Treatment of Early and Delayed Esophageal Perforation

Abstract

Esophageal perforations are life threatening emergencies associated with high morbidity and mortality. We report on 22 consecutive patients (age 20-86; 13 female and 9 male) with an oesophageal perforation treated at the university hospital Duesseldorf. The patients' charts were reviewed and follow-up was completed for all patients until demission, healed reconstruction or death. Patients' history, clinical presentation, time interval to surgical presentation, and treatment modality were recorded and correlated with patients' outcome. Six esophageal perforations were due to a Boerhaave-syndrome, eleven caused by endoscopic perforation, two after osteosynthesis of the cervical spine and three foreign body induced. In 7 patients a primary local suture was performed, in 4 cases a supplemental muscle flap was interposed, and 7 patients underwent an oesophageal resection. Four patients were treated without surgery (three esophageal stent implantations, one conservative treatment). Eleven patients (50 %) were presented within 24 h of perforation, and 11 patients (50 %) afterwards. Time delay correlates with survival. In 17 (80.9 %) cases a surgical sufficient reconstruction could be achieved. One (4.7 %) patient is waiting for reconstruction after esophagectomy. Four (18.2 %) patients died. A small subset of patients can be treated conservatively by stenting of the Esophagus, if the patient presents early. In the majority of patients a primary repair (muscle flap etc.) can be performed with good prognosis. If the patient presents delayed with extensive necrosis or mediastinitis, oesophagectomy and secondary repair is the only treatment option with high mortality.

Management of cervical esophageal and hypopharyngeal perforations

“…Most suggest that a delay in treatment greater than 24 hours results in increased morbidity with conservative management [8,15,16]. Not all studies, however, have correlated time to diagnosis with rate of complication [17,18].…”

Thoracic perforations—surgical techniques

“…The indications of the esophagectomy involves distal obstruction occurring because of a peptic stricture, neuromotor dysfunction (achalasia containing megaesophagus), multiple esophageal strictures, corrosive esophageal burns, intrinsic diseases such as esophageal reflux or esophagitis, massive necrosis, serious mediastinal contamination and inflammatory reaction, or early-tried surgical drainage, or poor closure. Resection helps both eliminate the underlying disease and ensure the continuity of the gastrointestinal system (54)(55)(56).…”

Regenerative Medicine Strategies for Esophageal Repair

“…Regardless of the etiology, severe esophageal perforation is a surgical emergency since patients can initially appear stable, but then decompensate quickly. [97][98][99][100] Decompensation usually results from esophageal and gastric contents leaking into the mediastinum with resultant necrotizing inflammation, sepsis, and ultimately multiorgan failure and death. 101,102 The Esophagus and Regenerative Medicine…”