Management Of Esophageal Perforation Research Articles

Esophageal perforation after anterior cervical spine surgery

ObjectiveTo report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches. MethodsThis is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity. ResultsA total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively. ConclusionsEsophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

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.

Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort

BackgroundEsophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort. MethodsPatients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined. ResultsSurgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009). ConclusionsEsophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

Management of esophageal perforations and postoperative leaks

: Esophageal perforations and postoperative leaks are challenging and life-threatening conditions, with a not well-defined management, yet. Perforation is defined as a full-thickness tear in the esophageal wall due to a trauma on the esophageal lumen or to a sudden increase of endoluminal pressure, like in spontaneous perforations. The most frequent causes are: iatrogenic injuries, spontaneous perforations, foreign body or caustic ingestion, trauma, tumors etc. The onset of symptoms varies depending on the location of perforation (cervical, intrathoracic or intraabdominal), the degree of tissue destruction and extension of contamination of surrounding organs, the cause, the timing of diagnosis and the presence of underlying esophageal disorders. Post-operative esophageal leaks have a different origin but a quite similar clinical presentation and treatment to esophageal perforations. The higher reported incidence is after cervical esophagogastric anastomosis, followed by intrathoracic anastomosis (above all after trans-hiatal one). It is already proven that short diagnostic timing and correct treatment can reduce mortality of 50%. Recent evidence also shows how better outcomes are achieved when the management is multidisciplinary, led by an expert team, and individualized treatments are adopted, involving all available modalities (medical, endoscopic and surgical). The purpose of this article is to review current standard practice, expert opinions and outcomes in the management of esophageal perforations and postoperative leaks.

Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation.

Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations. We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material. There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation. A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Endoscopic management of esophageal perforations and tears

: Esophageal perforation is a life-threatening condition burdened by high morbidity and mortality. The esophageal perforation can occur spontaneously (such as Boerhaave syndrome) or can be an iatrogenic complication. The diagnostic approach may be difficult as the clinical presentations is often non-specific. However, a proper and early diagnosis is crucial to reduce the mortality rate. Once the diagnosis is obtained, the therapeutic management differs among the different clinical scenarios. In some cases, a wait and watch approach is preferred, in other cases a more aggressive treatment is required. Although surgery was considered the standard of care, nowadays endoscopy is emerging as the first line treatment in esophageal perforations non-responsive to medical treatments. The endoscopic techniques available are the application of through-the-scope clips (TTSCs), over-the-scope clips, esophageal stents, endoscopic suturing techniques, endoluminal vacuum therapy (EVT), and locoregional application of regenerative medicine. The choice of the specific endoscopic technique depends on the injury length, the perforation site, and the presence of fluid collections. The complexity of the diagnostic and therapeutic approach to esophageal perforation imposes a multidisciplinary approach in order to choose the proper treatment in each singular case. The aim of this study is to assess the role of endoscopy in the management of esophageal injuries and to describe the endoscopic techniques nowadays available.

A O05 MUlti-center cohort Study of Oesophageal Injuries and related Clinical outcomes (MUSOIC) study

Abstract Background Perforation of the oesophagus (OP) represent a potentially lethal yet poorly managed clinical condition due to its rarity, variation in clinical presentation and little consensus on the optimal management of these patients. Previous studies have shown that timely and appropriate treatment of OPs is the most important determinant of patient outcomes, and a delay in initiating the correct management within 24 hours increased the mortality rate from 10% to over 60%. Historically, patients have been managed based on the personal experience and preference of the surgeon, and accordingly most patients underwent surgical management based on data from small retrospective case series. Depending on the cause of injury, location of perforation and status of the patient, options include conservative management; endoscopy (stenting or clipping); and surgery (drainage, diversion, primary repair, or oesophagectomy). Currently, there are no recent large-scale studies investigating the outcomes in oesophageal perforation, leading to a paucity of high-grade evidence on the management of oesophageal injuries. This study aims to characterise the variation in the management of OPs, update its epidemiology in the UK; and evaluate the mortality and morbidity outcomes of surgical and non-surgical modalities in managing OP. Methods This was a multi-centred cohort study involving eligible centers from the Association of Upper Gastro-intestinal Surgeons for Great Britain and Ireland (AUGIS) research network. All adult patients who were admitted with a diagnosis of esophageal perforation (iatrogenic, spontaneous or traumatic causes) and managed as an inpatient for more than 24 hours were included in the study. Exclusion criteria were as follows: pediatric population; OP due to anastomotic leaks post-esophagectomy; and unavailability of data matching primary outcome measures. The time period for inclusion of patients was from January 2016 to December 2020. Investigators were asked to actively monitor patients and their electronic medical records to identify post-intervention complications up to 90 days from time of intervention if appropriate. The primary outcome was 90-day mortality. Other secondary outcomes included the incidence of complications secondary to OP or interventions; incidence of 30-day re-intervention; length of hospital stay (LOS) and intensive care unit (ICU) stay; readmission within 30 days; and recurrence. Results During the study period 369 patients with oesophageal perforation from eight centres and were included in the study. The mean age of the population was 63 (18) years, body mass index was 25 (9)kg/m2, 60% were male, 30% were ASA grade 3, and 41% ECOG performance status 0. The aetiology of OP was spontaneous in 57% and iatrogenic in 37%. The mean time from presentation to referral and intervention were 37 hours and 111 hours respectively. In patients transferred from a district general to a tertiary hospital the mean time from presentation to transfer was 100 hours. Surgery was used as the primary treatment approach in 31%, endoscopic intervention in 10% and conservative management in 56%. Thoractomy and laparotomy was used in 20% and 24% respectively, endosponge and endoscopic stent used in 11% and 7% respectively. 90-day mortality was 20% across the cohort, 30-day re-admission rate was 18%, mean ICU stay, and LOS were 10 days and 37 days respectively. 90-day mortality was significantly reduced in the surgery group (9%) when compared with endoscopic (24%) and conservative management groups (28%) (p<0.001). Multivariate analyses identified key patient, procedural, and treatment factors associated with mortality from oesophageal perforation. Conclusions In a centralised oesophageal and gastric cancer service, the management of complex upper gastrointestinal conditions including oesophageal perforation is most commonly centralised to oesophageal and gastric cancer centres. This large multi-centre collaborative study provides robust data concerning modern practices of the management of oesophageal perforation in the UK. Through a detailed and highly granular dataset, we have examined factors associated with the patient pathway, presentation and treatment that are associated with mortality following oesophageal perforation.

Conservative management of Boerhaave’s syndrome: a case report

The management of esophageal perforation has evolved. The underlying principles of drainage of sepsis, adequate nutrition and repair, or defunctioning of the esophagus remain. We are presenting a case of Boerhaave syndrome, where we have successfully managed conservatively with endoscopic stenting. Endoscopic therapy and VATS are used with increasing frequency and in appropriately selected patients with good results. Careful selection of patients for such procedures are important. Implantation of self-expanding metallic stent in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.

Single-centre review of the management of intra-thoracic oesophageal perforation in a tertiary oesophageal unit: paradigm shift, short- and long-term outcomes over 15 years

BackgroundOesophageal perforation is an uncommon surgical emergency associated with high morbidity and mortality. The timing and type of intervention is crucial and there has been a major paradigm shift towards minimal invasive management over the last 15 years. Herein, we review our management of spontaneous and iatrogenic oesophageal perforations and assess the short- and long-term outcomes.MethodsWe performed a retrospective review of consecutive patients presenting with intra-thoracic oesophageal perforation between January 2004 and Dec 2020 in a single tertiary hospital.ResultsSeventy-four patients were identified with oesophageal perforations: 58.1% were male; mean age of 68.28 ± 13.67 years. Aetiology was spontaneous in 42 (56.76%), iatrogenic in 29 (39.2%) and foreign body ingestion/related to trauma in 3 (4.1%). The diagnosis was delayed in 29 (39.2%) cases for longer than 24 h. There was change in the primary diagnostic modality over the period of this study with CT being used for diagnosis for 19 of 20 patients (95%). Initial management of the oesophageal perforation included a surgical intervention in 34 [45.9%; primary closure in 28 (37.8%), resection in 6 (8.1%)], endoscopic stenting in 18 (24.3%) and conservative management in 22 (29.7%) patients. On multivariate analysis, there was an effect of pathology (malignant vs. benign; p = 0.003) and surgical treatment as first line (p = 0.048) on 90-day mortality. However, at 1-year and overall follow-up, time to presentation (≤ 24 h vs. > 24 h) remained the only significant variable (p = 0.017 & p = 0.02, respectively).ConclusionOesophageal perforation remains a condition with high mortality. The paradigm shift in our tertiary unit suggests the more liberal use of CT to establish an earlier diagnosis and a higher rate of oesophageal stenting as a primary management option for iatrogenic perforations. Time to diagnosis and management continues to be the most critical variable in the overall outcome.

S1112 Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study

Introduction: Endoscopic advancements in stenting and tissue plication have proven to be viable alternatives to surgical management of esophageal perforations and are increasingly being used in clinical practice. We aim to assess the efficacy and outcome of different endoscopic treatment modalities in patients with esophageal perforations. Methods: We performed a retrospective analysis of patients with esophageal perforations from an endoscopic database since 2007. Patients with esophageal fistula, stricture, or stenosis were excluded. Patients were categorized into four treatment groups: primary closure (endoscopic suturing), primary bypass (stenting), combination (suturing defect and stenting), and conservative therapy (NPO, trans-nasal feeding tubes). Baseline demographics, patient characteristics, and treatment modality outcomes were collected. Predictors of success were identified using logistic regression. Results: 95 patients (mean age 64 ±15, 67% male) with esophageal perforations were included. The most common etiology was iatrogenic after dilatations or endoscopic myotomy (40%). 64% of perforations were in the distal esophagus. Regardless of strategy employed, 49% of patients had successful endoscopic repair of perforation. Only 7 patients required subsequent operative intervention. The combination approach achieved the greatest clinical success (66%), defined as no need for surgical intervention, when compared to the other modalities (primary bypass 35%, closure 57%, and conservative 25%, p=0.05). Patients with concomitant systemic inflammatory response syndrome had greater clinical success if they were treated with combination approach compared to primary bypass approach (18% vs. 64%, p=0.01). If the perforation was greater than or equal to 20mm, combination therapy had greater clinical success compared to primary bypass approach (0% vs. 50%, p=0.04). Early stent migration was associated with greater need for rescue surgery (p=0.02). (Table) Conclusion: Esophageal perforations can be managed effectively with endoscopic therapy. Larger, prospective trials are needed to clarify ideal individualized endoscopic strategies. Patients with systemic inflammatory response and/or perforation ≥20 mm are managed most effectively with combination therapy. Table 1. - Demographics, Presentation and Outcomes by Treatment Group Variables (%) All (n=95) Primary bypass (n=43) Primary closure (n=12) Combination(n=29) Conservative(n=11) Demographics All Primary bypass (n=43) Primary closure (n=12) Combination (n=29) Conservative (n=11) p-value Age (± SD) 63 ±14 66 ±13 61 ±13 61 ±15 64 ±15 0.23 Sex (Male) 64(67) 16(70) 10 (83) 19(65) 7(63) 0.61 History of EC 14 (16) 6(26) 1(8.3) 3(10) 2(18) 0.31 History of Radiotherapy 15 (19) 6(26) 0(0) 4(14) 2(18) 0.245 Diabetes 14(15) 2(9) 7 (43) 3(10) 2(18) 0.686 Hypertension 48(51) 12(52) 7(58) 13(45) 5(46) 0.927 Sleep apnea 16(17) 5(22) 2(17) 5(17) 0(0) 0.45 Site of Perforation Proximal 4(9.3) 0 2(6.9) 6(54.5) Middle 7(6.3) 3(25.0) 7(24.1) 0 Distal 29 (67.4) 8(66.7) 20(69.0) 5(45.5) Etiology of perforation SpontaneousIatrogenicFood impactionAnastomotic leakEsophageal cancer Boerhaave syndrome 7(16.3)22(51.2)2(4.7) 4(9.3) 2(4.7)6(14.0) 1(8.3)9(75.0)1(8.3) 0 01(8.3) 021(72.4)2(6.9) 3(10.3) 01(3.4) 2 (18.2)7(63.6)1(9.1) 0 01(9.1) Symptoms at time of diagnosis DysphagiaChest painAbdominal painFeverOther 10(23.3)11(25.6)1(2.3) 4(9.3)10(23.3) 1(8.3)4(33.3)0 1(8.3)2(16.7) 4(13.8)4(13.8)1(3.4) 5(17.2)8(27.6) 4(36.4)1(9.1)1(9.1) 02(18.2) Outcomes by Treatment Group Pittsburgh Perforation Severity Score (n=47) 3.17 ±2.1 3.59 ±2.2 2.5±2.0 2.72±1.8 3.45±2.25 0.225 Operative intervention required 7(5.7) 2(4.7) 1(8.3) 3(10.3) 1(9.1) 0.95 Mortality 9(7.4) 4(9.3) 0 3(10.3) 2(18.2) 0.652 SIRS 44(36.1) 19(44.2) 4(33.3) 16 (55.2) 5(45.5) 0.635 Stent migration 11 10(23.3) 0 2(6.9) 0 0.182 LOS* (days) 16±15 19 ±15 11±10 18±19 7.9±7.0 0.123 LOF* (months) 4.6±4.1 4.25±1.5 6±8.8 3.5±2.1 9.3±6.4 0.07 *LOS – Length Of Stay In The Hospital; LOF - Time From Diagnosis To Last-Follow Up; SIRS - Systemic Inflammatory Response Syndrome)

451. CLINICAL PATTERNS AND TREATMENT OUTCOMES OF OESOPHAGEAL PERFORATION—A TEN-YEAR RETROSPECTIVE ANALYSIS FROM A TERTIARY CENTER IN SOUTH INDIA

Abstract Oesophageal perforation is a rare, often life-threatening clinical condition with reported mortality rates of 18 to 25%. Early diagnosis is often challenging with many patients presenting late and in shock. Management is even more challenging with a myriad of options but no standard options or criteria. We aim to review our ten-year experience of managing oesophageal perforation and propose an algorithmic approach for managing this condition. A retrospective review of patients diagnosed with oesophageal perforation from 2011 to 2020 was done. Oesophago-gastric anastomotic perforations and corrosive injuries were excluded. The data relevant for the study including Pittsburgh Severity Score (PSS) was collected from the hospital electronic medical records and strengthened using telephonic conversation. Thirty-six patients (M: F-26:10, mean age: 48 years) were included. In 21 (58%) patients, the perforation was localized to the thoracic oesophagus. The commonest cause of perforation was Iatrogenic (n = 22, 61%), followed by spontaneous (n = 9, 25%). A severe PSS score (≥7) was associated with increased risk of operative intervention (76%) and mortality (18%). Eighteen patients (50%) required operative interventions wherein a primary repair was performed in seven (39%) patients, sepsis drainage in eight (44%) patients, and a diversion in one (6%) patient. Overall, eleven (31%) patients required a re-intervention, and the overall in-hospital mortality was 8.3%. Early diagnosis and decision making using an algorithmic approach are critical in the management of oesophageal perforation. PSS score is a useful tool in assessing the severity of disease. A combined multidisciplinary approach involving therapeutic endoscopy, surgery, and critical care is essential. A minimally invasive surgical approach is a feasible option in selected group of patients.

571. ESOPHAGEAL PERFORATION AFTER LOBECTOMY: PADLOCK CLIP TO THE RESCUE

Abstract Esophageal perforation or fistula is a devastating condition with diagnostic and therapeutic challenges. It is associated with high morbidity and mortality due to its rapid progression to mediastinitis or peritonitis, septic shock and multiorgan failure. Iatrogenic perforation is the commonest in this era. We hereby report a case of esophagopulmonary fistula following a right lower lobectomy which was successfully treated with endoscopic clipping. A 52-year-old man presented with productive cough and weigh loss for 2 weeks. Initial workup in another center revealed right lung lower lobe lesion and a right lower lobectomy was done. Saliva and food particle were noted in chest drain on post-operative day 2 due to esophageal perforation. Re-thoracotomy, washout and esophageal repair was done. An open window thoracostomy was created for further drainage and parenteral nutrition was initiated. Histology of the lobectomy specimen revealed actinomycosis of right lung. However, there was persistent leak from the esophagus with suspicion of esophagopulmonary fistula. He was then transferred to our center for further treatment. OGDS revealed a 5mm defect at right lateral wall mid thoracic esophagus, about 28cm from incisor, with healthy and supple surrounding mucosa. Contrast study revealed esophagopulmonary fistula. Esophageal defect was successfully closed with over-the-scope padlock clip (Steris). Repeat contrast study 1 week later revealed resolution of fistula. Sepsis and source control, nutritional support with restoration of gastrointestinal tract intergrity are key steps in the management of esophageal perforation. Endoscopic treatment is efficacious, less invasive, and with the advantage of organ preservation. Endoscopic clipping is safe and effective in selected group of patients with esophageal perforation or fistula.

Management of esophageal perforations in infants by endoscopic vacuum therapy: a single center case series

BackgroundEndoscopic vacuum therapy (EVT) has become a standard treatment method for esophageal perforations in adults. However, experience with EVT in infants is scarce. In this retrospective case series, we report on four very young infants who were successfully treated with EVT for esophageal perforations of different etiology.MethodsFour infants were diagnosed with esophageal perforations on day 7, 32, 35 and 159 of life, respectively. The youngest one was prematurely born in the 31st week of pregnancy weighing 980 g only. Three infants had perforations due to foreign body insertion (nasogastric tube or pulling through of percutaneous endoscopic gastrostomy (PEG) tube through the esophagus). One child had an anastomotic dehiscence after Foker’s surgery for atresia. In three children EVT was applied as first-line therapy for perforation, in one child EVT was a rescue therapy due to persisting leakage after surgical closure involving thoracotomy. Depending on the esophageal diameter, either an open-pore drainage film or polyurethane sponge was attached to a single-lumen 8 Fr suction catheter, endoscopically (or fluoroscopically by wire-guidance) placed into the esophagus (intraluminal EVT) and supplied with continuous negative pressure (ranging between 75 and 150 mmHg). The EVT system was exchanged twice per week.ResultsComplete closure of the perforation/leakage could be achieved in all four infants (100%) after 22 days of continuous EVT (median value; range 7–39) and 4.5 EVT exchanges (median value; range 1–12). No serious adverse events occurred.ConclusionsEVT is an effective and safe addition to our therapeutic armamentarium in the management of esophageal perforations irrespective of its etiology. Here we prove the feasibility of EVT even in very young infants. The use of an extra thin vacuum open-pore drainage film is helpful to cope with the small esophageal diameter. EVT settings and exchange rates similar to those known from adult treatment were used.

Management of esophageal perforations and benign diseases

Management of esophageal perforations and benign diseases

Management of Esophageal Perforations During Achalasia Treatment â?? Experience of the General and Esophageal Surgery Clinic, Sf Maria Hospital

Introduction: Achalasia is a motility disorder characterized by the absence of optimal relaxation of the lower esophageal sphincter (LES) with swallowing and lack of peristalsis of the esophageal body. Excepting temporary medical options, the treatment aims to lower the LES pressure by endoscopic or surgical means. Either method involves a risk of perforation. We analyzed the management of esophageal perforations in patients who received treatment for achalasia. Material and Method: we conducted a retrospective study of patients with achalasia hospitalized and treated in the Clinic of General and Esophageal Surgery within the Sf. Maria Clinical Hospital in Bucharest between January 2016 and December 2021. Results: There were 57 patients, 35 men, with a mean age of 50 years and a mean duration of symptoms of 35 months. Almost all (91.89%) patients presented with dysphagia. Preoperative manometry was performed in 52 patients, of whom 17 were type I, 35 were type II. The treatment was laparoscopic Heller eso-cardiomyotomy (LHM) in most cases (55), with Dor anterior fundoplication. There were 10 recurrent cases after dilation or surgery in another medical unit. There were 3 mucosal perforations after LHM. The treatment varied from simple suture to a combined endoscopic and surgical approach, involving the use of esophageal stent, abscess drainage, and feeding jejunostomy. We also present the management of two cases of esophageal perforation after endoscopic dilation, in which the support of the surgical team was necessary. Conclusion: Esophageal perforation in the treatment of achalasia, either endoscopic or surgical, requires immediate identification and treatment to provide the best chance of favorable evolution. The treatment of achalasia is indicated to be performed in dedicated centers, prepared even in case of complications.

Conservative management of esophageal perforation following foreign body ingestion, a case report

A19 years old female presented to Shohadaye Tajrish hospital with a retrosternal chest and back pain since the day before. Chest CT showed pneumo-mediastinum, although there was no sign of contrast leakage in imaging. We decided on conservative management for the patient. Symptoms and radiologic signs were diminished after three days in the ICU. This report has discussed the importance of early diagnosis, diagnostic modalities, and management in esophageal rupture cases.

Treatment of esophageal perforation: A review of our experience at a tertiary referral hospital spanning the past 19 years

Introduction and aimsEsophageal perforation is an uncommon event that is a medical/surgical emergency, with a 15-30% mortality rate. The aim of the present study was to communicate our experience in the management of esophageal perforation, evaluating the different strategies utilized, in an effort to establish measures to guide decision-making in selecting treatment. Materials and methodsA retrospective descriptive study was conducted on patients diagnosed with esophageal perforation at our hospital center, within the time frame of 2000 and 2019. ResultsOver the past 19 years, 15 patients were diagnosed with esophageal perforation. Surgical treatment was carried out in 80% of the cases. Primary closure, reinforced with plasty, was performed in 67% of the patients, of whom 62.5% had early diagnosis and a 100% survival rate. Diagnosis was late in 37.5% of the cases, with a 33.3% survival rate. Esophagectomy and gastric pull-up were performed on 25% of the patients, 66.6% of whom had early diagnosis and a 100% survival rate. In the 33.3% that had late diagnosis, the mortality rate was 100%. Esophagectomy, with cervical esophagostomy and feeding jejunostomy, was performed on one of the patients (8.3%) that had early diagnosis and a 100% survival rate. ConclusionsThe main survival predictor in esophageal perforation is the interval of time between the injury and its diagnosis, and in turn, the resulting treatment. Each patient with esophageal perforation should have individualized treatment to adequately manage the condition.

Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks.

Esophageal wall defects, including perforations and postoperative leaks, are associated with high morbidity and mortality and pose a significant management challenge. In light of the high morbidity of surgical management or revision, in recent years, endoscopic vacuum therapy (EVT) has emerged as a novel alternative treatment strategy. EVT involves transoral endoscopic placement of a polyurethane sponge connected to an externalized nasogastric tube to provide continuous negative pressure with the intention of promoting defect healing, facilitating cavity drainage, and ameliorating sepsis. In the last decade, EVT has become increasingly adopted in the management of a diverse spectrum of esophageal defects. Its popularity has been attributed in part to the growing body of evidence suggesting superior outcomes and defect closure rates in excess of 80%. This growing body of evidence, coupled with the ongoing evolution of the technology and techniques of deployment, suggests that the utilization of EVT has become increasingly widespread. Here, we aimed to review the current status of the field, addressing the mechanism of action, indications, technique methodology, efficacy, safety, and practical considerations of EVT implementation. We also sought to highlight future directions for the use of EVT in esophageal wall defects.

Tratamiento de la perforación de esófago, revisión de nuestra experiencia en un hospital de tercer nivel en los últimos 19 años

Introduction and aimEsophageal perforation is an uncommon event that is a medical/surgical emergency, with a 15-30% mortality rate. The aim of the present study was to communicate our experience in the management of esophageal perforation, evaluating the different strategies utilized, in an effort to establish measures to guide decision-making in selecting treatment. Materials and methodsA retrospective descriptive study was conducted on patients diagnosed with esophageal perforation at our hospital center, within the time frame of 2000 and 2019. ResultsOver the past 19 years, 15 patients were diagnosed with esophageal perforation. Surgical treatment was carried out in 80% of the cases. Primary closure, reinforced with plasty, was performed in 67% of the patients, of whom 62.5% had early diagnosis and a 100% survival rate. Diagnosis was late in 37.5% of the cases, with a 33.3% survival rate. Esophagectomy and gastric pull-up were performed on 25% of the patients, 66.6% of whom had early diagnosis and a 100% survival rate. In the 33.3% that had late diagnosis, the mortality rate was 100%. Esophagectomy, with cervical esophagostomy and feeding jejunostomy, was performed on one of the patients (8.3%) that had early diagnosis and a 100% survival rate. ConclusionsThe main survival predictor in esophageal perforation is the interval of time between the injury and its diagnosis, and in turn, the resulting treatment. Each patient with esophageal perforation should have individualized treatment to adequately manage the condition.

Short- and long-term follow-up of patients with non-neoplastic esophageal perforation

PurposeEsophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. Although health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention, not much is known about HRQoL, particularly in the long-term follow-up of patients treated for non-neoplastic esophageal perforation with different treatment strategies. The aim of this study was to evaluate patients’ outcome after non-neoplastic esophageal perforation with focus on HRQoL in the long-term follow-up.MethodsPatients treated for non-neoplastic esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were included. Primary outcome and management of esophageal perforation were documented. Long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD), and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal specific QoL (QLQ-C30 and QLQ-OES18).ResultsFifty-eight patients were included in the study. Based on primary treatment, patients were divided into an endoscopic (n = 27; 46.6%), surgical (n = 20; 34.5%), and a conservative group (n = 11; 19%). Short- and long-term outcome and quality of life were compared. HRQoL was measured after a median follow-up of 49 months. HRQoL was generally reduced in patients with non-neoplastic esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group.ConclusionHRQoL in patients with non-neoplastic esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery, not only in the short-term but also in the long-term follow-up.