Perforation and rupture of the esophagus. Apropos of 35 cases

A series of 35 oesophageal perforations from the period 1980-1987 is reported. Sixteen perforations followed oesophageal endoscopy, 10 were spontaneous, 8 were due to foreign bodies and one was post-operative. The delay in reaching the right diagnosis was less than 24 hours in 18 cases and more than 24 hours in 17 cases. Oesophageal leak was demonstrated in 86% of our cases by contrast study; in the others by rigid oesophagoscopy. Perforation occurred in the cervical oesophagus in 6 patients, thoracic oesophagus in 28 and abdominal oesophagus in 2 (one had a double perforation). Three patients were managed non operatively and survived. Cervical oesophagostomy and oesophageal diversion were used in 4 patients as primary treatment because of perforation occurring in caustic burn cases (2 cases, both survived) or late severe sepsis (2 cases, both died). Two patients with neoplastic stricture were treated by oesophago-jejunal bypass without resection and partial oesophago-gastrectomy respectively: both survived. Direct suture and closure of the perforation were performed in 26 patients. Two died, one because of oesophageal leak. Post-operative localized leaks developed in 5 other patients without any mortality and 4 healed with conservative management. The overall mortality rate was 11% (4 patients). All had a delayed diagnosis (more than 48 hours). We suggest that even in patients with delayed diagnosis of a non-malignant oesophageal perforation, direct suture and closure should be attempted under protection of functional oesophageal diversion and "contact drainage" to canalize a possible post-operative localized leak. Good oesophageal diversion can be achieved by naso-oesophageal suction and gastric suction through gastrostomy or with oesogastric antireflux procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perforation and rupture of the oesophagus: treatment and prognosis

AIM OF THE STUDY: To analyze treatment and prognosis of perforations and ruptures of the oesophagus. MATERIAL AND METHODS: This retrospective study included 40 patients (26 men and 14 women; mean age = 59 +/- 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic (n = 6) or following ingestion of a foreign body (n = 1). Thirty-three perforations were thoracic: iatrogenic (n = 15), spontaneous rupture (n = 14), following ingestion of foreign body (n = 3) or traumatic (n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture (n = 13), oesophagectomy (n = 11) or double exclusion (n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body). RESULTS: The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion. CONCLUSION: Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.     

Esophageal perforation: which factors affect the prognosis? Results of a 10-year experience

Oesophageal perforations are a catastrophic event with a 10-40% mortality rate. The decisive prognostic factor is the time from the event to the diagnosis, while there is no agreement as to the therapeutic options. The aim of this study was to present our ten-year experience in the treatment of oesophageal perforations together with an evaluation of the prognostic factors. From January 1995 to January 2005, 18 patients (11 M, 7 F), mean age 49.3 years (range: 22-79), with oesophageal perforations were treated in our department. They were classified according to the cause and localization of the perforation and the time elapsing since the event. The perforation was localised in the cervical oesophagus in 4 patients (22.2%), in the abdominal oesophagus in 4 patients (22.2%) and in the thoracic oesophagus in 10 patients (55.5%). It was spontaneous in 4 patients (22.2%), traumatic in 4 (22.2%) and iatrogenic in the remaining 10 (55.5%). In 7 patients (38.9%), the treatment was started during the first 24 hours from the event, while the remaining 11 (61.1 %) were referred to us more than 24 hours after the perforation occurred. The overall mortality was 27.8% (5 patients). The only decisive prognostic factor was the time of observation: only 1 patient (14.3%) died in the group observed in the first 24 hours, while the remaining 4 who died (36.4%) were in the group treated more than 24 hours after the event (p < 0.05). Our series confirms that the time elapsing from the event to the diagnosis is the only decisive prognostic factor in the treatment of oesophageal perforations. There is no therapeutic option of choice since there is no significant influence of either cause or localisation of the perforation on outcome.     

Stent placement in the management of oesophageal leaks

Objective: To examine retrospectively the patients of our department who had a self-expandable totally covered metal stent placed for oesophageal leak. METHODS: Patients hospitalised in our department for oesophageal cancer and/or oesophageal perforation between 2004 and 2006. All medical records were retrospectively reviewed. Seventy-two patients underwent oesophageal resection for oesophageal cancer and 16 were managed for oesophageal perforations. RESULTS: Eight out of 72 patients submitted to resection for oesophageal cancer had postoperative leaks, while one patient developed tracheo-oesophageal fistula (TEF) due to prolonged mechanical ventilation. Six of them had stent placement in first intention, whereas two received the procedure after an unsuccessful repeat operation. The mean stent placement time was 18.4 days (SD=15.2 days), whereas the median was 14 days. The leak was managed efficiently by the stent in seven patients, whereas two patients needed repeat operations (one with TEF). The mean stent removal time was 56.8 days (SD=30.5 days) and the median was 40 days. None developed anastomotic stricture. On the other hand, three out of 16 patients with perforation had a stent, two of them for Boerhaave syndrome and one for iatrogenic rupture after bariatric surgery. One of them required the stent 17 days after surgical repair with excellent results, while the other two patients had the stent placed immediately, but still needed thoracotomy to control the leak. CONCLUSIONS: Stent placement can prove very useful in the management of post-oesophagectomy anastomotic leaks, but its contribution needs to be evaluated with caution in cases of oesophageal perforations or TEF. Larger series and prospective comparative clinical trials could eventually clarify the role of stents in clinical practice of surgical patients.     

Treatment of iatrogenic oesophageal perforation diagnosed with delay.

The number of iatrogenic perforations of the oesophagus has increased during the last decade and the condition still carries a high morbidity and mortality. The mortality increases considerably if treatment is delayed for more than 24 hours. In our department all patients with iatrogenic perforation of the thoracic oesophagus are treated in the same way: antibiotics and gastric decompression followed by thoracotomy with cleavage of the mediastinum and closure of the defect if it can be visualized and if the oesophageal wall is vital. During the last decade we have treated 15 patients in whom treatment was delayed for more than 24 hours. Two of the patients (13%) died during the postoperative course. We find that our strategy is associated with a low mortality.     

Instrumental perforations of the oesophagus and their management.

The records of 39 patients who had developed a perforation of the oesophagus after instrumentation were reviewed. Ten (group A) had cervical and 29 (group B) thoracic oesophageal perforation. Twenty three perforations occurred during dilatation of an oesophageal stricture, 10 during oesophagoscopic removal of a foreign body, and six during diagnostic oesophagoscopy. Of the 21 patients treated within 36 hours (early treatment group), four (19%) died; of the 18 treated more than 36 hours after the perforation (late treatment group), nine (50%) died. None of the 10 patients in group A had strictures and only two presented late. After drainage of the neck and mediastinum the outcome was successful in all patients. Thirteen of the 29 in group B were treated early and four of these died; nine of the 16 treated late died, the total mortality for thoracic perforation being 48%. An oesophageal stricture was present in 23 patients. Twelve of these underwent various forms of conservative surgery and there were 10 deaths. This contrasts with the 11 who received radical treatment with resection and reconstruction, only two of whom died. The six patients with no pre-existing stricture were treated with conservative forms of surgery, with one death.     

Carcinoma of the hypopharynx and the cervical oesophagus: a surgical challenge.

OBJECTIVE: To report our results after reconstruction of the upper digestive tract for locally advanced carcinoma of the hypopharynx and cervical oesophagus. DESIGN: Open study. SETTING: Teaching University hospital, Germany. SUBJECTS: Of the 517 patients who presented with carcinoma of the oesophagus between September 1985 and March 1997, 16 had a locally advanced tumour of the hypopharynx and 25 of the cervical oesophagus. INTERVENTIONS: Free jejunal grafts were used after circular resection in all patients with carcinoma of the hypopharynx, and for the 3 with oesophageal carcinoma in whom we obtained adequate resection margins. In the remainder stomach was used in 21 and colon in 1. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: After jejunal grafting 1 patient died within 30 days and 2 died in hospital. After gastric or colonic reconstruction 2 patients died within 30 days and 4 in hospital. There was 1 anastomotic leak, 1 transplant became necrotic and had to be replaced, in 2 patients the recurrent nerve was damaged, 1 patient developed a wound infection and 1 a cardiac infarction. After gastric or colonic replacement 7 patients had paralysed recurrent laryngeal nerves, there was 6 anastomotic leaks, 1 chylous leak, 1 haemorrhage, and in 1 the transplant necrosed. CONCLUSION: Despite the fact that we compared tumours in different sites, these results suggest that the jejunal graft is safer for upper oesophageal and hypopharyngeal reconstruction.     

An Eastern perspective on oesophageal perforation: a high incidence of ingested bones

Background: Oesophageal perforation is uncommon, with controversy surrounding its optimal management. Our local experience shows a high incidence of oesophageal perforation secondary to ingested bones. Methods: Fourteen patients with oesophageal perforation treated at Changi General Hospital in Singapore between January 1996 and December 2006 were retrospectively reviewed. Results: The median age was 52 years (16–79 years), with eight men and six women. There were 11 thoracic perforations and 3 cervical perforations. Ten perforations were the result of foreign body ingestion, three were spontaneous and only one was iatrogenic. The offending foreign body was a fish bone in five patients, a chicken bone in four and a tooth in one. Three of our 14 patients were treated surgically. The remaining 11 patients were treated non‐operatively. All nine patients with fish or chicken bone perforation were treated conservatively, except two in whom conservative therapy failed and they subsequently required surgery. The median length of hospital stay was 7 days (2–109 days). There was one death. Conclusion: Oesophageal perforation requires prompt diagnosis and treatment. Most of our oesophageal perforations are secondary to ingested bones. Such cases can often be treated conservatively in our experience.     

Traumatic rupture of the oesophagus and stomach

Thirty-nine cases of traumatic perforation of the oesophagus or stomach have been studied. Thirty-two of the perforations followed oesphagoscopy, five were `spontaneous,' and two were due to damage by a foreign body. Eight of the perforations occurred in the cervical oesophagus, 22 in the thoracic portion, and nine were in either the abdominal oesophagus or the stomach. Treatment was of two types—either operative closure of the perforation or a conservative routine of intravenous fluids, parenteral antibiotics, and cessation of oral feeding. In some patients treated conservatively, drainage procedures were also carried out. Five patients with terminal carcinoma, in whom oesophageal intubation after prolonged dysphagia caused perforation, had no treatment apart from analgesics and sedatives. Several of the patients treated by surgical closure had a concurrent definitive operation (resection of carcinoma in four cases and myotomy for achalasia in two cases). Fourteen of the 21 patients treated by repair or resection of the perforation survived. Ten of the 13 treated conservatively also survived. The good results of conservative treatment for cervical perforations appear to make it the treatment of choice. Only an occasional case of thoracic perforation is suitable for conservative treatment, and as a general rule perforations in this area and in the peritoneal cavity should be treated surgically.     

Anastomotic leakage: an avoidable complication of Lewis-Tanner oesophagectomy

Data were collected prospectively from 159 patients undergoing Lewis-Tanner oesophagectomy for carcinoma of the lower two-thirds of the oesophagus and analysed with regard to anastomotic leakage. The 30-day mortality rate was 3.8 per cent and none of these deaths was due to anastomotic leakage. In hospital, mortality was 7.5 per cent. Six patients (3.8 per cent) had evidence of a leak. In four patients this was from the suture line, but in the remaining two it was due to patches of gangrene in the fundus of the transposed stomach and was separate from the anastomosis. Two patients died with an unhealed leak. Anastomotic leaks were minor in three instances and healed with conservative treatment but the fourth required exploration. Gangrene of the oesophageal substitute resulted in gross leakage with mediastinitis and required exploration in both cases. An apparent predisposing cause was evident in five of the six cases with leakage and some of these might have been avoidable. Transthoracic oesophagectomy can be performed with acceptably low mortality and leak rates and may therefore be considered as the treatment of choice for most patients with oesophageal cancer.     

Perforation of the Intrathoracic Oesophagus

A series of 19 patients with perforation of the intrathoracic oesophagus is presented. Recent perforations were treated by primary suture. All these patients survived, although the suture did not hold in all cases. Old perforations, together with recent ones that leaked after suturing, were treated by drainage and gastrostomy. Two of these patients died; they were the only patients in whom the first attempt at drainage was unsatisfactory and thus had to be revised. The treatment of oesophageal perforations seems to be in accordance with the long-established principles of treatment of other gastro-intestinal and genito-urinary fistulas: firstly to restrict primary suturing to non-inflammatory tissue, and secondly to apply the principles of secondary healing by means of decompression and drainage.     

Prevention of the neoplastic progression of Barrett's oesophagus by endoscopic argon beam plasma ablation

BACKGROUND: Patients with Barrett's oesophagus have a risk of approximately 1 per 100 patient-years for the development of oesophageal adenocarcinoma. Endoscopic ablation of Barrett's oesophagus has been shown to lead to the regrowth of a 'neo' squamous epithelium if gastro-oesophageal reflux is controlled, but the incidence of subsequent tumour formation is unknown. METHODS: The follow-up of 55 patients who underwent endoscopic ablation of Barrett's oesophagus by argon beam plasma coagulation (ABPC) is reported. Of the 55 patients, nine had low-grade dysplasia, nine had high-grade dysplasia and the remainder had non-dysplastic Barrett's metaplasia. Twelve patients had reflux control by antireflux surgery and the remainder received proton pump inhibitor therapy. Barrett's metaplasia was ablated by ABPC to within 2 cm of the gastro-oesophageal junction. RESULTS: To date, one patient has died and one patient was unable to complete treatment. The remaining patients were followed by regular endoscopic surveillance for a mean of 38.5 months to give a total follow-up of 173.5 patient-years. No malignancy has developed in any patient during follow-up. CONCLUSION: The absence of malignant complications in this study of prophylactic ablation of long-segment Barrett's oesophagus strengthens the argument for endoscopic ablation in the prevention of oesophageal adenocarcinoma.     

Perforation of the lower thoracic oesophagus following crush injury to the chest and abdomen.

We report a case of perforation of the lower thoracic oesophagus following a crush injury to the chest and upper abdomen. A laparotomy was performed for abdominal injuries, and appropriately placed drains resulted in complete resolution of the oesophageal leak, 21 days following the injury. This case report demonstrates that a conservative approach to lower thoracic oesophageal perforations can be carried out successfully without the added morbidity of a thoracotomy, or risks of a direct repair.     

The diagnosis and treatment of esophageal perforations resulting from nonmalignant causes

Esophageal perforations are extremely difficult to diagnose and treat. We report herein our results of a review of 26 patients with esophageal perforation which were spontaneous in 11, iatrogenic in 11, and caused by a foreign body in 4. Surgical treatment was performed in 7 of the patients with spontaneous rupture, but the remaining 19 patients were treated conservatively. The abnormality was found by plain radiography (X-ray) in 22 (85%) of the 26 patients, and by computed tomography (CT) in all 13 patients who underwent this procedure. The detection rates by esophagography and esophagoscopy were 100%, or all of 25 patients examined, and 60%, or 9 of 15 patients examined, respectively. Of 12 patients with underlying diseases, 4 (33%) died after the perforation, whereas only 1 (7%) of 14 patients without any underlying disease died. Postoperative empyema developed in all of 3 patients treated by intraoperative unfixed intrathoracic drainage (UID), but in none of the 4 treated by fixed intrathoracic drainage (FID). Conservative treatment achieved satisfactory results for spontaneous esophageal ruptures confined to the mediastinum, and for iatrogenic perforations and esophageal perforations caused by foreign bodies, provided there was no serious underlying disease such as advanced cirrhosis. Moreover, intraoperative FID proved useful in helping to prevent postoperative empyema.     

Mismatch between trainees' subspecialist interest and advertised jobs; worrying implications for upper gastrointestinal trainees

AIMS: Spontaneous rupture of the oesophagus (SRO) is a rare and often fatal event. The aim of this study was to evaluate the presentation, management and outcome of SRO in a single unit. METHODS: Data were collected on all patients presenting with SRO over a 5-year period with respect to presenting features, diagnostic investigations and subsequent management. Statistical analysis was by Student's t test, chi2 and Fisher's exact tests. RESULTS: Fourteen patients were identified, 12 men and two women with a median age of 64 (range 18-78) years; eight were tertiary referrals. Thirteen of 14 patients presented with chest or upper abdominal pain following vomiting or retching and 13 had an abnormal initial chest radiograph; only one presented with Mackler's triad of pain, vomiting and surgical emphysema. The median delay to diagnosis was 21 (range 1-84) h; this delay did not significantly affect outcome (P = 0.16). An endoscopic assessment and contrast swallow were performed in all patients. Nine of ten patients with a demonstrable leak and full-thickness tear were managed surgically and the four patients with no leak were managed conservatively (P = 0.005); surgical management consisted of thoracotomy, lavage, repair of the perforation and a feeding jejunostomy. Seven patients had a repair over a T tube and two had a primary repair. All conservatively managed patients had contained, controlled or intramural perforations and two also required a feeding jejunostomy. Patients requiring surgery had a longer hospital stay (mean(s.d.) 57.9(34.8) versus 22.2(30.7) days; P = 0.081) and a significantly longer intensive care unit stay (P = 0.044). The overall mortality rate from SRO was 14 per cent (two patients); no deaths occurred in the conservatively managed group. CONCLUSIONS: SRO continues to be diagnosed late despite a classical history and/or abnormal chest radiograph. Endoscopic assessment of perforations is safe and in combination with a contrast swallow can confidently predict patients with contained or controlled rupture in whom non-operative management is successful.     

Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.     

Outcomes after oesophagogastrectomy for carcinoma of the oesophagus

BACKGROUND: Carcinoma of the oesophagus is a rare but a highly lethal malignancy. The incidence of adenocarcinoma in particular is increasing in the Western world. Despite improvements in staging, perioperative care and the use of adjuvant/neoadjuvant regimen the prognosis remains poor. METHODS: All patients who had biopsy-proven oesophageal carcinoma between the years 1992 and 2004 in the Wellington region, New Zealand, were retrospectively reviewed. The personal and tumour characteristics, operation details, complications and the details of hospital stay of patients who had had a resection were recorded in a database . Survival data were recovered from the notes, hospital database or general practitioner records and were available for all patients who had surgery. Survival analyses were calculated using Kaplan-Meier estimates. RESULTS: One hundred and ninety-one patients were diagnosed with oesophageal carcinoma during the study period (59% adenocarcinoma, 32% squamous cell carcinoma). Only 35% (n = 67) had a resection (81% adenocarcinoma, 13% squamous cell carcinoma). Fifty-one (77%) had an Ivor Lewis procedure, 9 (14%) had only a laparotomy and 6 (9%) had a laparotomy, right thoracotomy and cervical incision. Forty-six (70%) tumours were in the distal third of the oesophagus and 13 (20%) were at the oesophagogastric junction. Perioperative mortality was 10% (n = 7) and anastomotic leak rate 9% (n = 6). Five-year survival was 23%. CONCLUSION: Results from our institution for the resection of oesophageal cancer compare favourably with those in the published work. Staging with computed tomography and laparoscopy has resulted in acceptable resection and survival rates. Survival for this disease is still largely stage dependent and earlier diagnosis probably holds the key to improved prognosis.     

Operative and nonoperative management of esophageal perforations.

During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).     

Tracheo-oesophageal fistula and pre-operative mechanical ventilation

Twelve patients with tracheo-oesophageal fistula (TOF) and restrictive lung disease necessitating pre-operative ventilation are reported. Eight patients had respiratory distress syndrome, four had aspiration pneumonia, and 11 had associated oesophageal atresia. Two patients in whom a preliminary gastrostomy was performed died. Emergency ligation of the fistula was performed in 10 patients, nine of whom survived. Following division of the fistula, respiratory function improved dramatically in three patients and primary oesophageal repair was performed. Three patients underwent delayed primary repair and the oesophagus was sacrificed, with a view to replacement at a later date, in the remaining three patients. We believe that the presence of a TOF in a neonate with poorly compliant lungs requiring mechanical ventilation represents a serious surgical challenge. Gastrostomy alone should never be performed. Ligation of the fistula with either immediate or delayed primary repair of the oesophagus are the treatments of choice.     

Effect of surveillance of Barrett's oesophagus on the clinical outcome of oesophageal cancer

BACKGROUND: Surveillance programmes for Barrett's oesophagus have been implemented in an effort to detect oesophageal adenocarcinoma at an earlier and potentially curable stage. The aim of this study was to examine the impact of endoscopic surveillance on the clinical outcome of patients with adenocarcinoma complicating Barrett's oesophagus. METHOD: Consecutive patients who underwent oesophageal resection for high-grade dysplasia or adenocarcinoma arising from Barrett's oesophagus were studied retrospectively. The pathological stage and survival of patients identified as part of a surveillance programme were compared with those of patients presenting with symptomatic adenocarcinoma. RESULTS: Seventeen patients in the surveillance group and 74 in the non-surveillance group underwent oesophagectomy. Disease detected in the surveillance programme was at a significantly earlier stage: 13 of 17 versus 11 of 74 stage 0 or I, three versus 26 stage II, and one versus 37 stage III or IV (P < 0.001). Lymphatic metastases were seen in three of 17 patients in the surveillance group and 42 of 74 who were not under surveillance (P = 0.004). Three-year survival was 80 and 31 per cent respectively (P = 0.008). CONCLUSION: Patients with surveillance-detected adenocarcinoma of the oesophagus are diagnosed at an earlier stage and have a better prognosis than those who present with symptomatic tumours.