Minimally invasive treatment of esophageal perforation using a multidisciplinary treatment algorithm: a case series

Introduction

Esophageal perforation is a dreaded condition with high morbidity and mortality rates. The diagnosis often depends on clinical suspicion, features, and radiographic or endoscopic testing confirming an esophageal leak. The most common cause of esophageal perforation is secondary to an iatrogenic injury but it can also be the result of spontaneous perforation, chemical or foreign body ingestion, and penetrating trauma. Hence, due to mortality rates as high as 20 %, a high index of suspicion and established treatment algorithms are paramount [1].

Based on our institution’s reported aggressive conservative therapy in patients with esophageal perforations resulting in lower morbidity and mortality while avoiding major clinical experience surgery [2], and the various applications of endoluminal products [3] [4] [5] [6], our approach to the treatment of esophageal perforations has been revised with the development of a treatment algorithm. The hypothesis behind the algorithm is that endoscopic placement of fully covered self expandable removable esophageal stents together with aggressive conservative therapy is an effective method of treatment for patients with esophageal perforations, and results in low morbidity and mortality without the need for surgical intervention [7]. In addition, the utilization of an endoscopically placed removable covered stent also results in rapid leak occlusion, and a decrease in posterior mediastinal contamination, morbidity, and hospital stay. This type of modality enables the treatment of esophageal perforations in patients with significant co-morbidities and elderly patients who are often not suitable or hemodynamically stable enough for surgical intervention.

References

• 1 Huber-Lang M, Henne-Bruns D, Schmitz B et al. Esophageal perforation: principles of diagnosis and surgical management.  Surg Today. 2006;  36 332-340
• 2 Vogel S B, Rout W R, Martin T D et al. Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality.  Ann Surg. 2005;  241 1016-1021; discussion 1021 – 1013
• 3 Freeman R K, Van Woerkom J M, Ascioti A J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.  Ann Thorac Surg. 2007;  83 2003-2007; discussion 2007 – 2008
• 4 Kiev J, Amendola M, Bouhaidar D et al. A management algorithm for esophageal perforation.  Am J Surg. 2007;  194 103-106
• 5 McMahon M A, O'Kelly F, Lim K T et al. Endoscopic T-tube placement in the management of lye-induced esophageal perforation: case report of a safe treatment strategy.  Patient Saf Surg. 2009;  3 19
• 6 Sung H Y, Kim J I, Cheung D Y et al. Successful endoscopic hemoclipping of an esophageal perforation.  Dis Esophagus. 2007;  20 449-452
• 7 Ben-David K, Carreras J, Lopes J. Are incisionless fundoplication procedures a safer alternative to the laparoscopic Nissen for the treatment of chronic gastroesophageal reflux disease?.  J Gastrointest Surg. 2010;  [E-pub ahead of print]
• 8 Brinster C J, Singhal S, Lee L et al. Evolving options in the management of esophageal perforation.  Ann Thorac Surg. 2004;  77 1475-1483
• 9 Martinek J, Kovacova S, Nosek V et al. Successful endoscopic treatment (clipping) of esophageal perforation during balloon dilatation in a patient with achalasia.  Endoscopy. 2008;  40 Suppl 2 E61-E62
• 10 Cameron J L, Kieffer R F, Hendrix T R et al. Selective nonoperative management of contained intrathoracic esophageal disruptions.  Ann Thorac Surg. 1979;  27 404-408
• 11 Lyons W S, Seremetis M G, deGuzman V C et al. Ruptures and perforations of the esophagus: the case for conservative supportive management.  Ann Thorac Surg. 1978;  25 346-350
• 12 Shirkey H C. Conservative management of esophageal perforation.  JAMA. 1965;  193 537
• 13 DeMeester S R. Esophageal perforation.. In: Cameron J ed. Current surgical therapy. 9th edn.. Philadelphia: Elsevier Mosby; 2008: 16-19
• 14 Kiernan P D, Sheridan M J, Elster E et al. Thoracic esophageal perforations.  South Med J. 2003;  96 158-163
• 15 Okten I, Cangir A K, Ozdemir N et al. Management of esophageal perforation.  Surg Today. 2001;  31 36-39
• 16 Salo J A, Isolauri J O, Heikkila L J et al. Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair?.  J Thorac Cardiovasc Surg. 1993;  106 1088-1091
• 17 Freeman R K, Van Woerkom J M, Vyverberg A et al. Esophageal stent placement for the treatment of spontaneous esophageal perforations.  Ann Thorac Surg. 2009;  88 194-198
• 18 Orringer M B, Stirling M C. Esophagectomy for esophageal disruption.  Ann Thorac Surg. 1990;  49 35-42; discussion 42 – 33
• 19 Sung S W, Park J J, Kim Y T et al. Surgery in thoracic esophageal perforation: primary repair is feasible.  Dis Esophagus. 2002;  15 204-209