Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

Sudarshan, Monisha; Elharram, Malik; Spicer, Jonathan; Mulder, David S.; Ferri, Lorenzo

doi:10.1016/j.surg.2016.07.025

Cited by 39 publications

(38 citation statements)

References 15 publications

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“…Minimally invasive endoscopic stenting or clipping for iatrogenic perforation has also been proposed for small discontinuities with viable, non-necrotic edges [18, 19]. These strategies may be useful in selected, hemodynamically stable trauma patients with a contained leak [20]. …”

Section: Discussionmentioning

confidence: 99%

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

et al. 2017

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BackgroundTraumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality.MethodsThis National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications.ResultsA total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p = 0.008), 30-day mortality (4.2 vs. 9.3%, p = 0.005), and overall mortality (7.9 vs. 13.5%, p = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV–V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148–0.546; p < 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06–2.53; p = 0.026).ConclusionsDespite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival.Trial registrationiStar, HS-16-00883

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Section: Discussionmentioning

confidence: 99%

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

et al. 2017

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“…The Pittsburgh Perforation Severity Scores (PSSs) of all patients were calculated according to the study by Abbas et al Patients were rated as follows: 1 point for age >75 years, tachycardia (>100 bpm), leukocytosis (>10,000 WBC/mL), and pleural effusion (on chest X-ray, CT, or barium swallow); 2 points for fever (>38.5 °C), uncontained leak (on barium swallow or CT), respiratory compromise (respiratory rate >30, increasing oxygen requirement, or need for mechanical ventilation), and time to diagnosis >24 h; and three points for presence of cancer and hypotension. With reference to that, patients were divided into three groups as low PSS (≤2), intermediate PSS (3)(4)(5), and high PSS (>5). The initial treatment was categorized as operative or non-operative management that included conservative observation, endoscopic stenting, and surgical drainage.…”

Section: Methodsmentioning

confidence: 99%

“…In addition, some EPs can be diagnosed during endoscopy. [5] If a perforation is noticed during the procedure, the first step is to close the air insufflation and switch to carbon dioxide (CO 2 ). CO 2 is rapidly resorbed and has been shown to reduce post-procedural mediastinal emphysema.…”

Section: Diagnostic Toolsmentioning

confidence: 99%

A 4-year single-center experience in management of esophageal perforation

Sarı¹

2018

Ulus Travma Acil Cerrahi Derg

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BACKGROUND: Esophageal perforation (EP) is a lethal surgical emergency that needs to be diagnosed and treated immediately. Diagnosis and treatment options for EP are limited due to its lower incidence. There are scoring systems proposed for this purpose; however, they cannot be applied to every patient. The recent trend in the treatment of EP is toward the non-operative approach over the surgical treatment methods. The purpose of the present study was to evaluate our treatment methods and outcomes in patients with EP. METHODS: Thirteen patients with EP treated in our clinic between 2013 and 2017 were retrospectively reviewed. The Pittsburgh Perforation Severity Score (PSS), systemic condition status, and Clavien-Dindo Classification (CDC) score were assessed, and treatment methods were reviewed. Their effects on morbidity and mortality were examined using Fisher's exact test and biserial correlation test. RESULTS: A total of 13 patients (six males and seven females; median age 64 years) were included in the study. Ten patients were managed non-operative, and three were treated surgically. Of the 10 patients, two had additional surgery after non-operative management. The PSS, systemic condition status, CDC score, duration of stay in the hospital, time to diagnosis, presence of hypotension, and being in shock were strongly correlated with mortality (p<0.05). The PSS, CDC score, and stay in the intensive care unit were strongly correlated with morbidity (p<0.05). The comparison between the non-operative and operative groups did not yield a statistically significant difference in mortality and morbidity. CONCLUSION: Even if the scoring systems help to understand the severity of the condition, they are inadequate to determine the treatment option. Early diagnosis and treatment are the most important steps in management. Operative and non-operative treatment options are not superior to each other, but their complementary use will be more beneficial for the patients.

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“…A nasogastric tube is sent into the stomach in a way not to give any damage to the region of the repair. During the primary repair of the esophagus, a jejunostomy tube may be placed with mini laparotomy (28)(29)(30)(31).…”

Section: Primary Surgical Repairmentioning

confidence: 99%

Thoracic perforations—surgical techniques

Eroğlu¹,

Aydın²,

Yılmaz³

2018

Ann. Transl. Med.

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Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

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Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

Cited by 39 publications

References 15 publications

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

A 4-year single-center experience in management of esophageal perforation

Thoracic perforations—surgical techniques

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