Esophageal Perforation Management: A Single-Center Experience

Abstract

Background: Esophageal perforation is a rare and potentially life-threatening condition requiring urgent management. Successful therapy depends on the underlying etiology, clinical presentation, the time between rupture and diagnosis, the extent of the rupture and the underlying health of the patient. Method: From 2005 to 2012, the author retrospectively analyzed 36 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, comorbidities, the method of diagnosis, delay in diagnosis, therapeutic regimen, complications, hospital stay, follow-up and mortality. Results: The cause of perforation were iatrogenic in 14 cases (38.8%), foreign body ingestion in 11 (30.5%), spontaneous in 9 (25%), chest trauma in 1 (2.8%) and esophageal cancer in 1 case (2.8%). The most frequent signs and symptoms were chest pain in 27 cases (75%), fever in 15 (41.6%), dysphagia in 11 (30.5%), mediastinitis in 9 (25%) and vomiting in 8 (22%). The treatment included surgery in 26 cases (72.2%) which consists of thoracotomy (right or left), with or without esophageal suturing, washing, drainage with three chest tubes, jejunostomy and gastrostomy. The second group were patients treated medically in 10 cases (27.8%), medical treatment includes nil per os (NPO), parenteral nutrition, intravenous antibiotics and observation. Complications include fever (n = 14), auricular fibrillation (n = 7), esophageal fistula (n = 3), reoperation (n = 2), renal failure (n = 2), cerebrovascular accident (n = 1), pulmonary embolism (n = 1), pneumonia (n = 1) and deep vein thrombosis (n = 1). The average hospital stay for patients treated surgically was 36 days and for patients treated medically was 14.2 days. The overall mortality was 25% involving 8 patients treated surgically and 1 patient treated medically. Conclusion: The treatment method still must be chosen on an individual basis. Rapid diagnosis of this often life threatening condition is critical for expediting the choice of an optimal treatment strategy, whether surgical or non-surgical.

Conservative Management of an Iatrogenic Esophageal Tear in Kenya

“…Diagnosis of esophageal perforation is challenging owing to a nonspecific and varied clinical presentation [ 1 ] that mimics a myriad of other disorders such as myocardial infarction and peptic ulcer perforation [ 14 ]. Patients may present with any combination of nonspecific signs and symptoms including fever, tachycardia, tachypnea, acute onset chest pain, dysphagia, vomiting, and shortness of breath [ 4 , 6 , 15 ]. A high index of suspicion is therefore needed for recognition of esophageal perforation [ 5 ].…”

“…Traditionally, surgery has been the mainstay of treatment [ 14 ], but recent reports emphasize a shift in treatment strategies with nonoperative approaches becoming more common [ 4 , 9 ]. It has been shown that, with careful patient selection, nonoperative management can be the treatment of choice for esophageal perforations [ 6 ] with good outcomes [ 9 , 12 , 15 , 16 ]. Altorjay et al [ 17 ] and others have suggested criteria for selection of nonoperative treatment including early perforations (or contained leak if diagnosis delayed); leak draining back to the esophagus; nonseptic patients; perforation not involving a neoplasm, abdominal esophagus, or distal obstruction; and availability of an experienced thoracic surgeon and contrast.…”

Abordagem vídeo-toracoscópica, sem sutura, das perfurações do esôfago torácico diagnosticadas tardiamente

“…The literature reports several treatment options for late-diagnosis esophageal lesions [1][2][3][4][5]9 . The suture with pediculated flap protection over the perforated area is time-consuming and most teams indicate thoracotomy, given the difficulty in carrying out the dissection and suturing with a video-surgery approach.…”

“…At this time, both the perforated esophagus and the surrounding tissues are swollen and friable, rendering the surgical manipulation of the organ difficult and dangerous 4 . In such cases, the surgeon's insistence on correcting the perforation through sutures, partial or total esophagectomy, and derivations of alimentary transit invariably causes an increase in surgical time, an intense systemic inflammatory response and a high risk of complications, death or severe sequelae being common 3,5 . In view of this scenario of uncertainties, the objective of this study was to evaluate the impact of thoracoscopy in the treatment of late thoracic esophagus lesions, without suture or organ resection, a diagnostic technique and surgical approach adopted by us for more than 15 years.…”

The role of surgery in the treatment of endoscopic complications

“…Muscle flaps are commonly used to reinforce esophageal repairs, and several large-bore drains are typically left around the repair site. These operations are associated with significant morbidity, and a mortality as high as 15e40% [11,13]. Although endoscopic stent placement may avoid operation, stent migration is a possible complication of this approach, especially in a healthy esophagus.…”