Hybrid Minimally Invasive Management of Thoracic Esophageal Perforations: Technical Feasibility in Selected Patients.

Reinforced primary repair of thoracic esophageal perforation

Routine revascularization in patients with ST-segment elevation myocardial infarction (STEMI) presenting >48 h after symptom onset is not recommended. We compared outcomes of STEMI patients undergoing percutaneous coronary intervention (PCI) according to total ischaemic time. Patients included in the Bern-PCI registry and the Multicenter Special Program University Medicine ACS (SPUM-ACS) between 2009 and 2019 were analysed. Based on symptom-to-balloon-time, patients were categorized as early (<12 h), late (12-48 h), or very late presenters (>48 h). Co-primary endpoints were all-cause mortality and target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization at 1 year. Of 6589 STEMI patients undergoing PCI, 73.9% were early, 17.2% late, and 8.9% very late presenters. The mean age was 63.4 years, and 22% were female. At 1 year, all-cause mortality occurred more frequently in late vs. early [5.8 vs. 4.4%, hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.01-1.78, P = 0.04] and very late (6.8%) vs. early presenters (HR 1.59, 95% CI 1.12-2.25, P < 0.01). There was no excess in mortality comparing very late and late presenters (HR 1.18, 95% CI 0.79-1.77, P = 0.42). Target lesion failure was more frequent in late vs. early (8.3 vs. 6.5%, HR 1.29, 95% CI 1.02-1.63, P = 0.04) and very late (9.4%) vs. early presenters (HR 1.47, 95% CI 1.09-1.97, P = 0.01), and similar between very late and late presenters (HR 1.14, 95% CI 0.81-1.60, P = 0.46). Following adjustment, heart failure, impaired renal function, and previous gastrointestinal bleeding, but not treatment delay, were the main drivers of outcomes. PCI >12 h after symptom onset was associated with less favourable outcomes, but very late vs. late presenters did not have an excess in events. While benefits seem uncertain, (very) late PCI appeared safe.

Introduction: Morbidity and mortality rates of esophageal perforation are high. Treatment includes endoscopic, surgical, and conservative approaches. The OverStitchTM Endoscopic Suturing System (OESS) is a novel technique which has proved efficacious in treating an esophageal perforation. Case Description/Methods: A 91-year-old woman with past history of hypertension was transferred to our hospital with a retropharyngeal and mediastinum fluid collection concerning for esophageal perforation. The patient presented with shortness of breath and cough and was found to have right-sided pleural effusion. After chest tube placement, patient complained of dysphagia and reported aspiration. Computed tomography of the chest revealed a retropharyngeal abscess which was suspicious for esophageal perforation. Surgery performed an immediate left neck incision and drainage and placed a gastrostomy tube. A follow-up esophagram showed persistent leakage and gastroenterology was consult. Esophagogastroduodenoscopy revealed a 1cm perforation at the cricopharyngeal plane just above the upper esophageal sphincter. An OESS was performed, and she was kept n.p.o. with gastrostomy tube feeding. At a 17 day follow up, a repeat esophagram showed no evidence of contrast extravasation and the patient was doing well. Discussion: Esophageal perforation is a life-treathening condition and is a surgical emergency. Mortality rate can approach 60% with delays in treatment and can be reduced to 10-25% with immediate treatment. Death is cause by severe mediastinitis, empyema, or sepsis. The standard treatment is still controversial. Surgery remains mainstay of the treatment. In hemodynamically unstable patients, emergency airway should be established followed by primary closure and wide drainage. Non-operative management include volume resuscitation, respiratory supportive, and n.p.o. status. Endoscopic treatment include clips, stent, and suturing. The success of the repair depend on the extent of the nonviable tissue. In our patient, she has persistent leakage after drainage and underwent OverStitch closure. This case demonstrates the utility and efficacy of endoscopic suturing using OverStitch device to treat complicated esophageal perforation.Figure 1.: (A) EGD shows an esophageal perforation at the upper esophageal sphincter (UES) level (B) EGD shows an OverStitch suture in place.

Modified T-Tube Repair of Delayed Esophageal Perforation Results in a Low Mortality Rate Similar to That Seen With Acute Perforations

Prompt diagnosis and effective treatment are important for thoracic esophageal perforations. The decision for proper management is difficult especially when diagnosed late. However, there is an increasing consensus that primary repair provides good results for repair of thoracic esophageal perforations, which are not diagnosed on time. Primary repair for thoracic esophageal perforations was applied in 20 out of 25 consecutive patients. The time interval between perforation and repair was less than 24 h in six patients (group I), and more than 24 h in 14 patients (group II). The remaining five patients underwent esophagectomy with simultaneous or staged reconstruction because of incorrectable underlying esophageal pathology. Group I had much more iatrogenic causes (P < 0.05). Preoperative sepsis occurred only in group II (P=0.05) and was highly associated with Boerhaave syndrome (P=0.001). Regional viable tissue was used to reinforce the sites of primary repair (n=15, 75%). All of the postoperative morbidity (n=9, 45%) including esophageal leaks (n=6, 30%) and operative death (n=1, 5%) occurred in group II. In patients with postoperative leaks, five eventually healed, but one became a fistula that required reoperation. Primary healing with preservation of the native esophagus was achieved in all 19 patients except one operative death. In addition, the increased incidence of leak and morbidity did not lead to an increase in mortality. In the esophagectomy group, there was no mortality, but one minor suture leak. Regardless of the time interval between the injury and the operation, primary repair is recommended for non-malignant, thoracic, esophageal perforations, but not for anastomotic leaks. Reinforcement that may change the nature of a possible leak is also useful. For incorrectable underlying esophageal pathology, esophagectomy with simultaneous or staged reconstruction is indicated.

Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave's syndrome

Diagnosis and Recommended Management of Esophageal Perforation and Rupture

Delayed detection of psychosis: causes, consequences, and effect on public health.

Processes of care for carotid endarterectomy: Surgical and anesthesia considerations

BackgroundEsophageal perforation is a rare surgical pathology in children. Thoracic esophageal perforation is more severe than cervical esophageal perforation. Iatrogenic cause, mainly by endoscopy, is the most common in esophageal perforation. However, perforation induced by “Magill forceps” is exceptional.Case presentationA systematic physical examination revealed pyrexia severe respiratory distress and right-sided pleural effusion.We report the success of non-operative treatment applied to thoracic esophageal perforation due to Magill forceps in a 24-month-old male infant. The immediate and short-term outcomes were excellent.ConclusionsNon-operative treatment is possible in iatrogenic perforation of thoracic esophageal in infants. This treatment delivers excellent outcome in carefully selected patients.

Toxic epidermal necrolysis (TEN) is a rare, but life-threatening medical emergency with significant morbidity and mortality. Current treatment standards for TEN patients include stopping all possible drugs associated with the new onset of symptoms, prompt referral and treatment in a specialized center with fluid resuscitation, adequate analgesia and maintenance of nutritional needs. Extensive debridement of the involved epidermis followed by coverage with a skin substitute reduces the mortality from a skin infection and also improves the fluid and electrolyte balance and pain control. This is increasingly considered an important part of the intensive care of these patients. Admitting physicians should be aware of this rare but life-threatening emergency, to allow prompt diagnosis and avoid delays in treatment.

Spontaneous Perforation of the Esophagus in a Patient With Achalasia

This report describes our experience of successful surgical intervention of multiple esophageal perforations with delayed diagnosis in a 54 year-old male with alcoholic cirrhosis of the liver (Child B) resulting from endoscopic variceal ligation for bleeding. The patient presented with two episodes of perforation. The initial one was that of acute cervical esophageal perforation which was treated medically. During the second episode, delayed recognition led to right empyema and profound sepsis. Two weeks after the event, primary repair of the perforated esophagus plus local drainage for the cervical esophageal perforation and open window-drainage of the empyema resulting from thoracic esophageal perforation were carried out; decompressive gastrostomy and feeding jejunostomy were also performed. A second surgical operation was performed to place a T-tube at the site of cervical perforation because of poor drainage. Under broad spectrum-antibiotic treatment and continuous suction drainage of the perforation sites, the patient’s condition gradually improved, although he required a transient hemodialysis for acute renal failure during the postoperative course. The thoracic wound was closed with thoracoplasty and latissimus dorsi muscular transposition three months later. The oral intake was smooth without any esophageal symptoms at 1-year follow up. Multiple esophageal perforation is rare, and esophageal perforation is a potentially lethal condition, and a delay in diagnosis is the major factor contributing to its high morbidity and mortality. We hope that our experience will serve to improve the management of similar cases of multiple esophageal perforation, whether with or without delayed diagnosis, in the future.

Background/AimsEsophageal stricture is usually managed with outpatient endoscopic dilation. However, patients with food impaction or failure to thrive undergo inpatient dilation. Esophageal perforation is the most feared complication, and its risk in inpatient setting is unknown.MethodsWe used National Inpatient Sample (NIS) database for 2007–2013. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes were used to identify patients with esophageal strictures. Logistic regression was used to assess association between hospital/patient characteristics and utilization of esophageal dilation.ResultsThere were 591,187 hospitalizations involving esophageal stricture; 4.2% were malignant. Endoscopic dilation was performed in 28.7% cases. Dilation was more frequently utilized (odds ratio [OR], 1.36; p<0.001), had higher in-hospital mortality (3.1% vs. 1.4%, p<0.001), and resulted in longer hospital stays (5 days vs. 4 days, p=0.01), among cases of malignant strictures. Esophageal perforation was more common in the malignant group (0.9% vs. 0.5%, p=0.007). Patients with malignant compared to benign strictures undergoing dilation were more likely to require percutaneous endoscopic gastrostomy or jejunostomy (PEG/J) tube (14.1% vs. 4.5%, p<0.001). Palliative care services were utilized more frequently in malignant stricture cases not treated with dilation compared to those that were dilated.ConclusionsInpatient endoscopic dilation was utilized in 29% cases of esophageal stricture. Esophageal perforation, although infrequent, is more common in malignant strictures.

Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.