Esophageal intramural pseudodiverticulosis associated with esophageal perforation

We report a rare case of esophageal intramural pseudodiverticulosis with lower esophageal stricture which perforated into the peritoneal cavity after the patient vomited. A 61-year-old man was admitted with severe chest and epigastric pain after dysphagia and vomiting. Under a diagnosis of upper gastrointestinal perforation, laparotomy was performed. The anterior wall of the abdominal esophagus was found to have ruptured, and proximal gastrectomy with abdominal esophagectomy was performed. His-tological examination revealed esophageal intramural pseudodiverticulosis with esophageal stricture distal to the site of rupture, and postoperative endoscopy showed diffuse pseudodiverticulosis in the remaining esophagus. The patient is free of symptoms 5 years after the surgery. This case suggests that careful treatment may be indicated in patients with esophageal intramural pseudodiverticulosis with stricture and elevated intraluminal pressure, to minimize the possibility of severe complications such as esophageal perforation. Received: June 7, 1999 / Accepted: January 28, 2000     

Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures

BACKGROUND: Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. CASE: A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. CONCLUSION: Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.     

Thoracic osteophyte: rare cause of esophageal perforation

Esophageal perforation is a difficult problem in thoracic surgery. Esophageal perforations can be spontaneous, iatrogenic, or malignant. We report two cases of esophageal perforations caused by thoracic osteophytes and different management strategies leading to successful outcomes. An 80-year-old male presented with chest pain and dysphagia following a fall. On endoscopy, an esophageal perforation and foreign body was noted which was confirmed as a thoracic osteophyte on computed tomography scan. He was managed conservatively as he declined surgery. A 63-year-old male was admitted with dysphagia following a food bolus obstruction. Following esophagoscopy and dilatation, there was clinical and radiological evidence of perforation. During surgery, a thoracic osteophyte was identified as the cause of perforation. The perforation was closed in layers and the osteophyte was trimmed. Both patients recovered well. Thoracic osteophytes are a rare cause of esophageal perforations and a high index of suspicion is required in patients with osteoarthritis who present with esophageal perforations.     

Efficacy of Endoscopic Prosthesis in T4 Cancer of the Intrathoracic Esophagus

No remarkable improvement has yet been achieved in the survival of patients with advanced intrathoracic esophageal cancer. In particular, patients with complications such as esophago-bronchial fistula or invasion into the mediastinum have an especially miserable prognosis, even with surgical treatment. To improve the quality of life (QOL) of such patients, extensive palliative therapy should be provided. Thus, we have introduced an endoscopic esophageal intubation technique for the treatment of stenosis or perforation in patients with T4 esophageal cancer. Nine patients with unresectable intrathoracic esophageal cancer, complicated by stenosis or perforation, were treated with an endoscopic esophageal prosthesis. Four cases had an esophago-bronchial fistula, and in three the tumor had perforated the mediastinum. The prosthesis was successfully placed under endoscopic guidance in all nine cases. Six patients (66.7%) subsequently resumed oral intake without discomfort, while two had reasonably good outcomes in this regard (efficacy rate; 88.9%). Complications were seen in three patients: mainly chest discomfort, reflux esophagitis and migration of the prosthesis in one patient each. Six patients required prolonged administration of chemotherapeutic agents following prosthesis placement. Mean survival was 123.4±77.0 days. Four of the nine patients died in the hospital. Palliative endoscopic esophageal prosthesis was considered to be useful for patients with advanced esophageal cancer. With this technique, an improvement in QOL was achieved, as sufficient oral intake was facilitated and pulmonary and mediastinal complications due to perforation were diminished.     

Esophageal Perforation After Transesophageal Echocardiogram

Esophageal rupture after transesophageal echocardiogram (TEE) is a rare but life-threatening complication. Risk factors for perforation include spasm or hypertrophy of the cricopharyngeal sphincter, cervical arthritis, forward and left lateral bending of the distal esophagus, and esophageal disease such as inflammation or neoplasm. We present the case of a 80-year-old woman who developed perforation of her esophagus after TEE. Prior irradiation to the chest due to treatment for breast cancer and subsequent fibrosis probably contributed to this complication. Physicians referring patients for a TEE and physicians performing this procedure should be aware for the risk of perforation. The identification of risk factors and gentle maneuvering of the probe may prevent this severe, life-threatening complication.     

Boerhaave's syndrome as the primary manifestation of adult eosinophilic esophagitis. Two case reports and a review of the literature

Eosinophilic esophagitis (EoE) has been associated with an increased risk of esophageal mucosal tears induced by vomiting to dislodge impacted food or following endoscopic procedures. However, Boerhaave's syndrome or transmural perforation of the organ resulting from vomiting induced to dislodge impacted food has rarely been reported. In this article, we present two male adult patients with long‐term esophageal symptoms who suffered from Boerhaave's syndrome after the impaction of food in the esophagus. Both patients required surgical management because of clinical and radiological signs of perforation. This rare complication of EoE has been documented in 11 other reports, predominantly affecting young men in whom EoE had not been previously diagnosed, despite the majority having esophageal symptoms and a history of atopy. There are only two published cases of esophageal perforation that presented in children, which were managed conservatively. Our two patients and 4 out of the 11 described in literature required surgery because of esophageal perforation. Our two cases involved closure of the perforation, while in three published reports, perforation resulted in a partial or complete esophagectomy. No cases have been published on Boerhaave's syndrome caused by EoE that ended in fatalities. It is important to note that esophageal perforation caused by vomiting is a potentially severe complication of EoE that is being increasingly described in literature. Therefore, patients with non‐traumatic Boerhaave's syndrome should be assessed for EoE, especially if they are young men who have a prior history of dysphagia and allergic manifestations.     

Utility of ambulatory 24-hour esophageal pH and motility monitoring in noncardiac chest pain: report of 90 patients and review of the literature

It is unclear whether prolonged motility monitoring improves the diagnostic yield of standard esophageal tests in patients with noncardiac chest pain. Our aim was to assess the diagnostic value of ambulatory 24-hr pH and pressure monitoring in patients with noncardiac chest pain. Stationary manometry, edrophonium testing, and ambulatory pH and motility studies were performed in 90 consecutive patients with recurrent chest pain and normal coronary angiograms. Normality limits of ambulatory 24-hr motility were established in 30 healthy controls. The diagnoses of specific esophageal motility disorders (nutcracker esophagus and diffuse esophageal spasm) by stationary and ambulatory manometry were discordant in 48% of the patients. Edrophonium testing was positive in 9 patients, but correlated poorly with esophageal diagnoses. During ambulatory studies, 144 chest pain events occurred in 42 patients, and 72 (50%) were related to esophageal dysfunction. Strict temporal associations of events with esophageal dysfunction in relation to ambulatory 24-hr pH'motility scores permitted four patient categorizations: true positives (event-related and abnormal tests), N = 15; true negatives (event-unrelated and abnormal tests), N = 10; reduced esophageal pain threshold (event-related and normal tests), N = 4; and indeterminate origin (event-unrelated and normal tests), N = 13. Overall, 19 patients (21%) had a probable esophageal cause for chest pain (14 esophageal motility disorder, 4 acid reflux, 1 both). In conclusion, ambulatory manometry increases the diagnostic yield of standard esophageal testing in noncardiac chest pain, but the gain is small. Causes of chest pain other than high esophageal pressures and acid reflux must still be sought in most patients with chest pain of unknown origin after a negative cardiac work-up.     

Esophageal Foreign Body Perforation: Report of an Unusual Case and Review of the Literature

This report describes a patient with a foreign body esophageal perforation in whom the usual clinical symptoms of respiratory distress and severe chest pain as well as obvious abnormalities on X-rays of the chest and esophagus were not present. The possible subtle nature of esophageal perforation is emphasized and the evaluation of such cases is reviewed.     

Spontaneous esophageal rupture responding to simple suture closure, drainage, and percutaneous endoscopic gastrostomy (PEG): case report

Spontaneous esophageal rupture is a rare disease, and the diagnosis and treatment have not been fully established. Herein we present a 55-year-old man with spontaneous esophageal rupture who was successfully treated using simple suture closure, drainage, and intraoperative percutaneous endoscopic gastrostomy. He was brought to the emergency room after vomiting gastric contents and blood and then experiencing chest pain. On admission, vital signs were normal. Emergency endoscopy was performed for hemostasis, and spontaneous esophageal rupture was diagnosed. As chest computed tomography suggested intrathoracic perforation, surgery was performed about 8 h after onset. Surgery confirmed spontaneous esophageal rupture localized in the mediastinum. Simple suture closure, drainage, and intraoperative endoscopic gastrostomy were performed. On postoperative day (POD) 1, the patient was weaned off artificial ventilation, and enteral feeding through PEG was initiated. Oral intake was restarted on POD 10. The patient was discharged on POD 16.     

Management of spontaneous perforation of esophageal cancer with covered self expanding metallic stents

Optimal management of esophageal perforation is controversial, especially in the presence of malignancy. Esophagectomy has traditionally been employed for patients with malignant perforations. However, in patients with advanced disease, other less invasive treatment options may be of benefit. We present two cases of spontaneous perforation of advanced esophageal cancer successfully managed by insertion of covered self-expanding metallic stents and a review of the literature.     

Successful endoscopic hemoclipping of an esophageal perforation

We describe a case of esophageal perforation that resulted from a fishbone. A 71-year-old man had had a fishbone impacted in the lower esophagus for 2 days. At presentation, the bone was dislodged at endoscopy; one round opening in a deep ulceration was detected when the fishbone was removed. The perforation was closed by endoscopic hemoclipping, after the removal of the fishbone. A thoracic computed tomography revealed air around the esophagus, aorta and bronchus and the presence of a pleural effusion. These findings suggested mediastinal emphysema and mediastinitis due to the esophageal perforation after the removal of the fishbone. Esophagography revealed a focal esophageal defect and linear contrast leakage at the distal esophagus. The mediastinal emphysema and pleural effusion successfully resolved after the endoscopic hemoclip application and conservative management of the perforation.     

Esophageal perforation: the importance of early diagnosis and primary repair

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.     

Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK

Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23–86) years. The etiology of the perforations were Boerhaave's syndrome ( n = 19), therapeutic endoscopy ( n = 9), diagnostic endoscopy ( n = 2), gastric lavage injury ( n = 1), foreign body ( n = 1), blunt chest trauma ( n = 1), and spontaneous tumor perforation ( n = 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair ( n = 9), T-tube drainage ( n = 7), emergency esophagectomy ( n = 1), or intra-operative stent insertion ( n = 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.     

Esophageal dysmotility and acid sensitivity in patients with mitral valve prolapse and chest pain

Mitral valve prolapse (MVP) patients often experience non-cardiac chest pain. The aims of this study were to determine, in patients with non-cardiac chest pain: (i) whether esophageal dysmotility is more common in patients with MVP than in patients without MVP; and (ii) if acid sensitivity is an important cause of the chest pain in MVP patients. Esophageal manometry and acid perfusion testing were performed in 277 consecutive patients with non-cardiac chest pain. Patients with MVP (13 female, one male; mean age 49 years) were more likely (P = 0.01) to have esophageal dysmotility, while acid perfusion was less likely (P < 0.05) to provoke their chest pain, than in patients without MVP. The most common esophageal motor abnormalities detected in patients with and without MVP were diffuse esophageal spasm (prevalence, 57%) and non-specific motor disorder (prevalence, 9%), respectively. This study, the first large prospective series examining possible esophageal sensorimotor correlates of chest pain in MVP patients, demonstrates that in the absence of a cardiac cause for chest pain, a specific esophageal motility disorder should be excluded, rather than assuming the chest pain is likely to be due to acid sensitivity.     

Retrograde tube drainage for esophageal anastomotic leaks and perforation

The mortality and morbidity of esophageal anastomotic leaks or perforations remain high. We performed retrograde transanastomotic esophageal sump tube drainages for esophageal anastomotic leak or perforation in three patients. Our method is a modified procedure of the T-tube drainage. The Levin gastric tube was simply inserted into the esophagus via anastomotic leak or perforation to develop a defined fistula. All three patients were treated with a satisfactory outcome. An advantage of this method is that it is technically easy, and available for patients whose diseases are difficult to treat with standard T-tube drainage. In addition, one of our patients was successfully managed non-operatively by fluoroscopical guidance. This retrograde esophageal sump tube drainage was technically very easy, safe and useful for esophageal anastomotic leaks or perforations.     

Intramural esophageal hematoma after endoscopic injection sclerotherapy for bleeding varices

Endoscopic variceal sclerotherapy (EVS) is widely used to treat bleeding esophageal varices. A variety of complications have been reported after EVS, including intramural hematoma of the esophagus (IHO), which occurs infrequently. The present report describes four new cases of IHO after EVS and reviews the pathogenesis, diagnosis and treatment of the condition. In addition, 10 patients with IHO after EVS documented in the literature are analyzed. Between 1984 and 2001, 580 patients with bleeding esophageal varices had 5038 endoscopies and underwent a total of 2628 variceal injection sessions. The incidence, presentation and response to conservative management of IHO were evaluated. Four of the 580 patients (0.7%) developed IHO as a complication of EVS. All developed severe retrosternal chest pain, sudden‐onset dysphagia and odynophagia after EVS. Diagnosis was confirmed using upper gastrointestinal contrast studies. Patients were kept nil per mouth and received intravenous fluids until able to swallow without difficulty. Symptoms usually began to resolve spontaneously within 36–72 h and disappeared completely in 2–3 weeks. In a patient who has recently had EVS and has a clinical picture compatible with the diagnosis of IHO, contrast studies provide the simplest way of confirming the diagnosis and excluding an esophageal perforation. Treatment of IHO after endoscopic variceal sclerotherapy should be conservative, due to the benign, self‐limiting nature of this uncommon complication.     

Options in the management of esophageal perforation: analysis over a 12‐year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12‐year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro‐ or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.     

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.