Esophageal Perforation Management Using a Multidisciplinary Minimally Invasive Treatment Algorithm

Ben-David, Kfır; Behrns, Kevin E.; Hochwald, Steven N.; Rossidis, Georgios; Caban, Angel M.; Crippen, Cristina; Caranasos, Thomas G.; Hughes, Steven J.; Draganov, Peter V.; Forsmark, Christopher E.; Chauhan, Shailendra S.; Wagh, Mihir S.; Sarosi, George A.

doi:10.1016/j.jamcollsurg.2013.12.033

Cited by 63 publications

(30 citation statements)

References 27 publications

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“…In these well matched groups, the esophageal stent cohort realized significant differences in morbidity (4% vs. 43%; P=0.02), mean length of stay (6 vs. 11 days; P=0.0007), time to oral intake (3 vs. 8 days; P=0.0004), and cost ($91,000 vs. $142,000; P<0.0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Ben-David et al reported similar findings in a recently published single center experience (40).…”

Section: Discussionsupporting

confidence: 62%

Endoscopic management of esophageal leaks

Ong¹,

Freeman²

2017

J. Thorac. Dis.

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Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents.Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse J Thorac Dis 2017;9(Suppl 2):S135-S145 jtd.amegroups.com significantly less esophageal dilatation, a lower rate of migration and improved palliation for malignant esophageal strictures and malignant tracheo-esophageal fistulae (10,11). However, placement of these prostheses continued to be reserved only for the patient requiring palliative therapy for a malignancy because of the potential esophageal damage associated with extraction including reports of irreparable, sometimes life threatening, fistulae.To combat these complications, second generation metallic stent designs were developed incorporating a covering of silicone, polyurethane or other polymers (12). While offering the advantage of diminishing amount of tumor ingrowth and fixation to the esophageal wall, it came with the cost of higher migration rates. Later, the ends of these covered stents were modified to be partially covered with a margin of 1.5 cm on both proximal and distal ends to optimize purchase of the esophageal wall (13).Further evolution in esophageal stent biomaterials resulted in the development of an occlusive plastic prosthesis coated with silicone. This new design allowed ease of insertion, a minimal requirement for esophageal dilation and the ability to form an occlusive seal within the lumen of the esophagus (14). The distinctive advantage of these non-metallic endoprostheses was the ability for removal or replacement even after an extended period of time without damage to the esophagus. However, similar to the covered metallic stents, a higher incidence of migration was appreciated (15).These synergistic developments led to a crucial turning point in management of esophageal perforations. The ease in manipulation of high-quality covered, occlusive stents in the esophagus, led some investigators to implant these stents in select patients as a temporary measure to treat intrathoracic anastomotic leaks following esophagogastrostomy and acute perforations. Segalin et al. and Roy-Choudhury et al. were am...

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Section: Discussionsupporting

confidence: 62%

Endoscopic management of esophageal leaks

Ong¹,

Freeman²

2017

J. Thorac. Dis.

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“…patients in an immunosuppressive state or patients who already were under broad-spectrum antibiotics prior to perforation). Furthermore treatment with a proton pump inhibitor should be initiated to control acid reflux [52,217].…”

Section: Diagnosismentioning

confidence: 99%

“…Over time a clear treatment shift towards less invasive treatment options can be observed [52,215,[217][218][219][220][221][222][223].…”

Section: Diagnosismentioning

confidence: 99%

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis

Abu‐Omar

Kocher

Bosco

et al. 2017

Eur J Cardiothorac Surg

152

177

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Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.

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“…When coupled with adequate drainage of the mediastinum and pleural spaces, lung expansion, antibiotics, and nutrition, esophageal stenting as part of a comprehensive treatment plan might reasonably be expected to lead to similar outcomes as repair. 10 Supporting this logic are several retrospective single-institution or single health-system observational studies that have reported excellent outcomes associated with esophageal stenting among both patients who were and were not candidates for surgical repair. 2,3,10,11 …”

Section: Commentmentioning

confidence: 94%

A Nationwide Rise in the Use of Stents for Benign Esophageal Perforation

Thornblade

Cheng

Wood

et al. 2017

The Annals of Thoracic Surgery

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BACKGROUND Surgical repair or drainage is the standard treatment for benign esophageal perforation. The Food and Drug Administration has approved the use of esophageal stents for the management of malignant esophageal stricture and/or fistula. We hypothesize that increasing enthusiasm and experience with esophageal stents has led to greater use of stents for the management of benign esophageal perforation. METHODS We performed a retrospective cohort study (2007–2014) of patients with benign esophageal perforation using MarketScan®—a commercial claims database. Subjects had six months of follow-up. Regression was used for risk-adjustment. RESULTS A total of 659 patients (mean 49 years, 41% women) were treated for benign esophageal perforation (surgical repair: n=449, 69%; surgical drainage: n=110, 17%; stent: n=100, 15%). Stent use increased from 7% in 2007 to 30% in 2014 (p-trend<0.001). Over the same period, surgical repair decreased from 71% to 53% (p-trend=0.001), while surgical drainage did not change (p=0.24). After adjustment for other factors that could vary over time, stent use increased by 28% per year (incidence rate ratio=1.28, 95% confidence interval 1.17–1.39). There were no significant changes in risk-adjusted deaths, discharges home, readmissions, or costs over the same period (all p-trend>0.05). CONCLUSIONS The use of stents for the management of benign esophageal perforation has increased by over four fold in just eight years, but short-term outcomes have not changed over time for this population of patients. A national registry for off-label use of esophageal stents may clarify the indications for and risks and benefits of stenting benign esophageal perforations.

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Esophageal Perforation Management Using a Multidisciplinary Minimally Invasive Treatment Algorithm

Cited by 63 publications

References 27 publications

Endoscopic management of esophageal leaks

Endoscopic management of esophageal leaks

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis

A Nationwide Rise in the Use of Stents for Benign Esophageal Perforation

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