Treatment of Esophageal Perforation: A Single-Center Expertise

Abstract

Background and Aims: Esophageal perforation is a rare diagnosis, which is associated with a high morbidity and mortality. There is only small scientific background regarding the best choice of treatment. Parameters indicating a good clinical outcome seem to be localization, depth of the defect, pre-existing risk factors, and time interval between the event and start of treatment. Material and Methods: We evaluate retrospective data from 39 patients who were treated with a esophageal perforation in our hospital between 2004 and 2012. Results and Conclusions: Our collected data agree with the available published literature. Endoscopic treatment seems to be favorable in early diagnosis.

Conservative Management of an Iatrogenic Esophageal Tear in Kenya

“…Eventually, sepsis ensues leading to multiple-organ failure and death [ 3 , 4 ]. The extent of this inflammation (mediastinitis), and thus the morbidity and mortality of esophageal perforation, depends not only on the cause and location of the perforation but also on the time interval between onset and access to appropriate treatment [ 3 , 12 ]. It has been shown that early detection reduces mortality by over 50% [ 11 ] and treatment delays over 24 hours increase mortality significantly [ 13 ].…”

“…Once suspected, patients should be evaluated quickly with a combination of radiographs and esophagograms [ 8 , 14 ]. Accurate diagnosis may however require added investigations including computed tomography and flexible esophagoscopy [ 7 , 12 ].…”

“…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.…”

“…A nasogastric tube is placed to clear gastric contents and limit further contamination [ 9 ] and mediastinal contamination drained percutaneously/radiologically [ 18 ] via the chest tubes, thereby converting the esophageal perforations to esophagocutaneous fistulae that heal similar to gastrointestinal fistulae [ 6 ]. Apart from observation, the range of conservative management is growing, with the increasing use of endoscopic stents, clips, vacuum sponge therapy, and fibrin glue application [ 8 , 12 ] for the selected patients. Notably though, even with meticulous patient selection, up to 20% develop multiple complications within 24 hours and require surgical intervention [ 2 , 7 ].…”

Esophageal perforation: diagnosis, management and decision-making – a retrospective tertiary centre study

“…Across several studies, the mortality ranges between 10% to 25% within the first 24h after perforation and increases to 40% to 60% if the treatment is delayed beyond this point. One of the main reasons of this vastly increasing mortality with time seems to be the anatomical configuration and location of the esophagus (2). Due to the absence of immunocompetent tissue, bacteria and digestive enzymes have an easy entry to the mediastinum leading to the development of complications such as sepsis, empyema, mediastinitis and organ failures.…”