soon closed. Four patients had perforations too extensive to close. Of these, one was resected, the Urschel procedure was used in two, and the Abbott T-tube drainage was used in one. Three of the four patients died. It was quite significant that the pleural wrap was equally effective with both early (6 patients) and delayed perforations (8 patients). These data indicate that the pleural wrap should be used routinely. Extensive perforations that cannot be closed should probably be treated by resection and drainage, followed by esophageal reconstruction at a later time.     

Life-threatening acute posterior mediastinitis due to esophageal perforation

We analyzed the treatment of a recent group of patients with life-threatening acute posterior mediastinitis due to esophageal perforation to elucidate common factors in successful treatment. Life-threatening acute posterior mediastinitis due to esophageal perforation was diagnosed in 16 patients over the past 12 years. Esophageal perforation resulted from endoscopy in 11 patients, retching in 4, and blunt trauma in 1 patient. Preoperative serum albumin levels were higher in patients who survived. Fourteen of 16 patients (88%) underwent exploration: mediastinal drainage in 14 (10 survived), esophageal repair in 9 (7 survived) with diversion in 3 (3 survived), and stent placement in 2 (1 survived). Six of 16 patients (38%) died, always of polymicrobial sepsis. Female patients and those with cancer, endoscopic perforations, delayed diagnosis, persistent mediastinal contamination, mediastinal suppuration or necrotizing cellulitis, and postoperative complications did poorly. Antibiotics must be effective against both gram-positive and gram-negative bacteria, and against both anaerobic and aerobic bacteria. Early surgical intervention is key, particularly elimination of ongoing mediastinal soilage. Thorough mediastinal debridement and wide mediastinal drainage appear to be important in improving survival of patients with life-threatening acute posterior mediastinitis due to esophageal perforation.