Iatrogenic Oesophageal Perforations in Neoplastic Lesions: Management with Covered Self-Expanding Prostheses

Abstract

Background:Perforation of the oesophagus is a serious condition. Most of them are iatrogenic and are associated with significant morbidity and mortality, especially with late diagnosis. Aim: To prospectively analyse the results of the endoscopic management of iatrogenic perforations in oesophageal neoplasia, through the immediate insertion of a covered self-expanding prosthesis (CSES). Materials and Methods: Between 01.01.2006 and 12.30.2016, a series of 19 consecutive patients attended the Teaching Unit of Endoscopic Surgery of the Regional de Concepción Hospital, Chile, with the diagnosis of oesophageal neoplasia confirmed by biopsy were prospectively studied. All were subjected to a prior evaluation by the oncology team and subsequently referred for endoscopic palliative management of dysphagia. The average age was 77 ± 9.3 years, 8 (42.1%) were female and 11 (57.9%) were male. In 17 patients (89.5%) the stenosis compromised the oesophagus, in 2 (10.5%) the gastro-oesophageal junction, 16 had a squamous carcinoma (84.2%) and 3 an adenocarcinoma (15.8%). Results: Perforation was diagnosed during the procedure in 18 patients (94.7%) and in 1 (5.3%) 22 hours later. Follow-up was done for a minimum of 90 days or until death. The prostheses were inserted successfully in all cases. The immediate evolution was satisfactory in 12 patients (63.2%). In the rest (36.8%), 18 complications appeared. The most frequent were retrosternal pain, subcutaneous emphysema and fever. The early evolution was satisfactory in 12/19 cases (63.2%). Complication was evidenced in 7 (36.8%), the most frequent was retrosternal pain (36.8%). Fever occurred in 3 (15.8%), pleural effusion in 3 (15.8%) and mediastinitis in 2 of these. The prosthesis was kept in situ as a definitive palliation method for neoplastic dysphagia. In 10 of the 18 cases that survived more than a month, there were late complications (55.6%), none of them associated with the perforation itself. The only death (5.3%) was due to an oesophagus-pleural fistula, associated with an early prosthetic migration. Recovery of the oral intake occurred, on average, at 3.7 days. The hospital stay averaged 9.6 days. Conclusion: The use of CSES for the treatment of iatrogenic oesophageal perforations in the context of neoplasia, is a safe and effective method, with low morbidity, adequate recovery of the oral intake and prompt discharge from hospital.