Management of esophageal perforation: experience from a tertiary center in India.

BACKGROUND/AIM: The management of esophageal perforations remains controversial in large part due to variability in etiology, time of presentation, location, and underlying esophageal disease. We reviewed our experience in treating patients with esophageal perforations and evaluated the etiology, management and outcome of intervention in a tertiary center. METHODS: Between 1999 and 2007, 48 patients with esophageal perforation were treated in a tertiary referral center in southern India. Postdilatation corrosive stricture perforations constituted the major etiology. RESULTS: Thirty (62.5%) patients were diagnosed early (<24 h) and the remaining 18 (37.5%) were late (>24 h). The 30-day mortality was 6.2%, and mean hospital stay was 13 +/- 9.3 days. Comparing outcomes between early and late groups, statistically significant difference was observed, with increased mortality (p = 0.02) and hospital stay (p = 0.04) following late diagnosis. CONCLUSION: This report suggests that early diagnosis decreases mortality and hospital stay in esophageal perforation. Preservation of esophagus may be attempted while treating esophageal perforations.

Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading.

UNLABELLED: OBJECTIVE & BACKGROUND DATA: Mortality following pancreatoduodenectomy (PD) has fallen below 5%, yet morbidity remains between 30 and 50%. Major haemorrhage following PD makes a significant contribution to this ongoing morbidity and mortality. The aim of the present study was to validate the new International Study Group of Pancreatic Surgery (ISGPS) Clinical grading system in predicting the outcome of post pancreaticoduodenectomy haemorrhage (PPH). MATERIAL AND METHODS: Between January 1998 and December 2007 a total of 458 patients who underwent Whipple's pancreaticoduodenectomy in our department were analysed with regard to haemorrhagic complications. The onset, location and severity of haemorrhage were classified according to the new criteria developed by an ISGPS. Risk factors for haemorrhage, management and outcome were analysed. RESULTS: Severe PPH occurred in 14 patients (3.1%). Early haemorrhage (<24 hours) was recorded in five (36%) patients, and late haemorrhage (>24 hours) in nine (64%) patients. As per Clinical grading of ISGPS 7 (50%) belongs to Grade C and 7 (50%) belongs to Grade B. Haemostasis was attempted by surgery in 10 (71%) patients; angioembolisation was successful in two (14%) and endotherapy in one (7%) patient. The overall mortality is 29%(n=4). Age >60 years (p=0.02), sentinel bleeding (p=0.04), pancreatic leak (p=0.04) and ISGPS Clinical grade C (p=0.02) were associated with increased mortality. CONCLUSION: Early haemorrhage was mostly managed surgically with better outcome when endoscopy is not feasible. Late haemorrhage is associated with high mortality due to pancreatic leak and sepsis. ISGPS Clinical grading of PPH is useful in predicting the outcome.

Role of retrograde dilatation in the management of pharyngo-esophageal corrosive strictures.

Pharyngo-esophageal corrosive stricture is a complex clinical scenario. If an esophageal opening cannot be found orally through endoscopy, a retrograde approach with a mini-laparotomy and gastrostomy should be attempted. This study primarily aimed at defining the role of preoperative retrograde dilatation of pharyngo-esophageal corrosive strictures. A retrospective analysis of 51 cases of pharyngo-esophageal corrosive strictures identified between 1997-2005 was performed. The demographic details were analyzed. The details of the injury to the pharynx either in isolation or in combination were noted and the management details were recorded. In 21 patients preoperative retrograde dilatation was considered and the technique was successful in 14 (Group I). In seven the technique failed (Group II) and these patients underwent transhiatal resection and gastric pull-through and/or retrosternal pharyngocoloplasty. In Group I patients the postoperative stay was significantly less than in Group II (12 +/- 2.03 days vs. 18 +/- 4.32 days; p = 0.001) Recurrent aspiration, respiratory tract infections, choking sensation and the need for tracheostomy were less frequent in Group I. The overall functional assessment was good in Group I. For treatment of pharyngo-esophageal obstruction, if antegrade dilatation is not possible due to technical reasons, retrograde dilatation is a viable option before opting for organ replacement/bypass procedures. There is no best replacement of the native organ to maintain quality of life.