Advanced Endoscopic Techniques for the Management of Esophageal Perforation

Abstract

Introduction: Esophageal perforation is a life threatening condition, which must be recognized early. Traditional surgical approaches yield a high mortality rate. Limited data is available regarding the use of fully-covered self expanding metal stents (FSEMS) and even less is available for endoscopic suturing in the setting of esophageal perforation. It is the aim of this study to analyze the outcomes of esophageal perforation with esophageal FSEMS or endoscopic suturing, and compare them to the outcomes in traditional approaches. Methods: A retrospective chart analysis was conducted on eleven patients with a total of twelve esophageal perforations who underwent advanced endoscopic procedures (FSEMS placement, endoscopic suturing) from 2013 to 2016. Our review focused on the six characteristics; origin of defect, age, location of defect, method of closure, resolution of defect and any underlying esophageal disease Results: Origin of defect in our cohort include a total of eleven patients with esophageal perforation secondary to either tracheoesophageal fistula (27%), iatrogenic causes (27%), severe emesis (18%), anastomotic leak (9%), paraesophageal hernia (9%) or spontaneous perforation while eating (9%). Five patients were treated solely with FSEMS, 1 patient was treated solely with endoscopic suturing, and 5 patients were treated with a combination of stenting and endoscopic suturing. The outcomes of our cohort include 10 of 11 patients (91%) with complete resolution from one intervention, and 1 of 11 (9%) that required re-suturing. The survival rate for our cohort was 100 percent, without any incidence of stent migration, for patients treated with FSEMS. Conclusion: With the advances in interventional endoscopy, the paradigm is shifting from operative procedure to endoscopic closure in the setting of esophageal perforation. Covered metal stents and endoscopic suturing are more efficacious and allow for a faster treatment, with the diagnostic endoscopy and therapeutic intervention being accomplished in the same setting. Stent technology has greatly improved. Endoscopic suturing has increased the therapeutic profile of interventional endoscopy. Suturing decreases stent migration and also allows for “primary closure” which may facilitate the treatment of larger defects than ever before with decreased morbidity and improved patient outcomes. It is important that the endoscopists maintain proficiency and work with other surgical colleagues in a multi-disciplinary approach.Table: Table. Cohort Data