Management of Iatrogenous Esophagus Perforation

Abstract

Objectives: The management of patients with iatrogenous, instrumentally caused esophageal disruptions is still a controversially discussed challenge for any physician. We reviewed indications, morbidity, and mortality of esophagectomy compared to less aggressive treatment schemes in the light of our single-unit experience. Patients and Methods: We reviewed the cases of 38 consecutive patients suffering from iatrogenous esophageal disruption treated within the last 10 years at the University Medical School Graz. Results: Severe sepsis was diagnosed in seventeen patients; fourteen of the seventeen patients were treated by esophagectomy followed by primary or secondary reconstruction at a mortality rate of 28.6 % (four of fourteen patients). All fourteen patients thus treated had major preexisting esophageal pathologies. In three of the total seventeen cases reviewed, conservative treatment modalities were used. The mortality rate in the non-septic group treated by direct suturing (n = 21) was 4.8 % (one of twenty-one patients). Major preexisting esophageal pathology was present in thirteen. The overall mortality was 13.2 % (five of thirty-eight patients). Conclusion: The strategy of primary repair for iatrogenous esophageal injury should only be adopted in patients with minor or without intrinsic esophageal disease, and in the absence of severe sepsis suggesting mediastinitis. Severe sepsis following iatrogenous esophageal trauma should prompt the decision for esophagectomy where anatomically and/or oncologically possible.

Key words

Esophageal perforation - Iatrogenous - Repair management

References

• 1 Reeder L B, De-Filippi V J, Ferguson M K. Current results of therapy of esophageal perforations.  Am J Surg. 1995;  169 615-617
• 2 Whyte R I, Iannettoni M D, Orringer M B. Intrathoracic esophageal perforation: the merit of primary repair.  J Thorac Cardiovasc Surg. 1995;  109 140-146
• 3 Bufkin B L, Miller J I, Mansour K A. Esophageal perforation: emphasis and management.  Ann Thorac Surg. 1996;  61 1447-1451
• 4 Holzinger F, Metzger A, Barras J P, Baer H U. Temporary exclusion of the perforated esophagus using a linear vascular stapler: A new surgical treatment.  Hepato Gastroenterol. 1996;  43 155-159
• 5 Orringer M B, Stirling M C. Esophagectomy for esophageal disruption.  Ann Thorac Surg. 1990;  49 35-43
• 6 Lawrence D R, Ohri S K, Moxon R E, Townsend E R, Fountain S W. Primary esophageal repair for Boerhaave's syndrome.  Ann Thorac Surg. 1999;  67 (3) 818-820
• 7 Davies A P, Vaughan R. Expanding mesh stent in the emergency treatment of Boerhaave's syndrome.  Ann Thorac Surg. 1999;  67 1482-1483
• 8 Michel L, Grillo H C, Malta R A. Operative and nonoperative management of esophageal perforations.  Ann Surg. 1981;  194 57-63
• 9 Bone R C, Sibbald W J, Sprung C L. The ACCP-SCCM consensus conference on sepsis and organ failure.  Chest. 1992;  101 1481-1483
• 10 Akiyama H. Surgery for carcinoma of the esophagus.  Curr Probl Surg. 1980;  17 55
• 11 Skiner D B, Little A G, DeMeester T R. The management of esophageal perforation.  Am J Surg. 1980;  139 760-764
• 12 Salo J A, Isolauri J O, Heikkila L J. et al . Management of delayed esophageal perforation with mediastinal sepsis: Esophagectomy on primary repair?.  J Thorac Cardiovasc Surg. 1993;  106 1088-1091
• 13 Attar S, Hankins J R, Suter C M, Coughlin T R, Sequeira A, McLaughlin J S. Esophageal perforation: a therapeutic challenge.  Ann Thorac Surg. 1990;  50 45-51
• 14 Ohri S K, Liakakos T A, Pathi V, Townsend E R, Fountain S W. Primary repair of iatrogenous thoracic esophageal perforation and Boerhaave's syndrome.  Ann Thorac Surg. 1993;  55 603-606
• 15 Lawrance D R, Ohri S K, Moxon R E, Townsend E R, Fountain S W. Primary esophageal Repair for Boerhaave's syndrome.  Ann Thorac Surg. 1999;  67 (3) 818-820
• 16 Wright C D, Mathisen D J, Wain J C, Moncure A C, Hilgenberg A D, Grillo H C. Reinforced primary repair of thoracic esophageal perforation.  Ann Thorac Surg. 1995;  60 245-249
• 17 Maier A, Pinter H, Anegg U, Fell B, Tomaselli F, Sankin O, Smolle-Jüttner F M. Boerhaave's Syndrome: A continuing challenge in thoracic surgery. Hepato-Gastroenterol, in press 2000
• 18 Sawyer R, Phillips C, Vakil N. Short- and long-term outcome of esophageal perforation.  Gastrointest Endosc. 1995;  41 130-134
• 19 Iannettoni M D, Vlessis A A, Whyte R I, Orringer M B. Functional outcome after surgical treatment of esophageal perforation.  Ann Thorac Surg. 1997;  64 1606-1610
• 20 Maier A, Pinter H, Friehs G B, Renner H, Renner F M. Self-expandable coated Stent after intraluminal treatment of esophageal cancer: A risky procedure?.  Ann Thorac Surg. 1999;  67 781-784