Iatrogenic Esophageal Perforation Research Articles

Unusual foreign bodies in upper aero digestive tract – Our experience at tertiary care centre

Foreign bodies ingestion is especially common in the pediatric age group, whereas in adults occur accidently or among those with psychiatric disorders, mental retardation, prisoners and alcoholics, Preexisting GI tract abnormalities, such as previous surgery, strictures, or functional abnormalities, increases the risk of a swallowed foreign body becoming lodged at the site of the abnormality.This retrospective study was conducted in 32 patients with upper aero digestive tract unusual foreign bodies presenting to our department on emergency basis in a duration of one year. This Study was conducted in ENT department tertiary care Centre in duration of 2021-2022, 32 patients presented with unusual FB in upper aero digestive tract were treated in our department on an emergency basis. There were 14 male (43.75%) and 18 female (56.25%) ranging in age from 2 to 62 years. The main symptoms patients complained were difficulty in swallowing and pain. Detailed history with examination of nasal cavity, oral cavity and pharynx by indirect laryngoscopy and finally X-ray or CT scan were the diagnostic tools as required. The location of the FB was in the esophagus, Pyriform sinus, hypopharynx in decreasing order.The treatment consisted of rigid endoscopy and foreign body removal under general anesthesia or sedation. No major complications occurred in procedure except one in with iatrogenic esophageal perforation that was managed conservatively. Endoscopy is a reliable method in the treatment of upper aero digestive tract foreign body (FB) impaction.

Management of Esophageal Perforation in an Elderly Woman

Esophageal perforation is a feared complication of therapeutic esophageal procedures. It is known to occur in 50% of cases following therapeutic esophageal procedure. Esophageal perforation is associated with increased morbidity and mortality owing to difficulties in accessing the esophagus, the weak serosal layer, the peculiar blood supply of the organ, and its proximity to vital structures. We report the management of iatrogenic esophageal perforation following stricture dilatation in an elderly woman with a history of esophageal carcinoma. The patient was managed with stenting of the esophagus and parenteral nutrition. Thus, immediate identification and prompt management of iatrogenic esophageal perforation may reduce further complications.

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

Emergency rescue esophageal stenting through retrograde and antegrade rendezvous gastroscopy for an iatrogenic complicated esophageal perforation.

Emergency rescue esophageal stenting through retrograde and antegrade rendezvous gastroscopy for an iatrogenic complicated esophageal perforation.

Endoscopic iatrogenic esophageal perforation and management: a retrospective outcome analysis in the modern era

IntroductionIatrogenic esophageal perforation (IEP) is a severe adverse event (AE) of upper endoscopy procedures (UEPs) associated with morbidity. Management has shifted from surgery to endotherapy with clip closure (CC), self-expanding metal stent (SEMS), and vacuum therapy (VT). Limited analyses measure outcomes during contemporary interventional endoscopy periods.MethodsIEPs associated with EGD, upper EUS, small bowel enteroscopy (SBE), and ERCP at a 3-hospital academic center from January 2011 to December 2023 were identified retrospectively from a centralized AE database. Additional information was obtained from medical records. Statistical analysis was performed using Microsoft Excel and STATA.ResultsThirty-two IEPs from 26 EGDs, 4 EUS, 1 SBE, and 1 ERCP were identified. IEPs occurred mostly after dilation (bougie N = 7; balloon, N = 5) or foreign body removal (N = 6). Most IEPs occurred in the lower esophagus (N = 10) or gastroesophageal junction (N = 8). Diagnosis was made at a median 2 h after the injury by endoscopy (N = 14), CT scan (N = 12), esophagram (N = 5), or x-ray (N = 1). Initial treatment included conservative therapy alone (N = 7), CC (N = 3), SEMS (N = 14), SEMS plus CC (N = 3), or surgery (N = 3). Eleven patients required additional treatment including repeat SEMS or adjustment (N = 4) or VT (N = 1). No surgical interventions were required after 2013. The median hospital stay was 3 days. Disposition included discharge to home (N = 25), long-term care facility (N = 2), 4 deaths (12.5% of IEPs), and 1 unknown.ConclusionsIEPs are rare and occur throughout the esophagus after any UEP. The majority are recognized immediately and managed with endotherapy, or rarely, surgery today. These characteristics likely explain the low mortality in this study.

S3374 Successful Endoscopic Clipping of Iatrogenic Esophageal Perforation with Massive Subcutaneous Emphysema

S3374 Successful Endoscopic Clipping of Iatrogenic Esophageal Perforation with Massive Subcutaneous Emphysema

S713 Iatrogenic Esophageal Perforations and Their Management

S713 Iatrogenic Esophageal Perforations and Their Management

Iatrogenic Esophageal Perforation in Premature Infants: A Multicenter Retrospective Study from Poland.

Greater awareness of possible iatrogenic esophageal perforation (EP) is needed. Though rare, EP is a legitimate health risk as it may lead to long-term morbidities. This study presents and discusses iatrogenic EP in a subset of preterm infants. Using radiographic images, we study and describe the consequences of the orogastric/nasogastric tube position (in radiographic images). We analyze the possible influence of histological chorioamnionitis on the development of esophageal perforation. This retrospective study examines the hospital records of 1149 preterm infants, 2009-2016, with very low birth weight (VLBW) and iatrogenic EP, comparing mortalities and morbidities between the two groups of preterm infants who had birth weights (BWs) of less than 750 g and were less than 27 weeks gestation age at birth: one group with iatrogenic esophageal perforation (EP group) and one group without perforation (non-EP group-the control group). Histopathological chorioamnionitis of the placenta showed no statistically significant differences between the groups. The only statistically significant difference was in the air leaks (p = 0.01). Three types of nasogastric tube (NGT) X-ray location were identified, depending on the place of the perforation: (1) high position below the carina mimicking esophageal atresia; (2) low, intra-abdominal; (3) NGT right pleura-directed. We also highlight the particular symptoms that may be indicative of EP due to a displacement of the nasogastric tube.

Iatrogenic esophageal perforation in infants: how to avoid thoracotomy? Two case reports

Background: Esophageal perforation is uncommon and often iatrogenic in the neonatal period, and premature and low birth weight infants (<1500 g) are particularly susceptible. Esophageal injury in neonates usually occurs at the pharyngoesophageal junction and can be confused with esophageal atresia due to respiratory signs and excessive salivation. Diagnostic evaluation and treatment are still debated. 
 Case Presentation: This case report aims to describe two neonatal cases of iatrogenic esophageal perforation. The suspected diagnosis was confirmed only with thoracotomy. Diagnostic difficulties and therapeutic modalities are discussed. 
 Conclusion: These two cases show the importance of the clinical clues (anamnesis and clinical findings) to suspect the diagnosis of esophageal perforation.

The outcome of esophageal perforation in neonates and its risk factors: a 10-year study.

Esophageal perforation is a rare complication in infants that can be difficult to diagnose. The mortality rate due to esophageal perforation is high. This condition is more common in low birth weight premature infants. This study examines esophageal perforation in relation to various demographic and clinical variables. This study has a cross-sectional design. All pre-term neonates with esophageal perforation at Valiasr Hospital in Tehran, Iran, were included in the study over the span of ten years, from 2011 to 2021. Factors, such as gestational age, sex, weight, type of delivery, and interventions performed that could contribute to the condition, including intubation and Orogastric (OG) tube insertion, were investigated in the participants. Among the 9924 infants studied over the 10-year period, 15 cases (0.15%) had esophageal perforation. All these infants underwent non-operative management with acceptable results. Learning about the risk factors for iatrogenic esophageal perforation in neonates can help prevent this unwanted event in most cases. Also, the majority of these cases can be managed non-operatively provided that early diagnosis is made.

Subtotal esophagectomy with esophagogastroplasty after esophageal perforation and stent insertion: Case report of a challenging situation

We present a case of failure of uncovered metal esophageal stent removal, which was inserted after iatrogenic esophageal perforation during endoscopy. A 58-year-old male patient presented with dysphagia, chest pain, globus sensation and vomiting. Based on the data of the performed preoperative studies and to avoid the possibility of developing fatal complications (primarily aortoesophageal fistula) the surgical intervention was recommended. The successful subtotal esophagectomy with immediate esophagogastroplasty was then performed. The control X-Ray examination was performed at 6th p/o day, which reveals no extravasation and free passage of contrast to the distal part of GI tract. The patient started peroral eating and was discharged the Hospital at 7th p/o day. We consider, that this surgical procedure seems to be the most optimal and radical surgical intervention in case of failed esophageal stent placement.

Iatrogenic Neonatal Esophageal Perforation: A European Multicentre Review on Management and Outcomes.

The aim of this multicenter retrospective study and literature review was to review management and outcomes of neonatal esophageal perforation (NEP). Protocol data were collected from four European Centers on gestational age, factors surrounding feeding tube insertion, management and outcomes. The 5-year study period (2014-2018) identified eight neonates with median gestational age of 26 + 4 weeks (23 + 4-39) and median birth weight 636 g (511-3500). All patients had NEP from enterogastric tube insertions, with the perforation occurring at median 1st day of life (range 0-25). Seven/eight patients were ventilated (two/seven-high frequency oscillation). NEP became apparent on first tube placement (n = 1), first change (n = 5), and after multiple changes (n = 2). Site of perforation was known in six (distal n = 3, proximal n = 2 and middle n = 1). Diagnosis was established by respiratory distress (n = 4), respiratory distress and sepsis (n = 2) and post-insertion chest X-ray (n = 2). Management in all patients included antibiotics and parenteral nutrition with two/eight receiving steroids and ranitidine, one/eight steroids only and one/eight ranitidine only. One neonate had a gastrostomy inserted, while in another an enterogastric tube was orally successfully re-inserted. Two neonates developed pleural effusion and/or mediastinal abscess requiring chest tube. Three neonates had significant morbidities (related to prematurity) and there was one death 10 days post-perforation (related to prematurity complications). NEP during NGT insertion is rare even in premature infants after evaluating data from four tertiary centers and reviewing the literature. In this small cohort, conservative management seems to be safe. A larger sample size will be necessary to answer questions on efficacy of antibiotics, antacids and NGT re-insertion time frame in NEP.

Esophageal emergencies.

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

S347 Endoscopic Suture Repair of a Transmural Esophageal Perforation

Introduction: Iatrogenic esophageal perforations during endoscopic procedures are associated with considerable morbidity and mortality. Traditional management of large esophageal perforations included an aggressive approach involving surgery, but despite advances in techniques, postoperative complications remain high. Conservative management with endoscopic suturing and stenting has drastically improved patient outcomes. Herein, we present a patient with a guidewire associated 12 cm full thickness esophageal perforation that was successfully repaired by endoscopic suturing and stent placement. Case Description/Methods: A 60-year-old female with pmhx of GERD and chronic dysphagia presented s/p outpatient EGD empiric guidewire assisted dilation to 54Fr that was complicated by an approximately 12cm full thickness esophageal tear/perforation and pneumomediastinum. On endoscopic evaluation a large esophageal perforation was found 40 cm from incisors. A total of 4 endoscopic sutures were used to approximate the edges of the perforation in an interrupted fashion. A 15 cm fully covered stent was then endoscopically deployed over the defect with 2 sutures used for stent fixation. Following the procedure, CT esophagram showed absence of an esophageal leak. She underwent repeat EGD 2 weeks later for stent removal which showed adequate healing of the esophagus and no evidence of ongoing defect or perforation. Discussion: Endoscopic suturing was first approved by the USDA in 1998 and its uses have expanded to the repair of fistulas, perforations and anastomotic leaks. The closure technique involves approximating the defect edges using continuous and interrupted sutures, via an endoscopic suturing device. The size of the perforation limits other endoscopic interventions including over the scope clips (OTSC) which are effective in closing perforations up to 1-2 cm in size. Sharaiha et al. reported the successful closure of esophageal perforations in 13 patients using endoscopic suturing. However, the defect size ranged from 25 to 50 mm in length, much smaller than the case we present which included a 12 cm transmural defect. Further, endoscopic suturing alone is not as effective in perforation closure when compared to the addition of stent placement. Watch the video at https://tinyurl.com/ACGAbstractS347

S2423 A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

S2423 A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

463. OESOPHAGEAL PERFORATIONS: CAUSES, MANAGEMENT, AND OUTCOMES AT A SPECIALIST UPPER GASTROINTESTINAL UNIT OVER A TEN-YEAR PERIOD

Abstract Perforation of the oesophagus is a relatively rare but life-threatening condition, which requires early laparoscopic or surgical intervention. The aim of this work was to describe the causes, management and outcomes of emergency patients treated at a single high volume upper gastrointestinal specialist unit in the United Kingdom. In this retrospective case series, we identified all patients who presented to a tertiary upper gastrointestinal surgery unit with a spontaneous or iatrogenic oesophageal perforation. Patient demographics, clinical management, and outcomes were identified by hand review of the medical notes. Between March 2011 to July 2020, 58 patients were identified. The median age was 71 years (interquartile range 52 years to 83 years) and 64% were male. A total of 83% of patients had benign perforations, the rest being malignant. Management of all patients was supportive in 41%, endoscopic in 19% and surgical in 40%. In total 63% of spontaneous benign perforations were managed surgically, and only 6% endoscopically. The median length of hospital stay for all patients that survived more than 90 days was 13 days. The 90-day mortality rate for all patients was 42%. Oesophageal perforations are a relatively rare but lethal disease, carrying a mortality. Whilst surgery has historically been the most common management of benign spontaneous perforations, endoscopic treatments are likely to become increasingly common in the future.

162. EXPERIENCE IN PRIMARY REPAIR OVER T TUBE IN IATROGENIC OESOPHAGEAL PERFORATION

Abstract Iatrogenic oesophageal perforation can be a devastating event following endoscopic or surgical procedures. It remains a challenge for the surgeon to intervene. The most common cause of oesophageal perforation which accounts for about 70% of the cases is iatrogenic perforation with mortality ranging from about 10 to 25%. Most of the iatrogenic perforations are from endoscopic procedures. This case report like to highlight one of the treatments for iatrogenic oesophageal perforation. A 73-year-old female presented to the ORL team with the inability to swallow and associated with choking sensation and drooling of saliva for 2 days. The patient developed intrascapular pain post-Rigid Esophagoscopy which intensified postprandially, and developed respiratory distress with excruciating pain over the centre of the chest anteriorly and intrascapular region. Examination revealed reduce air entry of the right lung with Xray revealed right pneumothorax with a collapsed lung. CT Thorax revealed mid-oesophageal injury at above the carina with extravasation of oral contrast. Oesophagogastroduodenoscopy, Right Thoracotomy, Primary Oesophageal perforation repair over T-tube, Right Thoracic Decortication, and Washout were done. Defect at mucosa anteriorly with stricture 23 cm and submucosal flap 28 cm from the incisor into the left thoracic cavity with perforation at the right lateral wall of the oesophagus 5 cm below the azygos vein crossing point. Myotomy performed and T-tube catheter inserted as control fistula. Oesophageal repair done and 2 chest tubes inserted at the site of perforation and base of thorax. Intraoperatively right lung expanded well. A contrast swallow study on day 46 shown no evidence of fistula between trachea and oesophagus or leak. The surveillance endoscope showed remarkable healing. Iatrogenic oesophageal perforation remains amongst the main causes for oesophageal emergencies which require proper planning, and prompt management. Proper selection of both non-operative and operative management are interchangeable with the time, and progression of a patient’s conditions. As these cases are rarely encountered thus such cases should be managed at a centre that is equipped with a trained, and experienced specialist unit, thus preventing misdiagnosis, undertreated treatment, and unwanted outcomes.

530. LAPAROSCOPIC REPAIR OF ESOPHAGEAL PERFORATION

Abstract Esophageal perforation is associated with high morbidity and mortality. Early detection and treatment are vital as delays substantially increases mortality risk. Management options include surgical repair, drainage, diversion, endoscopic stenting/clipping and conservative management. Treatment of choice depends on etiology, location and duration between perforation and detection. Surgical repair remains as the mainstay of treatment if perforation is diagnosed <24 hours. However, for perforation detected > 24 hours, management is controversial with many advocating non-operative therapy. We present the case of a 68-year-old gentleman who underwent laparoscopic repair of an iatrogenic esophageal perforation. He first presented with dysphagia secondary to esophageal peptic stricture, initial biopsy showing no signs of malignancy. Patient underwent serial endoscopic dilatations, which was complicated with an iatrogenic esophageal perforation during his second dilatation. He underwent an urgent laparoscopic distal esophagectomy and proximal gastrectomy to resect the diseased part of the esophagus- intraoperatively noted a 1cm perforation over distal esophagus. A double tract reconstruction was then performed to restore continuity of the gastrointestinal tract and reduce gastric reflux to the esophagus. Patient was started on clear feeds on post-operative day 1 with gradual escalation of feeding to soft diet on post-operative day 4. His post-operative recovery was largely uneventful and he was discharged on post-operative day 7. Histological examination however returned as a pT3N1a moderately differentiated oesophageal squamous cell carcinoma. A PET-CT scan and repeat gastroscopy done showed no residual or distant disease. His condition was discussed in multidisciplinary meeting and patient then underwent definitive chemotherapy and radiotherapy. Although early recognition, detection and treatment of esophageal perforation are important for good outcomes, delays in diagnosis and treatment are usually due to rarity of this condition and lack of familiarity with management. Our video aims to showcase the surgical repair of a distal esophageal perforation and reconstruction in a minimally invasive fashion. Aim of surgery should include repair of perforation, cleaning up contamination, restoring gastrointestinal continuity and resolution of any underlying etiology.

393. ENDOSCOPIC VACUUM THERAPY FOR PATIENTS WITH ESOPHAGEAL PERFORATION: A MULTI-CENTER RETROSPECTIVE COHORT STUDY

Abstract Esophageal perforations are associated with high morbidity. Recently, endoscopic vacuum therapy (EVT) has been introduced as a novel treatment option for esophageal perforations. This technique has so far mainly been described for anastomotic leakage after upper gastrointestinal surgery. The aim of this study was to describe the initial experiences with EVT for treatment of esophageal perforations caused by Boerhaave syndrome or with an iatrogenic cause. For this retrospective, multicenter cohort study, all patients primarily treated with EVT for an esophageal perforation at four hospitals in the Netherlands, Switzerland and Sweden between January 2018 and October 2021, were included. Data on patient characteristics, EVT and outcomes were analyzed. The primary endpoint was success rate of EVT, defined as closure of the defect, as assessed by endoscopy or CT-scan. 27 patients were included (Table 1). EVT succeeded in 24/27 patients (89%, 95%CI[71,98]) with 16/19 using EVT alone (84%, 95%CI[60,97]). In 8 patients an additional treatment modality was used. In 3 patients EVT failed: 2 (Boerhaave and unknown cause) deceased due to a pulmonary embolism and septic embolic stroke, and 1 (Boerhaave) underwent an additional esophagectomy. All had a ‘large’ perforation-size. Median hospital stay was 18 days, with median 12 days EVT-duration and 1 sponge-exchange. Additional drainage was performed in 8 patients. EVT-associated complications occurred in 3 patients: 1 iatrogenic defect-expansion from the overtube and 2 hemorrhages, which spontaneously stopped. EVT is a promising, possibly organ-preserving treatment for Boerhaave syndrome or iatrogenic esophageal perforation, with a success rate of 84–89%. More experience with the technique and indications for use will likely improve success rates in the future.