Author
Date
Study period
Pat. n
Management
Mortality
Operative (%)
Non-operative (%)
Operative (%)
Non-operative (%)
Overall (%)
Vallboehmer et al. [21]
2009
1996–2008
44
55
45
8
5
6.8
Abbas et al. [3]
2009
1998–2008
119
76
24
15
4
14.2
Schmidt et al. [20]
2010
1998–2006
62
51
49
16
13
14.5
Keeling et al. [22]
2010
1997–2008
97
74
26
8
8
8.3
Shaker et al. [17]
2010
2002–2008
27
83
17
12
25
18.5
Hermansson et al. [23]
2011
1970–2006
125
79
21
20
15
19
Bhatia et al. [24]
2011
1981–2007
119
67
33
16
35
18.4.
Kuppusamy et al. [25]
2011
1989–2009
84
59.
41.
2.
6.
4.
Minnich et al. [26]
2011
1998–2009
81
64
36
12
10
11
Søreide et al. [11]
2012
2000–2010
47
45
55
–
–
23.4
Lindenmann et al. [18]
2013
2002–2012
120
55
45
16.7
5.6
11.7
Schweigert et al. [27]
2013
2002–2012
33
61
39
5
15
9.1
Studies included | 75 |
Study period | 2000–2012 |
N pat. | 2,971 |
Mortality | |
Overall | 11.9 % |
Location | |
Cervical | 5.9 % |
Thoracic | 10.9 % |
Abdominal | 13.2 % |
Cause | |
Foreign body | 2.1 % |
Iatrogenic | 13.2 % |
Spontaneous | 14.8 % |
Treatment | |
<24 h | 7.4 % |
>24 h | 20.3 % |
Primary repair | 9.5 % |
Esophagectomy | 13.8 % |
T-tube, any other repair | 20 % |
Stent | 7.3 % |
Drainage alone is typically used when the patient is unstable and more demanding procedures are not feasible or in late presenting patients, after failed or inadequate previous treatment. Decortication is required in patients with extensive pleural contamination and trapped lung.
Primary repair represents the main approach in esophageal perforation and should be applied to large perforations with healthy esophageal tissue. The approach is determined by the site and size of the perforation and can be performed via a cervical, thoracic or abdominal approach. Typically the perforation is reapproximated and sutured in one to two layers. Buttressing of primary repairs, using pleura, pericardial fat, intercostal, chest wall or diaphragmatic muscle flaps, stomach or omentum, have also been described.
In large esophageal defects, in which primary repair would lead to stricture of the esophagus or in very unstable patients a T-Tube can be placed in order to establish a controlled fistula.
Esophagectomy should be reserved for malignant perforations in non-disseminated cancers. Esophageal exclusion have been applied in the past in extensive perforations in unstable patients. The use of exclusions procedures in experienced centers is decreasing. Esophageal resection with esophagostomy and gastrostomy should only be performed in a non-viable esophagus which cannot be primarily repaired.
Open surgery historically had been strongly advocated for patients with Boerhaave Syndrome, with mortality rates ranging from 2 to 36 %. In a recent meta-analysis spontaneous perforations had an average mortality of 14.8 % [2]. Schweigert recently reported a morbidity rate in patients with Boerhaave Syndrome treated with either surgery or endoscopic stents of 30 % and 84 % respectively [27]. However, recent studies reported successful conservative and endoscopic management for spontaneous perforations and Boerhaave Syndrome [28–30].
Minimally Invasive Surgery
Minimally invasive approaches are being increasingly applied in both iatrogenic and spontaneous perforations especially in stable patients with limited contamination [31]. Cho and colleagues compared thoracotomy versus thoracoscopy with decortication and repair in 15 patients with Boerhaave Syndrome. The seven patients with the thoracoscopic approach were hemodynamically more stable, had shorter operation time, less prolonged ventilation time and reduced mortality [32]. Laparoscopic primary repair of pneumatic perforations in patients with achalasia with subsequent fundoplication has also been reported [33].
Endoscopic Therapy
Recent published data shows a substantial increase in the use of endoscopic techniques in managing esophageal perforations and its current application in the literature ranges from 17 to 55 %. With the etiological shift from spontaneous to iatrogenic perforations endoscopic treatment is increasingly appropriate in selected patients. Kuppusamy and colleagues highlighted the increased fraction of non-operative treatment from nearly 0 % in the early nineties to 75 % of cases treated in 2009 [4]. Furthermore the ability to combine diagnostic and therapeutic goals at the time of endoscopy increases efficiency. Endoscopy is currently utilized in up to 70 % of cases as a component of the initial assessment [4].
Endoluminal Stenting
Stent deployment is typically performed under endoscopic visualization with or without fluoroscopic guidance to position the stent correctly and maximize the opportunity to exclude the perforation. Full stent deployment can take up to 24 h, therefore follow-up contrast esophagography can be performed either shortly after stent placement or the following day to confirm exclusion of the perforation. Pleural and mediastinal fluid collections and contaminated spaces must be radiologically drained subsequently. Ideally an experienced surgeon should be involved when non-operative therapy is being contemplated [5].
A variety of removable stents are currently available. The majority of current reports utilizing stents in patients with esophageal perforation have used the self-expandable plastic PolyFlex Stent (SEPS) or the self-expandable metallic stent (SEMS), an example being the UltraFlex (Boston Scientific, Natick, MA, USA). Both of these stents have versions with complete or partial silicone cover. Other SEMS-options include the WallFlex (Boston Scientific, Natick, MA, USA), the ALIMAXX (Merit Medical System, Inc, South Jordan, UT, USA), the Evolution (Cook Medical, Bloomington, IN, USA) and the Niti-S (Taewoong Medical, Geyonggi-Do, South Korea). Van Boeckel and colleagues compared in their study fully covered SEMS, SEPS and partially covered SEMS with no significant difference in efficacy with success rates of 73, 83 and 83 % respectively [34]. SEMS have been introduced for the palliative treatment for patients with esophageal cancer whereas SEPS have seen application in both malignant and benign diseases. The PolyFlex-Stent is the only stent currently approved by the FDA for removal in benign disease.
The reported success rates of treating acute perforations with stents vary from 60 to 94 %. Virtually all current reports were conducted in single centers. The most commonly reported complication is stent migration. Migration occurs in approximately 25 % of cases with reported ranges varying from 3 to 38 % [28, 30, 35–42]. Table 32.3 provides a summary of recent studies reporting stent treatment in esophageal perforations. Van Boeckel and colleagues reported associated migration rates of 20, 14 and 12 % for fully covered SEMS, SEPS and partially covered SEMS respectively [34]. However, no current comparison of the efficacy of individual stents is available. Typically fully covered stents are associated with a higher migration rate [35]. In contrast partially covered stents allows granulation into the uncovered portions which can decrease migration but potentially make removal more challenging. Using the appropriate size and whenever possible avoiding placing the stent across the lower esophageal sphincter can minimize the incidence of migration. Diverse options for stent fixation are described in the literature [43, 44]. Endoscopical clipping of the stent edges and transcervical or transnasal fixation are options but efficacy of these techniques are currently poorly defined [45].
Table 32.3
Endoscopic stents
Author | Date | Pat. n | Perforation I/S | Treatment | Mean LOS | Success (%) | Migration (%) | Morbidity (%) | Mortality (%) |
|---|---|---|---|---|---|---|---|---|---|
Leers et al. [35] | 2009 | 9 | 9/0 | SEMS | 6 | 94 | 3 | 13 | 6 |
Salminen et al. [37] | 2009 | 8 | 4/4 | SEMS | – | 75 | 10 | 20 | 25 |
Van Heel et al. [38] | 2010 | 29 | 19/10 | SEMS/SEPS | – | 74 | 33 | 33 | 21 |
Freeman et al. [36] | 2011 | 36 | 17/19 | SEPS | 9 | 92 | 19 | 24 | 0 |
Dai et al. [39] | 2011 | 7 | – | SEPS | 32 | 85 | 35 | 35 | 2 |
David et al. [40] | 2011 | 12 | 6/6 | SEMS | – | 73 | 7 | 40 | 10 |
D’Cunha et al. [41] | 2011 | 15 | 13/2 | SEMS/SEPS | 33 | 60 | 16 | 24 | 13.5 |
van Boeckel et al. [42] | 2012 | 17 | 13/4 | SEMS/SEPS | 39 | 76 | 30 | 46 | 2 |
Koivukangas et al. [30] | 2012 | 14 | 0/14 | SEMS | 34 | 86 | – | 14 | 14 |
Endoscopic Clips
Currently two different types of endoscopic clips are available which are both FDA approved for closure of perforations. The Resolution Clip (Boston Scientific, Natick, MA, USA) which is used through the working channel of the scope and previously has been applied for hemostasis in gastrointestinal bleeding. These clips have rather limited opening diameter of 11 mm and therefore are most appropriate for mucosal tears or very small esophageal perforations which are recognized at the time of occurrence [46, 47]. There is an evolving experience in routinely closing the mucosal layer after the peroral endoscopic myotomy (POEM) procedure with the application of several clips to close the mucosal tunnel. In selected cases clips and stents can be used in combination. Swallow studies to verify closure of the perforation must be done and selected drainage of mediastinal or pleural fluid must be performed separately.
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