Surgical treatment of iatrogenic perforations of the distal third of the esophagus. Personal experience

AIM: The esophageal perforations are associated with a high mortality and morbidity when they are not diagnosed and treated quickly. The aim of our study is to analyze the treatment and prognosis of the distal iatrogenic esophageal perforations on the basis of time of onset, concomitant disease and size of perforations. METHODS: The retrospective review was performed on 10 patients treated for distal iatrogenic esophageal perforations at our Institution from 1994 to 2003. The cause of perforations was: pneumatic dilation (7 patients) and esophageal endoprosthesis placing (3 patients). Seven patients presented within 24 h (Group A), and 3 patients presented after 24 h (Group B). In Group A, 4 patients underwent primary repair, 2 patients required esophagectomy and 1 patient was treated conservatively. In Group B, 2 patients were treated conservatively and 1 patient required an esophagectomy. RESULTS: Hospital morbidity was 20% and mortality was 30%. In Group A no patients died. In Group B hospital mortality was 100%. The most common cause of death was multiorgan failure resulting from sepsis. CONCLUSIONS: The prognosis for esophageal perforations is influenced by the time elapsed between diagnosis and treatment. Esophagectomy is indicated for patients with extensive perforation and necrosis of the esophagus when primary repair cannot be carried out. It is indicated also as treatment for the concomitant disease.     

Traumatic perforations of the esophagus

Over the past 15 years nine patients with traumatic mechanical perforations of the esophagus have been treated. Seven perforations were iatrogenic, two were accidental. One patient treated conservatively did well. Two patients were operated on without delay. Their hospitalization was short and they had no complications. Six patients were referred to surgery after a delay ranging from 5 days to 17 days from the time of perforation. Their hospitalization ranged from 9 to 113 days, averaging 62.7 days. Complications were common and two patients died. In order to assure survival of patients with esophageal perforation, early aggressive treatment is essential in nearly all instances. In an occasional patient with a small and clean perforation at the esophageal inlet, conservative treatment may be justified.     

Treatment of endoscopic esophageal perforation

Background: The increasing usage of flexible endoscopy leads to a higher incidence of esophageal perforations, whose treatment strategies (conservative or operative) still are discussed controversially. We present our experiences and therapy concepts in relation to 75 iatrogenic esophageal perforations. Patients: Between 1983 and 1997, 75 patients were treated for endoscopic perforation of the esophagus. The gender distribution was 31 females (41.3%) and 44 males (58.7%), with a mean age of 64.4 years (range 2–90 years). Results: Therapeutic endoscopy was the most common cause of perforation (73 of 75 patients; 97.3%). Diagnostic endoscopy caused perforation in 2 patients (2.7%). The perforation was located in the cervical part of the esophagus in 7 patients (9.3%), the intrathoracic part in 25 patients (33.3%), and the abdominal part in 43 patients (57.3%). In this study population, 25 patients (33.3%) were treated surgically, and 50 patients (66.7%) conservatively. The overall in-hospital mortality rate was 14 of 75 patients (18.7%). In the surgically treated group the rate was 6 of 25 patients (24%) and in the conservative group 8 of 50 patients (16%). Conclusions: The decision of a treatment strategy depends on different factors such as the location and extent of the injury, the time interval between perforation and treatment onset, the preexisting diseases, and the patient's general condition. In view of these factors, an individual therapy concept should be determined for every patient. Received: 20 October 1998/Accepted: 26 March 1999     

Diagnosis and management of esophageal perforations.

Esophageal perforation remains a difficult diagnostic and management problem. Recommendations regarding treatment remain controversial. A 15-year experience with perforation of the esophagus from all causes was reviewed at Louisiana State University and Veterans Administration, Medical Centers (Shreveport, LA). The majority of the injuries involved the thoracic esophagus (28 or 54%), followed by the cervical (21 or 40%), and the intraabdominal esophagus (3 or 6%). Iatrogenic causes constituted most of the injuries (52%), followed by external trauma (23%), barogenic rupture (15%), and ingested foreign bodies (10%). Diatrizoate methylglucamine 66 per cent, sodium diatrizoate 10 per cent (Gastrografin; Squibb, Princeton, NJ) contrast studies and flexible esophagoscopy were performed in 44 and 22 patients, respectively. In the cervical esophagus, contrast studies were more sensitive and specific than endoscopy (P less than .01), but both studies were equally effective as diagnostic methods in thoracic perforations. Cervical perforations were treated with either drainage alone (7 patients) or primary repair with drainage (14 patients) with an operative mortality of 4.8 per cent. Several procedures were used in thoracic perforations, which carried a mortality of 36 per cent and were more lethal than cervical tears (P less than 0.2). Any thoracic esophageal perforation treated more than 24 hours after the onset of symptoms, irrespective of what procedure was used, was associated with a significantly higher mortality than if operated on earlier (P less than .001). Five patients with perforated carcinomas were treated by esophageal resection with no mortality. Significantly higher mortality was seen with a delay in diagnosis, thoracic perforations, and Boerhaave's Syndrome. A subset of patients with perforated carcinomas may benefit from esophageal resection with delayed reconstruction.     

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.     

Esophageal Perforation

Esophageal perforation can be caused by any instrument, device, or foreign body reaching the hypopharynx. Diagnosis remains difficult. If esophageal perforation is suspected, Gastrografin (meglucamine diatrizoate) swallow study, eventually followed by barium swallow study, is the most useful diagnostic test. Absolute rules cannot be made about the selection of nonoperative or surgical treatment. If diagnosed early, cervical or thoracic esophageal perforations can sometimes be treated conservatively if there are no signs of systemic sepsis. Recurrent leakage after surgical closure is not unusual. Local tissue flaps can reinforce the closure, particularly after delayed operation, thereby often avoiding the necessity for a reoperation or an esophageal exclusion.     

Endoclipping of iatrogenic colonic perforation to avoid surgery

BACKGROUND: Colonoscopy is an established tool for the diagnosis and management of colonic and rectal pathology. Even though colonic perforation is rare after colonoscopy, it is a serious and typical complication. The definitive management remains controversial. Both operative and nonoperative techniques have been described in the literature, though the standard treatment for these patients is still an operative repair of the perforation site. Recently, endoscopic clip application was recommended, particularly for iatrogenic perforations, but less is known about the effectiveness of endoluminal repair of colonic perforations with clips. METHODS: In this series, 7589 colonoscopies were performed over a 34-month period in a tertiary-level referral center. Three perforations occurred during 5413 diagnostic colonoscopies. Therapeutic colonoscopy was under taken in 2176 patients, resulting in a total of 27 perforations. Out of 30 patients with colonic perforation, five patients underwent operative management and 25 patients were subsequently treated nonoperatively. RESULTS: In 27 patients, endoscopic application of inert metallic clips was used for closure of iatrogenic perforation. Twenty-five of these patients were treated non-operatively, while two patients underwent surgery. The mean postoperative length of hospitalization for patients was 12.2 days, compared to 3.5 days for patients treated conservatively. CONCLUSIONS: Endoluminal repair of colonic perforations with clips and further conservative treatment seems to provide a tool that avoids the major additional trauma associated with laparotomy or laparoscopy and minimizes the length of hospitalization.     

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.     

Clipping for endoscopic perforations: initial success but late complication requiring surgery

Introduction

This response discusses the article by Kim and colleagues entitled "endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients". Iatrogenic colonoscopic perforation, although uncommon, implies serious management problems for endoscopists and surgeons. Nonoperative treatment currently is recommended under certain conditions, and endoscopic clips can primarily close iatrogenic perforations, helping to avoid surgery. Of the 27 colonoscopic perforation cases presented in the article by Kim and colleagues, 16 were managed by endoscopic clipping closure and 11 by primary surgery. Conservative treatment failed for three patients. Only perforation size obtained statistical significance among the nine variables contrasted between the 11 cases with primary surgery and the 13 cases with successful endoscopic clipping. The results for the three patients whose endoscopic closure failed are not reported.

Authors′ opinion

The authors of this letter think it would have been interesting if these three patients had been included in the analysis due to the high importance of discovering factors that can predict failure of endoscopic clipping for perforations.

Conclusions

To call attention to possible late complications requiring surgery even when initial conservative management of endoscopic perforation succeeds, the authors of this letter present a case of a colocutaneous (actually, sigmoid-scrotal) fistula in a patient 2 weeks after an apparently successful closure of colonoscopic perforation with an “over-the-scope” clip.     

Colonoscopic perforations: a review of 30,366 patients

Background Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. Methods A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients’ demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. Results In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. Conclusion Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.     

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.     

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.     

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.     

Evolving options in the management of esophageal perforation

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.     

Pediatric endoscopic injuries: incidence, management, and outcomes

Background

Endoscopy has assumed a significant role in the management of gastrointestinal disorders. However, endoscopic-related injuries are poorly reported.

Methods

Review of our surgical database (1980-2006) identified all patients age 18 years or younger with an endoscopic-related injury managed at our institution.

Results

A total of 3269 colonoscopies were performed; there were 3 iatrogenic perforations (incidence, 0.09%). All were managed operatively: 2 underwent fecal diversion, and 1 was repaired primarily. There was 1 postoperative complication (internal hernia) and no deaths related to colonoscopic perforation. Nine thousand three hundred eight esophagogastroduodenoscopy (EGD) procedures were performed, resulting in 6 iatrogenic injuries (0.06%): bleeding (2), perforation (2), and mucosal tears (2) (0.02% each). All EGD-related injuries occurred in the esophagus except for 1 duodenal perforation which was managed operatively by primary repair. Both patients with bleeding complications underwent repeat endoscopy and cautery with satisfactory results. The other 3 patients were managed conservatively without complication. Three hundred eighty-nine endoscopic retrograde cholangiopancreatogram procedures were performed with 2 iatrogenic injuries (0.5%): 1 bleed and 1 perforation (0.25% each). Both were managed conservatively without complication.

Conclusion

Endoscopic injuries are uncommon. Colonoscopic perforations require prompt surgical intervention. Esophagogastroduodenoscopy- and endoscopic retrograde cholangiopancreatogram-related injuries are amenable to conservative therapy in clinically stable patients devoid of peritonitis.     

Ruptures and perforations of the esophagus: the case for conservative supportive management

A series of 31 patients treated for ruptures and perforations of the intrathoracic esophagus is reviewed. Eighteen of these patients underwent major thoracotomy; 11 were treated with minor procedures. Two died before treatment could be implemented. Of the 18 undergoing major operations, 7 died; among the 11 managed conservatively there was only 1 death. Based on this experience, we conclude that major surgical repair for esophageal perforation is often unnecessary. It has the additional drawback of sometimes resulting in equally serious secondary procedures.     

Stented esophageal transfixion injury

Esophageal perforation is a rare, but life-threatening condition with a mortality rate ranging between 10% and 40%. It can happen at the level of the cervical, intrathoracic, or intra-abdominal segment. It usually occurs as a result of iatrogenic injury after endoscopic procedures or as a spontaneous rupture. It is seen less frequently in trauma after gunshot or stab wounds. Stenting of the esophagus after iatrogenic perforation is well documented in the literature, but yet it is to be published for management of penetrating injury. We report a case of esophageal perforation with a wooden fence post treated successfully with a covered esophageal stent.     

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation

Background

Management of endoscopic retrograde cholangiopancreatography (ERCP)–associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment.

Methods

A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival.

Results

Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days.

Conclusion

Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.     

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.     

Esophageal perforation

Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.