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A RETROSPECTIVE ANALYSIS OF 18 CONSECUTIVE CASES OF ESOPHAGEAL PERFORATIONS MANAGED AT OUR INSTITUTE FROM DECEMBER 2013 TO NOVEMBER 2016.
Pankaj N. Desai*, Dhaval Mangukiya
Surat Institute Of Digstive Sciences, Surat, India
Aim : To understand for the best modality of management of management of esophageal perforations.
Methods: All the cases which presented with esophageal perforations were given immediate resuscitative management with airway support, intravenous fluids, third generation cephalosporin or carbapenem antibiotics. A Contrast enhanced CT scan was done and they were then subjected to either surgical or endoscopic management. Cases who came between 6 to 24 hours after perforation and all case that came after 24 hours, were subjected to surgical management. It included thoracoscopic lavage, attempt at repair of the perforation and drainage. Feeding jejunostomy was performed in all cases who underwent surgery. All cases were then post operatively stented using a fully covered esophageal wide flange SEMS. Those cases which presented with six hours and without mediastinal sepsis, were subjected to esophageal stenting. Cases where the perforation was around 2 cms in diameter were closed with a Padlock clip and then stented. A naso jejunal feeding tube was then placed for feeding in these cases.
Observations:
Commonest cause of esophageal perforation in our series is Boerhaave’s Syndrome followed by Iatrogenic ( post dilatation elsewhere ) and chronic foreign body impaction ( dentures in both cases ).
Cases that come within 6 hours have excellent prognosis and surgery can be avoided. Only placement of FCSEMS or application of Padlock clip with FCSEMS suffices.
Cases that come within 24 hours require surgery without fail due to mediastinal contamination and FCSEMS but only surgical lavage and repair is possible in these cases. They have good prognosis.
Cases that come later than 24 hours have the worst prognosis. They require lavage and drainage in addition. Repair is not possible in majority of these late cases due to severe inflammation and sepsis.
All case who underwent surgery had a feeding jejunostomy and those who underwent only endoscopic management required naso jejunal feeding to avoid Total Parenteral Nutrition and feeds could be resumed early with adequate nutritional support.
Good success was achieved with all forma of management in 88.9% cases.
Two deaths were due to severe ongoing sepsis and associated comorbidities of the patient.
Conclusions: Esophageal perforations pose serious management problems. Not one treatment is enough for all. Surgery and endoscopy with highly skilled intensive care are required for better outcomes and salvaging the patients. Early diagnosis and initiation of management are the key factors for better outcomes. Late diagnosis and referrals with ongoing sepsis are bad prognostic factors.
Findings
| Total Number of Cases | 18 | | Etiology: Boerhaave’s Syndrome | 14 | | Iatrogenic | 2 | | Foreign Body Impaction | 2 | | Cases within 24 hours | 8 | | After 24 Hours | 5 | | Within 6 Hours | 5 | | Surgical Intervention | 6 | | Thoracoscopic Lavage & Repair Only | 8 | | Thoracoscopic Lavage, Repair and Drainage | 5 | | Only Endoscopic Management | 5 | | Padlock Clip with Stent | 2 | | Hospital Stay | 10 to 36 days (Average 23 Days ) | | Death | 2 (11%) | | Recovered | 16 ( 88.9% ) | | Oral Feeding after Surgery | 21 days | | Oral Feeding After Endoscopic Management | 15 Days |
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