Current results of therapy for esophageal perforation

doi:10.1016/S0002-9610(99)80232-3

The American Journal of Surgery

Volume 169, Issue 6, June 1995, Pages 615-617

https://doi.org/10.1016/S0002-9610(99)80232-3 Get rights and content

Background

Prior reviews of esophageal perforation with delayed recognition have reported mortality rates as high as 66%. We performed a retrospective review of patients with nonmalignant esophageal perforation to assess the outcome of current management techniques.

Patients and methods

Charts were reviewed of all patients who were treated for nonmalignant esophageal perforation between 1980 and 1993. They were 23 men and 10 women, mean age 49 ± 3 years, 19 of whom were diagnosed early (≤24 hours) and 14 of whom were diagnosed late (>24 hours).

Results

Perforations were due to instrumentation (16), operative injury (7), spontaneous rupture (4), trauma (4), and other causes (2). Preexisting esophageal disease was identified in 23 patients (70%), including achalasia (9), stricture (7), varices (5), and other (2). Treatment included closure and fundoplication or muscle wrap (10), closure with or without pleural flap (7), resection only (7), resection and reconstruction (3), drainage only (4), and observation (2). Nonfatal complications included empyema (4), arrhythmia (3), persistent leak following attempted closure (2), and other (5). They occurred in 50% of both the early and late diagnosis groups and were of comparable severity in both. The overall mortality was 9% (3/33). Causes of death were sepsis (1) and multisystem organ failure (2). Mortality was 5% (1/19) in patients diagnosed early and 14% (2/14) of those diagnosed late.

Conclusions

Current mortality rates in nonmalignant esophageal perforation are improved compared to previously published rates of 19% for all patients with the condition, 9% following early and 29% following late diagnosis (47 patients overall). We conclude that, despite a high incidence of associated complications, the survival rate following nonmalignant esophageal perforation is improving and the impact of delayed recognition is decreasing.

References (17)

JonesWG et al.
Esophageal perforation: a continuing challenge
Ann Thorac Surg
(1992)
SkinnerDB et al.
Management of esophageal perforation
Am J Surg
(1980)
BladergroenMR et al.
Diagnosis and recommended management of esophageal perforation and rupture
Ann Thorac Surg
(1986)
CameronJL et al.
Selective nonoperative management of contained intrathoracic esophageal disruptions
Ann Thorac Surg
(1979)
NealonTF et al.
Instrumental perforation of the esophagus
J Thorac Cardiovasc Surg
(1961)
GougeTH et al.
Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus
Ann Surg
(1989)
WhiteRK et al.
Diagnosis and management of esophageal perforations
Am Surg
(1992)
GoldsteinLA et al.
Esophageal perforations: a 15 year experience
Am J Surg
(1982)

There are more references available in the full text version of this article.

Cited by (119)

Risk factors for serious adverse events associated with multiband mucosectomy in Barrett's esophagus: an international multicenter analysis of 3827 endoscopic resection procedures
2020, Gastrointestinal Endoscopy
Multiband mucosectomy (MBM) is a widely used technique for the treatment of Barrett’s esophagus (BE). However, large multicenter studies enabling a generalizable estimation of the risk of serious adverse events, such as perforation and postprocedural bleeding, are lacking. The aim of this study was to estimate the rate of, and risk factors for, serious adverse events associated with MBM.
In this retrospective analysis, consecutive patients who underwent MBM for treatment of BE in 14 tertiary referral centers in Europe, the United States, Canada, and Australia were included. Primary outcomes were perforation and postprocedural bleeding rate. Potential risk factors were identified by logistic regression.
Between 2001 and 2016, a total of 3827 MBM procedures were performed in 2447 patients (84% male, mean age 66 years, median BE length C2M4). Perforation occurred in 17 procedures (0.4%; 95% confidence interval [CI], 0.3-0.7), of which 15 could be treated endoscopically or conservatively. Female gender was an independent risk factor for perforation (odds ratio [OR], 2.77; 95% CI, 1.02-7.57; P = .05). Postprocedural bleeding occurred after 35 procedures (0.9%; 95% CI, 0.6-1.3). The number of resections (OR, 1.15; 95% CI, 1.06-1.25; P < .001) was significantly associated with postprocedural bleeding.
The results of this study show that MBM for BE is safe with a low risk of serious adverse events. In addition, most of the adverse events could be managed endoscopically or conservatively. The number of resections was an independent risk factor for postprocedural bleeding.
Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series
2019, Annals of Medicine and Surgery
Citation Excerpt :
In stable patients, signs in chest x-ray such as pleural effusions, subcutaneous emphysema and pneumo-mediastinum could facilitate a diagnosis of esophageal perforation [37]. Our findings are consistent with the recent literature, reporting a radical decrease in mortality for patients with esophageal perforation [28–31]. This reduction is due to modern surgical techniques, new technology, advanced diagnostic methods, as well as the better insight of surgeons [28].
Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries.
A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level.
Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects.
Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome.
Esophageal T-tube: A novel approach to atrioesophageal fistula repair
2017, HeartRhythm Case Reports
Citation Excerpt :
The majority of patients who presented after 24 hours were treated with an esophageal T-tube, with a mortality rate of only 8%. This is much better than the 20%–40% mortality reported in the literature for late perforation treated with primary repair.11,15 It is not clear if the persistent high mortality following operative repair in the setting of AEF relates mainly to failure of the primary esophageal repair or to other factors.
Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system
2016, Journal of Thoracic and Cardiovascular Surgery
The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population.
In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups.
Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS.
The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.
T-tube placement as a method for treating penetrating oesophageal injuries
2016, International Journal of Surgery Case Reports
Penetrating oesophageal injuries are extremely rare. Their timely recognition can be difficult and optimal treatment remains controversial. Early recognition of injury is possible with the help of a high index of suspicion and early radiological and endoscopic examinations. Prompt surgical intervention with primary repair of injury, should be the goal.
We describe two cases of penetrating oesophageal trauma where T-Tube placement through the oesophageal defect, was successfully employed. Both cases proved to be challenging due to time lapse after injury and anatomical location.
Penetrating injuries to the Oesophagus are rare with a reported incidence of 11–17%, most are due to gunshot injuries or stabbings, cervical followed by the thoracic Oesophagus are most at risk. In delayed presentations and sepsis related multi-organ instability, diversion and drainage are considered appropriate. T-tube placement through defects in difficult situations of delayed presentation is well described in setting of iatrogenic perforations. Their use has been described in penetrating injuries but much less frequently.
T-tube placement though oesophageal defects can prove to be an effective treatment option to repair both iatrogenic and penetrating injuries of the Oesophagus, whether early or delayed.
Esophageal Perforation
2014, Surgical Clinics of North America

View all citing articles on Scopus

View full text

Current results of therapy for esophageal perforation

Background

Patients and methods

Results

Conclusions

Ann Thorac Surg

Am J Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus

Ann Surg

Diagnosis and management of esophageal perforations

Am Surg

Esophageal perforations: a 15 year experience

Am J Surg