Asymptomatic esophageal perforation discovered after elective cardiac surgery: the importance of clinical awareness.

Transesophageal echocardiography (TEE) has become an indispensable part of cardiothoracic surgery at present and is considered to be a safe procedure, rarely associated with complications. However, TEE may cause serious and life threatening complications, as presented in this case report. We describe a patient who developed an empyema after elective cardiac surgery due to an esophageal perforation caused by TEE, without any clinical symptoms. Risk factors for TEE-related complications, identified in recent literature, will be discussed as well as the remarkable absence of clinical symptoms in this particular patient.

Classification of the oesophageal perforation.

OBJECTIVES: Esophageal perforations are a complex clinical scenario that have been poorly studied. To date, there is no grading of esophageal perforations, the reason being that the outcome is very heterogeneous, because the perforation is very heterogeneous. A grading of the severity of the perforation may guide treatment, and could ultimately affect morbidity and mortality. METHODS: The observation period of the study was four years. All patients with a perforation of the esophagus aged 18 to 90 years were included. All anastomotic insufficiencies or fistulas after surgery of the esophagus were excluded. The cause of the injury and the time interval between the event and the start of therapy were analyzed. The severity of each perforation was classified based on the results of a diagnostic CT scan, gastroscopy as well as clinical and laboratory findings. Therapy and signs of infection were evaluated. Endpoints of the study were patient recovery or death. The study was conducted as a retrospective single-center study at a university hospital of Düsseldorf. The study has been approved by the review board. Patients gave their informed consent before data collection. All data were analyzed using SPSS 29 (IBM SPSS Statistics software). RESULTS: Age, gender and cause of the esophageal perforation did not impact significantly on overall survival. The duration of injury > 24 h (p = 0.01), presence of mediastinitis (p = 0.01) and necrosis of the esophagus (p = 0.02) were associated with an unfavorable outcome. The correlation of the clinical grading of the severity of the perforation based on the endoscopic, radiological and clinical findings with the overall survival of patients was significant. Patients categorized into the four grades of severity (I-IV) had an overall survival of 100%, 100%, 70% and 50%, respectively. CONCLUSION: The severity of esophageal perforations can be systematically rated grades I to IV based on the radiological, endoscopic and clinical findings at diagnosis. Due to the grading and its correlation to the overall survival, a comparison of patients, their treatment and outcome becomes possible. In future, the grade of a perforation may guide treatment, and therefore affect morbidity and mortality.

Oesophageal perforation by migrated Ryles tube.

A 72-year woman with a history of multiple cerebrovascular accidents presented with severe epigastric pain. An oesophageal perforation by the tip of a Ryles tube, which had migrated into the mediastinum, was diagnosed by radiography. An attempt at pushing the nasogastric tube into the stomach resulted in increasing the rupture to about 6 cm in size. Replacement by a triple-lumen nasojejunal feeding tube and subsequent feeding with c.1,400 calories per day enabled the perforation to close without further intervention.

The role of radiology in diagnosing gastrointestinal tract perforation.

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

Barogenic perforation of the esophagus: An unusual manifestation / Perforación barogénica del esófago: una presentación inusual

Abstract Introduction: Typically, when esophageal perforation secondary to barotrauma is mentioned as the causal pathophysiological mechanism of perforation, the literature refers to spontaneous esophageal perforation or Boerhaave syndrome as an entity. It involves the longitudinal and transmural rupture of the esophagus (previously healthy) secondary to an abrupt increase in intraluminal esophageal pressure, frequently triggered during vomiting. However, in the medical literature, some reports list mechanisms of barotrauma other than this entity. Case report: A 64-year-old female patient with a history of surgically managed gastric adenocarcinoma (total gastrectomy and esophagoenteral anastomosis) presented with stenosis of the esophagojejunal anastomosis, which required an endoscopic dilatation protocol with a CRETM balloon. The third session of endoscopic dilation was held; in removing the endoscope, we identified a deep esophageal laceration with a 4 cm long perforation at the level of the middle esophagus (8 cm proximal to the dilated anastomosis), suspecting the mechanism of barotrauma as the causal agent. She required urgent transfer to the operating room, where we performed thoracoscopic esophagectomy, broad-spectrum empiric antimicrobial coverage, and enteral nutrition by advanced tube during in-hospital surveillance. The control esophagram at seven days showed a small leak over the anastomotic area, which was managed conservatively. Imaging control at 14 days showed a decrease in the size of the leak, with good evolution and tolerance to the oral route. The patient was later discharged.

Resumen Introducción: típicamente, cuando se menciona la perforación esofágica secundaria a barotrauma como el mecanismo fisiopatológico causal de la perforación, la literatura se refiere a la perforación esofágica espontánea o síndrome de Boerhaave como entidad, la cual hace referencia a la ruptura longitudinal y transmural del esófago (previamente sano) secundaria a un aumento abrupto de la presión intraluminal esofágica, que se desencadena frecuentemente durante el vómito. Sin embargo, en la literatura médica existen algunos reportes que mencionan otros mecanismos de barotrauma diferentes a esta entidad. Reporte de caso: se presenta el caso de una paciente de 64 años con antecedente de adenocarcinoma gástrico manejado quirúrgicamente (gastrectomía total y anastomosis esofagoenteral), quien presentaba estenosis de anastomosis esofagoyeyunal, que requirió un protocolo de dilatación endoscópica con balón CRETM. Se llevó a una tercera sesión de dilatación endoscópica, en la que durante la extracción del endoscopio se identificó una laceración esofágica profunda con perforación de 4 cm de longitud a nivel del esófago medio (8 cm proximal a anastomosis dilatada), y se sospechó del mecanismo de barotrauma como agente causal. Requirió traslado urgente a sala de cirugía, en la que se realizó esofagorrafia por toracoscopia, cubrimiento antimicrobiano empírico de amplio espectro y nutrición enteral por sonda avanzada durante la vigilancia intrahospitalaria. El esofagograma de control a los 7 días mostró una pequeña fuga sobre el área anastomótica, la cual se manejó de manera conservadora. El control imagenológico a los 14 días evidenció una disminución del tamaño de la fuga, con una evolución satisfactoria y tolerancia a la vía oral, y posteriormente se dio el egreso.

Colgajo muscular de esternocleidomastoídeo para el manejo de perforación esofágica tardía: reporte de dos casos / Muscle flap of sternocleidomastoid for the management of late esophageal perforation: report of two cases

Resumen Introducción: La perforación esofágica es una complicación poco frecuente en la cirugía de columna cervical por vía anterior, sin embargo, puede tener graves consecuencias cuando hay demoras en diagnóstico y tratamiento. Casos Clínicos: Presentamos dos casos clínicos de pacientes con perforación esofágica secundaria a cirugía de columna cervical por vía anterior. Se usaron para su reparación colgajo muscular de esternocleidomastoideo (ECM). Conclusión: La perforación esofágica secundaria a cirugía de columna cervical es poco frecuente, variable desde el punto de vista clínico, el TC y estudio radiológico contrastado son fundamentales en el diagnóstico de esta patología. El colgajo muscular ECM en estos casos es una herramienta fiable y extremadamente útil debido a sus características anatómicas, fácil disección quirúrgica y baja morbilidad asociada.

Introduction: Esophageal perforation is a rare complication in cervical spine surgery by anterior way, however it can have serious consequences when there are delays in diagnosis and treatment. Cases Report: We present two clinical cases of patients with esophageal perforation secondary to cervical spine surgery by anterior way. Sternocleido-mastoid muscle flaps were used for repair. Conclusion: Esophageal perforation secondary to cervical spine surgery is rare, clinically variable, CT and radiologic study are fundamental in the diagnosis of this pathology. The Sternocleidomastoid muscle flap in these cases is a reliable and extremely useful tool due to its anatomical characteristics, easy surgical dissection and low associated morbidity.

Enfoque terapéutico en el Síndrome de Boerhaave / Therapeutic Approach of Boerhaave's Syndrome

RESUMEN Introducción: La perforación del esófago constituye una de las urgencias más graves y difíciles que ha de afrontar un cirujano por las características y ubicación del órgano. El pronóstico depende sobre todo de la rapidez del diagnóstico y de la elección del tratamiento instaurado en principio. Objetivo: Presentar un caso portador del Síndrome de Boerhaave. Caso clínico: Paciente masculino en la 5ta década de vida que acudió por dolor torácico posterior a cuadro emético. Luego de estudio radiográfico se diagnosticó ruptura espontánea de esófago o síndrome de Boerhaave. Conclusiones: El enfoque terapéutico adecuado asociado al diagnóstico oportuno y precoz del síndrome garantiza mejores índices de sobrevida(AU)

ABSTRACT Introduction: Esophageal perforation is one of the most serious and difficult emergencies that a surgeon has to face due to the characteristics and location of the organ. Such prognosis depends mainly on the speed of the diagnosis and the choice of treatment established initially. Objectives: To present a case with such syndrome and to review the literature to update the therapeutic approach of this entity given its high mortality. Clinical case: Male patient in the fifth decade of life who presented for chest pain after an emetic condition. After a radiographic study, a spontaneous rupture of the esophagus or Boerhaave syndrome was diagnosed. Conclusions: The appropriate therapeutic approach associated with the early and timely diagnosis of the syndrome guarantees better survival rates(AU)

Perforación esofágica cervical tardía por rotura y desplazamiento de placa de artrodesis cervical anterior / Delayed cervical esophageal perforation by rupture and displacement of anterior cervical arthrodesis plaque

Resumen Introducción: La perforación esofágica es una posible complicación de la artrodesis cervical anterior. Sin embargo, estas suelen ocurrir intraoperatoriamente o en el posoperatorio precoz. Caso clínico: Mujer de 35 años sometida, 3 años antes, a artrodesis de C3-C5, que tras sufrir un traumatismo leve con latigazo cervical, comienza con disfagia. Se objetiva un absceso retroesofágico por perforación esofágica, causado por rotura de la placa protésica y extrusión de un tornillo.

Introduction: Esophageal perforation is a possible complication after anterior cervical fusion. However, these complications usually appear intraoperatively or in the early postoperative course. Case report: A 35-years-old females, who underwent a C3-C5 anterior cervical fusion 3 years ago, after suffering a mild cervical trauma, she complained of dysphagia. A retroesophageal abscess was observed, caused by esophageal perforation, secondary to plaque rupture and screw extrusion.

Perforación esofágica por cuerpo extraño / Esophageal perforation by foreign body

Presentamos un caso de perforación esofágica por cuerpo extraño. Las causas de perforación esofágica pueden clasificarse en: instrumentales, espontáneas, quirúrgicas, traumáticas y cuerpos extraños. La perforación esofágica es una situación grave con alto índice de morbimortalidad debido a su difícil diagnóstico y falta de consenso pleno en su tratamiento. La clínica es polimorfa e inespecífica y el diagnóstico requiere alto grado de sospecha. La mortalidad oscila entre 10 y 40%.

We report a case of esophageal foreign body perforation. The causes of esophageal perforation can be classified into: instrumental, spontaneous, surgical, trauma and foreign bodies. Esophageal perforation is a serious condition with high morbidity and mortality rates due to its difficult diagnosis and lack of full consensus on treatment. The clinic is polymorphous and unspecific and diagnosis requires a high index of suspicion. Mortality ranges from 10 to 40%.