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Background: Endoscopic techniques, particularly stents, are increasingly utilized for acute management of esophageal perforation. However, migration remains a problem and extensive chest or abdominal contamination and placement of enteric drainage or feeding tubes often necessitates open or minimally invasive surgical procedures. This report describes a method of surgical stent stabilization to simplify recovery by decreasing stent migration rates.
Methods: All patients presenting with esophageal perforation between 1991 and 2012 were prospectively entered into an IRB-approved database. A total of 101 patients were treated for esophageal perforation during the study period. Five patients had combined surgical and endoscopic (hybrid) treatment including placement of transesophageal or transgastric suture for intra-operative stent stabilization.
Results: The study group comprised 5 patients who were referred to our institution between December 2005 and June 2012, mean age 52.6 (range 32-75). Two had iatrogenic (1 dilation, 1 post Nissen) and 3 had Boerhaave's perforations. Four patients presented at >24 hours and endoscopic examination documented perforations in the distal esophagus 3, and EG junction 2. Four patients had abdominal approaches, 1 had a right thoracotomy. Three patients had primary repairs and all had drainage as well as placement of gastrostomy and jejunostomy tubes. Stents were placed intra-operatively, 3 Wallstents, 1 Niti-S and 1 Celestin tube. All stents were stabilized with transgastric or transesophageal chromic sutures. No significant migration occurred. Post-op barium studies done on Day 3-8 showed no leak in 4 patients and a small leak communicating with a drain in 1 patient. Stents were removed post-operatively at 4-8 weeks (mean 5.4). Stent removal was straightforward and no complications associated with stabilization sutures were identified. One patient had a small residual fistula which communicated to a drain. All patients recovered uneventfully. Mean LOS was 22 days, range 7-54.
Conclusion: Acute management of esophageal perforation is increasingly multidisciplinary. Selected patients will continue to require surgical management for drainage or enteral feeding. Hybrid procedures provide a simple additional treatment option in selected patients. Surgical stent stabilization can be done safely and decreases the incidence of stent migration, which can decrease the need for additional procedures and improve outcomes in these complex patients.