Esophageal Perforation Management Using a Multidisciplinary Minimally Invasive Treatment Algorithm - 20/03/14

Doi : 10.1016/j.jamcollsurg.2013.12.033

Kfir Ben-David, MD, FACS ^a,^⁎ , Kevin Behrns, MD, FACS ^a, Steven Hochwald, MD, FACS ^c, Georgios Rossidis, MD ^a, Angel Caban, MD ^a, Cristina Crippen, RN ^a, Thomas Caranasos, MD ^a, Steven Hughes, MD, FACS ^a, Peter Draganov, MD ^b, Christopher Forsmark, MD ^b, Shailendra Chauhan, MD ^b, Mihir S. Wagh, MD ^b, George Sarosi, MD, FACS ^a
^a Department of Surgery, University of Florida, Gainesville, FL
^b Department of Medicine, University of Florida, Gainesville, FL
^c Roswell Park Cancer Center, Buffalo, NY

^∗Correspondence address: Kfir Ben-David, MD, FACS, Division of General Surgery, 1600 SW Archer Rd, Room 6164, P.O. Box 100109, Gainesville, FL 32610.

Abstract

Background

The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients.

Study Design

An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected.

Results

We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945.

Conclusions

Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.

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Plan

Disclosure Information: Dr Ben-David receives pay as a consultant and received a research grant from Ethicon; Dr Forsmark is paid as a consultant by Applied Clinical Intelligence; and Dr Hochwald is paid as a consultant for Ethicon Endosurgery. All other authors have nothing to declare.