Iatrogenic oesophageal perforation

Abstract

Oesophageal perforation can be a devastating injury, associated with high morbidity and mortality. Known causes include iatrogenic, spontaneous, traumatic and foreign bodies. Iatrogenic perforations remain the most common. Early diagnosis is vital but difficult, as symptoms are often nonspecific and sometimes relatively mild. Therefore, a high index of suspicion is important, especially after any oesophageal instrumentation or intra-thoracic surgery. The presentation of oesophageal perforation can vary significantly. Timing of diagnosis, presence of systemic symptoms, underlying oesophageal pathology, site and size of perforation influence management. In the lack of evidence, management options vary and there is not one recognized optimum treatment strategy, however there is consensus that oesophageal perforations managed within 24 hours have significantly better outcomes. Historically, the mainstay of treatment has been surgical, with methods including drainage and primary repair, exclusion and diversion techniques, and oesophagectomy. In carefully selected patients with a prompt diagnosis and no systemic symptoms a conservative approach has been successful. This includes fluid resuscitation, intravenous antimicrobials, nothing-by-mouth, gastric decompression and parenteral nutrition. Endoscopic clipping, suturing or stenting have gained popularity in the last couple of decades and are now established approaches in selected patients, as an alternative or in combination with surgery. Novel treatments include the use of endoscopic vacuumassisted therapy (EVT). This review outlines the current approach to iatrogenic oesophageal perforation.

The laparoscopic transabdominal approach for resection of the large epiphrenic esophageal diverticulum

“…Esophageal perforation, a major complication of laparoscopic Heller myotomy, occurs in 7% of patients 18 . At this time, there are still no guidelines, only management options: conservative, surgical, or an endoscopic approach with clipping, suturing, or stenting 19 . Since we recognized the perforation intraoperatively, we decided to suture the lesion laparoscopically with a single suture.…”