Early Diagnosis Is Associated With Improved Clinical Outcome in Benign Esophageal Perforations: An Individual Patient Data Meta-Analysis

Vermeulen, Bram D.; Leeden, Britt van der; Rosman, Camiel; Siersema, Peter D.

doi:10.1055/s-0039-1681883

ESGE Days 2019 2019

DOI: 10.1055/s-0039-1681883

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Early Diagnosis Is Associated With Improved Clinical Outcome in Benign Esophageal Perforations: An Individual Patient Data Meta-Analysis

Bram D. Vermeulen

Britt van der Leeden

Camiel Rosman

et al.

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2021

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Vermeulen

Siersema

2021

Gastrointestinal Endoscopy

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We commend Vermeulen et al 1 for their article on endoscopic dilation of benign esophageal strictures. Although we generally agree with their conclusions, some points need comment.Our major concern is breaching the "rule of 3." Richter 2 and Johnson 3 recommend that the rule of 3 should not be abandoned. The contrary view by Grooteman et al, 4 that breaching the rule of 3 was not associated with an increase in perforation rates, needs to be interpreted with caution. Esophageal perforations may be rare but can have disastrous adverse events. We believe that this rule should not be broken, especially in strictures with transmural fibrosis such as radiation and complex strictures.The authors classified radiation strictures as benign strictures. It is worth emphasizing that many of these strictures often have residual or recurrent disease, and this may influence the outcome of endoscopic dilation. 5 Measurement of stricture by the diameter of the first dilator has a fallacy. The diameter of the first dilator is decided by visual impression, and 1 size larger than the estimated stricture size is recommended to start with. 6 The authors found no difference in the outcomes of dilation for strictures <1 cm or >1 cm, which is in contradiction to earlier studies. 7 A quarter of the patients in this study who underwent endoscopic stent placement experienced clinical success, which is lower than in other reported studies. 8 One reason could be that, unlike in previous studies, the authors treated a heterogenous group of patients with various causes of stricture (higher proportion of patients with anastomotic stricture) and performed a wide range (1 to 25) of dilation sessions before resorting to stent placement.Finally, a small statistical point: instead of providing the mean number of dilations as decimals, providing median numbers would have been more appropriate.

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Vermeulen

Siersema

2021

Gastrointestinal Endoscopy

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Endoscopic negative pressure therapy (ENPT) of a spontaneous oesophageal rupture (Boerhaave’s syndrome) with peritonitis – a new treatment option

Loske

Albers

Mueller

2021

Innovative Surgical Sciences

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Objectives Boerhaave’s syndrome is a life-threatening disease with high mortality and morbidity. Endoscopic negative pressure therapy (ENPT) can be used to treat oesophageal perforations. Case presentation We report on a case of oesophageal rupture with peritonitis in a 35-year-old male patient. The start of treatment was 11 h after the perforation event. The treatment of the perforation defect was performed exclusively by intraluminal ENPT, the treatment of peritonitis was performed by laparotomy with abdominal lavage. For ENPT we used two different types of open-pore drains. The first treatment cycle of four days was performed with an open-pored polyurethane foam drainage (OPD), which was placed intraluminal to cover the perforation defect and to empty the stomach permanently. The second treatment cycle of nine days was performed with a thin nasogastric tube like double-lumen open-pored film drainage (OFD). For suction OPD and OFD were connected with an electronic vacuum pump (−125 mmHg). OFD enables active gastric emptying with simultaneous intestinal feeding via an integrated feeding tube. Intraluminal ENPT with a total treatment duration of 13 days was able to achieve the complete healing of the defect. Surgical treatment of the perforation defect was not necessary. The patient was discharged 20 days after initial treatment with a non-irritating abdominal wound and a closed perforation. Conclusions In suitable cases, endoscopic negative pressure therapy is a minimally invasive, organ-preserving procedure for the treatment of spontaneous oesophageal rupture.

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Early Diagnosis Is Associated With Improved Clinical Outcome in Benign Esophageal Perforations: An Individual Patient Data Meta-Analysis

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Endoscopic negative pressure therapy (ENPT) of a spontaneous oesophageal rupture (Boerhaave’s syndrome) with peritonitis – a new treatment option

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