Spontaneous Esophageal Perforation Research Articles

Spontaneous Oesophageal Perforation treated with Oesophageal Stent

Spontaneous Oesophageal Perforation treated with Oesophageal Stent

326. SPONTANEOUS OESOPHAGEAL PERFORATION TREATED WITH OESOPHAGEAL STENT

Abstract We present the case of a 66-year-old male with spontaneous oesophageal perforation treated with oesophageal stenting. This patient reports sudden onset severe anterior chest pain after coughing and haematemesis with a background medical history of Type II DM, ESRF on Haemodialysis, Hypertension, OSA and takes prophylactic Aspirin. Endoscopy reveals multiple areas of oesophageal perforation in the proximal, middle, and distal oesophagus as well as a haematoma extending the entire length of the oesophagus to the COJ. This was treated with insertion of a WallFlex™ Fully Covered Oesophageal Stent as the patient was unsuitable for surgery. The result was re-epithelialisation of the entire oesophagus and complete resolution of the perforation at the mid-oesophagus. Dutch physician Boerhaave first described spontaneous oesophageal perforation in 1724. Commonly, these were treated surgically with associated high morbidity and mortality. Advances in endoscopic and stent technology has given clinicians a greater armamentarium to treat patients especially in the frail end elderly population. These advances include choices such as stent covers, biodegradable and removable stents, and anti-reflux valves. Complications with oesophageal stents such as fistula formation, stent migration and retrosternal pain are often associated with the length of placement. The choice of a fully covered retrievable oesophageal stent in our case provided reconstitution of oesophageal lumen and minimisation of mediastinal sepsis. With the progress in stent technology, we believe there will be greater use of endoscopic oesophageal stenting for oesophageal perforations bridges the gap between operative and non-operative management.

627. LEFT THORACOSCOPIC PRIMARY REPAIR OF ESOPHAGEAL PERFORATION SECONDARY TO BOERHAAVE SYNDROME

Abstract Background With the advancement of the minimally invasive surgical techniques, more and more acute surgical conditions including esophageal perforations can be performed safely using minimally invasive surgical approach. Methods A middle aged male patient presented to our department with 3 days history of epigastric pain and vomiting. He was febrile on admission and investigation revealed the left sided esophageal perforation due to Boerhaave Syndrome with left sided pleural effusion. He underwent left thoracoscopic primary repair of esophageal perforation and wash out successfully. This is the video of the thoracoscopic primary repair of the perforation. Patient was put in the right lateral semi prone position, the area of perforation was identified by careful dissection of the pleura and repaired was performed in 2 layers. The pleura cavity was washed out with warm saline and underwater sealed chest tube drain was inserted. Results Post operatively patient was transferred to surgical intensive care unit for 1 day. Patient was kept nil by mouth with parenteral nutrition for 7 days. Contrast study was performed on post operative day 7 and started oral feeding when there was no evidence of leakage. Patient recovered and discharged well. Conclusion Thoracoscopic primary repair with wash out of spontaneous esophageal perforation secondary to Boerrhave Syndrome is challenging however it is safe and can be performed successfully. https://drive.google.com/file/d/1JTfJLV-ngUBwzMybGV4FL8EEQB-ysj9O/view

Outcome of treatment modalities for spontaneous esophageal rupture: a meta-analysis and case series.

Current treatment modalities for spontaneous esophageal perforation remain controversial because of their rarity. To describe our institution's experience in managing patients with spontaneous esophageal rupture and conduct a meta-analysis of existing studies to determine the best evidence-based treatment options. We enrolled patients with spontaneous esophageal rupture who underwent their first treatment at our institution. We also identified studies through a systematic search of the MEDLINE, EMBASE, and Cochrane Library databases before April 1, 2024, for inclusion in the meta-analysis. This case series included data from 17 patients with delayed diagnosis who were treated with esophageal stents, with an immediate mortality rate of 5.9%. In addition to the cases from our institution, we obtained 944 patients from 46 studies in the final analysis. The combined immediate mortality rate was 11% (95% confidence interval [CI]: 0.08-0.15). The combined re-intervention rate was 11% (95% CI: 0.05-0.19). The combined immediate mortality was 6% (95% CI: 0.04-0.09) after primary closure, 14% (95% CI: 0.02-0.32) after T-tube drain repair, 2% (95% CI: 0.00-0.15) after esophagectomy, 8% (95% CI: 0.03-0.15) after stent placement, and 22% (95% CI: 0.03-0.47) after conservative treatment. The subgroup analysis based on the timing of the intervention showed that the immediate mortality rate in patients initiating treatment within 24 h of rupture was 3% (95% CI: 0.01-0.08), whereas that in patients initiating treatment > 24 h later was 12% (95% CI: 0.08-0.18). Outcomes are best after esophagectomy, and primary closure or esophageal stenting is a good option compared with other treatment modalities. Prognosis is related to the timing of intervention, and accurate diagnosis and treatment within 24 h significantly reduces the risk of death in patients. Patients with delayed diagnosis may have a better prognosis with stent placement.

Spontaneous Pneumomediastinum in Children: Underdiagnosis and Overtreatment

Background: Spontaneous pneumomediastinum (SPM) is a rare and benign self-limiting condition characterized by the presence of air in the mediastinum without an apparent cause. Boerhaave syndrome, on the other hand, is a rare condition caused by spontaneous esophageal perforation due to severe vomiting. The mediastinum is a complex anatomical region housing vital organs, making clinical comprehension challenging. Objectives: There is no established approach to diagnosing and treating children with SPM. Despite similarities in the presence of air in the mediastinum, SPM and Boerhaave syndrome are distinct entities. However, the primary challenge for patients is ruling out esophageal perforation. We aimed to highlight this rare issue by presenting the results of our patient series to guide further examination in pediatric patients with mediastinal air. Methods: We included twenty-four pediatric patients diagnosed with SPM between 2014 and 2022. Demographic and clinical characteristics, diagnostic procedures, treatments, and follow-up details were retrospectively recorded. Results: The mean age of the twenty male and four female patients was 14 years. Common triggers included coughing (45%), increased physical exertion (33%), and retching/vomiting (8%). All patients experienced chest pain, with additional symptoms such as dyspnea (50%), neck pain (30%), and dysphagia (12%). Symptoms resolved within two days of hospitalization. Patients were often misdiagnosed and received inappropriate treatment at other centers before being transferred to our hospital. A fluoroscopic esophagogram conducted within an average of 22 hours from admission revealed no abnormalities. Oral feeding was withheld for an average of 28 hours. The mean duration of symptom-free hospitalization without treatment was 32 hours. Conclusions: It appears that emergency department physicians may lack familiarity with pneumomediastinum. Surgeons' concerns about missing Boerhaave's syndrome may lead to unnecessary tests, prolonged fasting, and hospital stays for patients with SPM.

Efficacy of esophageal stents as a primary therapeutic option in spontaneous esophageal perforations: a systematic review and meta-analysis of observational studies.

Spontaneous esophageal perforation traditionally mandates urgent surgical treatment. Lately, esophageal stents have been used to reduce the associated morbidity and mortality. The current systematic review aimed to assess the efficacy of stents as a primary treatment option in this scenario. A systematic search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library for studies published in the English language between 2000 and 2023. We included observational studies reporting on the use of stents, alongside conservative measures and drainage procedures, in patients with spontaneous esophageal perforations. Primary outcomes were sealing rate (persistent leak occlusion) and failure rate (mortality or conversion to a major surgical operation). Secondary outcomes included patients' presentation, sepsis, drainage procedures, and reinterventions. Results for primary outcomes were presented as pooled rates with 95% confidence intervals (CIs), using a random-effects model. Methodological quality was assessed using the MINORS score. Eighteen studies involving 171 patients were included. Sealing rate was 86% (95%CI 77-93%) and failure rate was 14% (95%CI 7-22%). Weighted mortality rate was 6% (95%CI 2-13%), while conversion to surgical treatment was 2% (95%CI 0-9%). Late presentation was not related to a statistically significant increase in treatment failure (odds ratio 1.85, 95%CI 0.37-9.30; P=0.72). Drainage procedures were required for the majority of patients, with a high rate of surgical and endoscopic reinterventions. Our results imply that stents may offer an effective and safe alternative treatment for patients with spontaneous esophageal perforations. Additional endoscopic and surgical drainage procedures are frequently needed.

Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects.

Endoscopic vacuum therapy (EVT) can heal a variety of defects within the gastrointestinal (GI) tract via applying negative pressure, which reduces the defect size, aspirates the infected fluid, and promotes granulation tissue. Here we present our experience with EVT as it relates to both spontaneous and iatrogenic upper GI tract perforations, leaks, and fistulas. This retrospective study was conducted at four large hospital centers. All patients who underwent EVT between June 2018 and March 2021 were included. Data on multiple variables were collected, including demographics, defect size and location, number and intervals of EVT exchanges, technical success, and hospital length of stay. Student t-test and the chi-squared test were used to analyze the data. Twenty patients underwent EVT. The most common defect cause was spontaneous esophageal perforation (50%). The most common defect location was the distal esophagus (55%). The success rate was 80%. Seven patients were treated with EVT as the primary closure method. The mean number of exchanges was five with a mean interval of 4.3 days between exchanges. The mean length of hospital stay was 55.8 days. EVT is a safe and effective initial management option for esophageal leaks and perforations.

Snare-tip soft coagulation to treat esophageal stent epithelial hyperplasia.

A 65-year-old man with a spontaneous esophageal perforation (Boerhaave syndrome) was managed with a partially covered metal stent (23 mm wide × 12.5 mm long). After an indwelling time of 8 weeks, endoscopic removal was attempted. Significant epithelial hyperplasia was noted at the proximal and distal ends of the stent ([Fig. 1 a, b]). Despite treatment with argon plasma coagulation (APC) combined with stent-in-stent insertion [1], attempts at removal failed.

A storm or a storm in a teacup? A retrospective review of spontaneous pneumomediastinum at a tertiary Australian Hospital

Background: Spontaneous pneumomediastinum (SP) is defined as the presence of free air in the mediastinum without a clear precipitating cause. Whilst uncommon and with a relatively benign course, SP is often thoroughly investigated by surgeons as spontaneous oesophageal perforation (Boerhaave’s syndrome) must be identified early due to high morbidity and mortality. This study aimed to evaluate current practice in the investigation and management of SP at our institution. Methods: All patients with imaging-confirmed pneumomediastinum at a tertiary hospital from 2014 to 2022 were reviewed. Those with precipitating trauma, recent surgery or aerodigestive instrumentation were excluded. Results: 70 patients were included; 4 (5.7%) patients were diagnosed with Boerhaave’s syndrome based on computed tomography (CT) evidence of oesophageal injury alone and were treated with immediate surgery. The remaining 66 patients were diagnosed with SP. In this group, common predisposing factors were young age, smoking, illicit drugs and alcohol. The lead presenting symptoms were dyspnoea, chest pain, vomiting and cough. Of the 13 different admitting specialties, respiratory and upper gastrointestinal surgery were most common. Of those patients diagnosed with SP, 37 (54%) patients underwent imaging to exclude oesophageal injury; 30 (43%) were assessed using CT with oral contrast, 16 (23%) had a fluoroscopic contrast oesophagram, and 9 were investigated with both modalities. Conclusions: SP is uncommon, benign and does not require operative intervention. Multiple specialities manage SP at our institution and the use of imaging modalities differs between teams. We propose a management algorithm to assist clinicians unfamiliar with SP, risk-stratify patients for oesophageal injury and avoid unnecessary investigation.

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.

胸部下部および腹部食道における特発性食道破裂に対する腹腔鏡手術5例の経験

特発性食道破裂は食道内圧の上昇により食道壁が全層で破裂する疾患で，時間とともに重症化し致命的となる．早急な治療が必要であり，これまで開胸手術が外科治療の中心であったが，近年は鏡視下手術の報告が増えている．当院では2013年12月から2018年10月に特発性食道破裂に対する腹腔鏡手術を5例経験したため，その有用性について検討した．穿孔部位は胸部下部食道左側が1例，腹部食道左側が4例で，全例で穿孔部の縫合閉鎖と胃穹窿部による被覆が行われた．手術時間は中央値で190分，出血量は10 mlであった．合併症は2例に胸水貯留と1例に肺炎を認めたが，縫合不全は認めなかった．死亡例はなかった．腹腔鏡手術は緊急手術としても許容しうる手術時間で，より低侵襲かつ確実な穿孔部の処置が可能であり，胸部下部および腹部食道における特発性食道破裂において有用な術式となりうることが示唆された．

Endoscopic endoluminal therapy with the Eso-SPONGE® system for the treatment of spontaneous esophageal perforation with associated paraoesophageal collection.

We present the case of a 92-year-old woman with no relevant history, who consulted for sore throat, progressive dysphagia to solids and fever. A cervical-thoraco-abdominal CT was performed with the finding of a paraesophageal collection at the level of C3-T1 without a clear solution of continuity, although with passage of oral contrast to the collection, exerting a mass effect on the esophageal lumen, suggestive of contained esophageal perforation, of cause not clarified. A gastroscopy was performed, in which three esophageal fistulous orifices were observed, two 4-5 mm, and a third 10 mm deeper, located 22cm from the dental arch, septate, with perilesional purulent material and bubbling.

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.

A case of esophageal perforation caused by suicidal caffeine poisoning in a teenager

Spontaneous esophageal perforation (also known as Boerhaave syndrome) is associated with sudden increase in intra-esophageal pressure by vomiting, coughing or straining at stool. This case describes a 13-year-old girl who developed the perforation after consuming 270 mg/kg of caffeine tablets for a suicide attempt. Presumably, the perforation was caused primarily by caffeine-induced severe vomiting, and secondarily by caffeine-induced gastric acid secretion with smooth muscle relaxation and by the large amount of caffeine-induced sudden increase in intra-esophageal pressure.

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.

S2450 Acute Esophageal Necrosis: Low Flow Leading to Darkness

Introduction: Acute esophageal necrosis (AEN), commonly referred to as black esophagus due to the striking circumferential blackening of the esophageal mucosa, is a rare clinical condition with a prevalence of up to 0.2%. The etiology of this condition is unclear but thought to involve the interplay of ischemia and gastric outlet obstruction with gastroesophageal reflux. As this condition carries with it a mortality rate of nearly 40%, prompt recognition and aggressive management is of the utmost importance to prevent perforation or stricture. Considering this, AEN should be recognized as a possible outcome of an ischemic event and considered a potential cause of spontaneous esophageal perforation. Case Description/Methods: A 43-year-old female with a history of epithelioid hemangioendothelioma status post resection, Crohn’s colitis in remission, and recent hospitalization for a complicated urinary tract infection and abdominopelvic ascites concerning for malignancy with hospitalization complicated by cardiopulmonary arrest presented to the emergency department 8 days after discharge following a near syncopal episode. She was found to be hypotensive with tachycardia concerning for shock. She was started on broad spectrum antibiotics, 3 vasopressors, intubated, and admitted to the ICU. A CT scan of her chest, abdomen, and pelvis showed extensive pneumomediastinum concerning for esophageal perforation and pneumatosis intestinalis. Perforation was confirmed utilizing serial chest x-rays with contrast demonstrating a right-sided esophageal leak at the gastroesophageal junction. Both cardiothoracic surgery and gastroenterology were consulted, she was not deemed a surgical candidate and endoscopy with covered stent placement was planned. Endoscopy revealed a black esophagus consistent with an ischemic process throughout the entire esophagus and pneumatosis intestinalis suggesting small bowel ischemia. Stenting was aborted and the findings were discussed with the patient’s family who decided to pursue comfort measures. The patient died the following day (Figure). Discussion: It has been demonstrated that critically ill patients often experience low flow states, poor nutritional status, and disruption of intrinsic repair mechanisms. Coupled together, these insults increase the risk of developing AEN and must be acknowledged as a possible complication in this patient population. Although this is a rare condition, it should be recognized as a potential outcome of an ischemic event.Figure 1.: Images A-D depicts a diffusely abnormal mucosa throughout the esophagus, characterized by black/brown tissue consistent with ischemia.

S2287 Case Series: The Changing Paradigm in Management of Spontaneous Esophageal Perforation

S2287 Case Series: The Changing Paradigm in Management of Spontaneous Esophageal Perforation

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.

Benign esophageal strictures after stent-in-stent placement for spontaneous esophageal perforation

Benign esophageal strictures after stent-in-stent placement for spontaneous esophageal perforation

Treatment goals in eosinophilic esophagitis: Looking beyond eosinophil count

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease characterized by eosinophil infiltration of the esophageal mucosa, resulting in tissue fibrosis and esophageal dysfunction. The natural history of EoE involves progression from an inflammatory to a fibrostenotic disease, highlighting the need for early diagnosis and effective treatment to prevent long-term complications including poor growth, nutritional deficiencies, food impaction, stricture formation, and spontaneous esophageal perforation. 1 Muir A Falk GW. Eosinophilic esophagitis: a review. JAMA. 2021; 326: 1310-1318 Crossref PubMed Scopus (17) Google Scholar