Outcome Of Esophageal Perforation Research Articles

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.

A - 13 Years of Single-Center Experience in the Management and Outcome of Esophageal Perforation

A - 13 Years of Single-Center Experience in the Management and Outcome of Esophageal Perforation

Management and outcomes of esophageal perforation.

Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65years (hazard ratio [HR] 1.89 [1.02-3.26], P= 0.044) and a malignant perforation (HR 4.80 [1.31-17.48], P= 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39-4.43], P= 0.046) and sepsis (OR 3.26 [1.44-7.36], P= 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.

Esophageal perforation in very low birth weight infants.

We aimed to assess the prevalence and outcomes of esophageal perforation in very low birth weight infants. This retrospective cohort study utilized the US National Inpatient Sample dataset for the years 2000 to 2017. A total of 1,755,418 very low birth weight infants were included; of them, 861 (0.05%) were diagnosed with esophageal perforation. The majority (77.9%) of infants were in the birth weight category < 1000 g and 77.7% in infants ≤ 28 weeks of gestation. The majority (73%) of infants were tracheally intubated and received mechanical ventilation; of them, 24 infants (2.8%) had tracheostomy. Mortality associated with esophageal perforation was 25.8%. Regression analysis did not show an association between esophageal perforation and increased mortality in preterm infants (aOR = 1.0, CI: 0.83-1.20, p = 0.991). Procedures encountered in these infants include thoracentesis (10.8%), laparotomy (4.1%), percutaneous abdominal drainage (4.1%), and gastrostomy tube insertion (6.2%), whereas the rest of the infants were managed conservatively. There was a significant trend for increasing prevalence of esophageal perforation over the years.Conclusion: Esophageal perforation does not independently increase the risk for mortality in very low birth weight infants. The increasing prevalence is possibly related to increased care offered to infants at limits of viability in recent years. What is Known: • Knowledge about esophageal perforation is derived from anecdotal single-center case reports. • Esophageal perforation in neonates is mostly iatrogenic. • It is considered a critical complication that is associated with high mortality. What is New: • This is the first and largest national study on prevalence of esophageal perforation in preterm infants. • Esophageal perforation does not independently increase the risk for mortality. • Septicemia and pneumothorax are frequent complications to esophageal perforation.

ATRIO-ESOPHAGEAL FISTULA: A RARE AND GRAVE COMPLICATION OF ATRIAL FIBRILLATION ABLATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Atrio-esophageal fistula (AEF) is an extremely rare, life-threatening complication of catheter radiofrequency ablation (RFA) which has an increasing incidence of > 50,000/year in the US. AEF commonly causes death via cerebral air embolism, massive gastrointestinal bleeding (GIB) and septic shock in 2 months post RFA. The associated mortality of AEF is > 80% and requires prompt diagnosis and intervention.(1) CASE PRESENTATION: An 80 year old female with heart failure with reduced ejection fraction and cardiomyopathy due to persistent atrial fibrillation (AF) despite prior interventions presented 18 days post convergent VATS, left atrial (LA) clip/LA appendage ligation with epicardial ablation of LA posterior wall, while on Eliquis to the ER after 1 episode of hematemesis. There was no history of PUD, melena, NSAID use or heavy alcohol use. She had tachycardia but other vitals were normal. Exam revealed dried blood in the mouth, generalized abdominal tenderness but was otherwise normal. Pantoprazole infusion was commenced. Esophagogastroduodenoscopy (EGD) revealed a large deep mid-esophageal ulcer with clot. Post EGD, she became lethargic with acute hypoxic respiratory failure and was intubated. Chest x-ray showed new lung infiltrate and she was started on Zosyn and vancomycin. CTA of the chest revealed a 2.5 cm thrombus in the posterior left atrium and air within the right atrium. Fluconazole was added and she was taken to the OR for LA repair. The next day she underwent esophagectomy and gastric tube placement, during which she developed hemorrhagic shock requiring multiple transfusions and vasopressor support. Blood cultures grew Rothia mucinolaginosus, B6-deficient streptococcus and lactobacillus and CT head showed an acute stroke. Unfortunately, she died after palliative extubation 10 days post admission. DISCUSSION: AEF following RFA has an incidence of < 0.03% and is thought to be multifactorial. Thermal injury during the ablation, results in fistulization of the esophagus into the atrium i.e. AEF, a 1-way valve, causing strokes more often than upper GIB. CTA chest is the modality of choice, as EGD increases the risk of air embolization resulting in stroke or death. Currently early surgical repair appears to have the best survival.(2) Preventative measures such as an esophageal temperature probe for real-time temperature monitoring was used in this case. However, there is a 0.016% incidence of esophageal perforation despite monitoring in 90% of patients.(3) Other strategies to prevent AEF include: reduced power titration while ablating the posterior LA wall, decrease delivery time and active esophageal cooling with saline. CONCLUSIONS: The incidence of RFA for AF is rapidly increasing for which AEF is a rare yet grave complication that uncommonly presents as hematemesis. Awareness is imperative for prompt diagnosis as without urgent surgical intervention mortality approaches 100%. Reference #1: Patricia C, Franz HM, Abel CD, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart. 2015; 2(1), e000257. https://doi.org/10.1136/openhrt-2015- 000257. Reference #2: Singh SM, d’Avila A, Singh SK, et al. Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm. 2013; 10(11):1591–1597. Reference #3: Chirag RB, Saurabh K, Yu G, et al. Global Survey of Esophageal in Atrial Fibrillation: Characteristics and Outcomes of Esophageal Perforation and Fistula. JACC: Clinical Electrophysiology. 2016; 2(2):143-150. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Nisha Gandhi, source=Web Response No relevant relationships by Alexandra Gottdiener, source=Web Response No relevant relationships by Gene Otuonye, source=Web Response No relevant relationships by Dan Ran-Castillo, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response

Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center

Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.

Influence of centralization on the outcome of esophageal perforation

Influence of centralization on the outcome of esophageal perforation

Causes and Outcomes of Esophageal Perforation in Eosinophilic Esophagitis.

To characterize patients who suffer perforation in the context of eosinophilic esophagitis (EoE) and to identify predictors of perforation. Esophageal perforation is a serious complication of EoE. We conducted a retrospective cohort study of the University of North Carolina EoE clinicopathologic database from 2001 to 2014. Subjects were included if they had an incident diagnosis of EoE and met consensus guidelines, including nonresponse to a PPI trial. Patients with EoE who had suffered perforation at any point during their course were identified, and compared with EoE cases without perforation. Multiple logistic regression was performed to determine predictors of perforation. Out of 511 subjects with EoE, 10 (2.0%) had experienced an esophageal perforation. Although those who perforated tended to have a longer duration of symptoms before diagnosis (11.4 vs. 7.0 y, P=0.13), a history of food impaction (odds ratio, 14.9; 95% confidence interval, 1.7-129.2) and the presence of a focal stricture (odds ratio, 4.6; 95% confidence interval, 1.1-19.7) were the only factors independently associated with perforation. Most perforations (80%) occurred after a prolonged food bolus impaction, and only half of individuals (5/10) carried a diagnosis of EoE at the time of perforation; none occurred after dilation. Six patients (60%) were treated with nonoperative management, and 4 (40%) required surgical repair. Esophageal perforation is a rare but serious complication of eosinophilic esophagitis, occurring in ∼2% of cases. Most episodes are due to food bolus impaction or strictures, suggesting that patients with fibrostenotic disease due to longer duration of symptoms are at increased risk.

Management and Outcomes of Esophageal Perforation: A National Study of 2,564 Patients in England.

Traditionally esophageal perforation is a rare clinical emergency that confers a high rate of mortality and major morbidity. The objective of this study was to establish the annual rate and mortality from esophageal perforation and determine the effect of hospital volume on clinical outcomes. Hospital Episode Statistics database was used for the identification of patients admitted to hospitals within England with esophageal perforation between 2001 and 2012. The influence of hospital volume and treatment approach upon clinical outcomes was analyzed using multivariable analysis to control for patient age and medical comorbidities that may influence outcome. Over the 12-year study period 2,564 patients with esophageal perforation were treated at 158 hospitals. The 30- and 90-day mortality rates were 30.0 and 38.8%, respectively. Esophageal perforation etiology was spontaneous in 81.9% and iatrogenic in 5.9% of cases. There was a significant increase in the percentage of patients managed supportively and a reduction in surgical management over time. Furthermore there were significant reductions in 30-day (36.6% to 24.9%; P<0.001) and 90-day mortality (44.1% to 35.4%; P=0.006) over the 12-year study period. Important patient demographics associated with 30- and 90-day mortality included age ≥70 years, preoperative congestive cardiac failure, ischemic heart, liver, and renal disease. High hospital volume was associated with significant reductions in 30- (odds ratio (OR)=0.68; P=0.001) and 90-day mortality (OR=0.69; P=0.001). In a subset analysis of patients undergoing endoscopic intervention, hospital volume was identified as an important factor associated with mortality. This study provides evidence for the centralization of management of esophageal perforation to high volume centers with appropriate multi-disciplinary infrastructure to treat these complex patients.

Full-thickness esophageal perforation after fluoroscopic balloon dilation: incidence and management in 820 adult patients.

The purpose of this study is to investigate the incidence, management, and outcomes of esophageal perforation after fluoroscopic balloon dilation in 820 adult patients with esophageal diseases. Between December 1990 and April 2014, a total of 820 adult patients (age range, 21-93 years) underwent 1869 fluoroscopic balloon dilation sessions (mean, 2.3 sessions/patient; range, 1-29 sessions/patient) for esophageal diseases. We retrospectively reviewed the prospectively collected medical records and images of these patients and collected the data of patients who developed esophageal perforations after fluoroscopic balloon dilation. During this period, 12 patients (six men and six women; mean age, 51 years; age range, 28-69 years) developed perforations. The perforation rate was 1.5% per patient and 0.6% per dilation. Among the first eight patients, four who were treated with surgery had perforations 2 cm or larger, and the other four who underwent fasting, parenteral alimentation, and treatment with antibiotics had perforations smaller than 2 cm. The last four patients underwent stent placement immediately after the diagnosis, regardless of the perforation's size. The median hospital stay was 11.5 days. Fluoroscopic balloon dilation of esophageal diseases is a safe procedure with a low perforation rate. A perforation size greater than 2 cm is considered large and requires aggressive treatment. Although the number of patients with esophageal perforation we treated is relatively small and further clinical trials are needed, temporary stent placement seems to be an initial choice in the management of esophageal perforations after fluoroscopic balloon dilation.

Options in the management of esophageal perforation: analysis over a 12-year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.