Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

Abstract

Background: Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population. Case presentation: We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations. Conclusions: Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

Clinical profile and treatment outcomes of Boerhaave’s syndrome: A 13-year experience from an upper gastrointestinal surgical unit

“…Key steps of primary repair include debridement of non-viable tissues, esophageal myotomy on either end of the perforation to expose healthy mucosal edges and a meticulous closure, preferably in double layers (1,24). Trans-thoracic repair can be reinforced with a pleural, pericardial or intercostal muscle flap or a gastric fundal wrap, whereas an omental or a gastric fundal wrap may be utilized to buttress a trans-hiatal repair (1,12). Although delayed diagnosis does not preclude a primary repair, a high risk of a postoperative leak, re-interventions and mortality is reported, particularly when the delay is >48 hours (1,5,8,9,25).…”

“…Recently, VATS is our preferred operative approach for addressing thoracic sepsis, as in three of our patients. Although we preferred laparotomy for the repair of the perforations, the feasibility and safety of laparoscopic, trans-hiatal, and videoassisted trans-thoracic repairs have been shown by other authors, including in patients with delayed diagnosis (12,13,19,23).…”

“…We generally avoid routine feeding or venting gastrostomy for perforations related to B, since it allows gastric preservation, for esophageal reconstruction, if an esophagectomy is indicated. Surgical repair of esophageal perforation and sepsis drainage could also be achieved with minimally invasive surgery (10,12,13,19,23). Haveman et al have demonstrated comparable effectiveness and safety of pleural sepsis drainage utilizing video-assisted thoracoscopic surgery (VATS) and open thoracotomy techniques (10).…”

“…With recent advances in minimally invasive surgery and therapeutic endoscopy, there is a paradigm shift towards a more conservative treatment approach for this condition. The safety and effectiveness of minimally invasive surgical approaches have been demonstrated by Haveman et al, Aref et al, Lee et al, Cho et al, and in a recent review by Aiolfi et al (10)(11)(12)(13)(14). Minimally invasive surgery can potentially reduce surgical trauma, but the choice of operative access depends on the site of the perforation, the extent of pleuro-mediastinal contamination/necessity for pleural drainage.…”