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Ann Thorac Surg 2002;74:1233-1235
© 2002 The Society of Thoracic Surgeons

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Case report

Successful management of a nonmalignant esophageal perforation with a coated stent

^a Division of Cardiothoracic Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
^b Division of Transplant Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Accepted for publication May 1, 2002.

* Address reprint requests to Dr Ozdemir, Division of Cardiothoracic Surgery, Slot 713, University of Arkansas for Medical Sciences, 4301 West Markham St, Little Rock, AR 72205 USA
e-mail: ozdemiraytekin{at}uams.edu

	Abstract

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This case report details our experience in the management of an iatrogenic perforation that recurred after two surgical repairs. A self-expanding coated stent was eventually placed to seal the esophageal perforation with significant improvement in the clinical condition of the patient. At 1-year follow-up, the patient is tolerating an oral diet with no evidence of esophageal leak or gastroesophageal reflux. This case report and a literature review suggest that self-expanding coated stents may be a useful salvage option in the management of inveterate nonmalignant esophageal perforations.

	Introduction

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Esophageal perforation is a potentially life-threatening complication with a high mortality rate. Primary surgical repair remains the treatment of choice in early-diagnosed perforations. The surgical treatment of old or recurrent perforations associated with local and systemic sepsis is often associated with significant morbidity and mortality.

A 37-year-old woman presented 2 months after an uncomplicated combined kidney-pancreas transplant with dysphagia, abdominal pain, and fever. Upon admission, an abdominal computed tomographic scan revealed thickened cecum and ascending colon consistent with possible cytomegalovirus colitis. Esophagogastroscopy did show biopsy-proven extensive cytomegalovirus esophagitis. Subsequently, she developed recurrent bloody diarrhea that necessitated a right hemicolectomy with placement of a feeding gastrostomy tube for nutritional support. The excised colon showed extensive cytomegalovirus ulcerations.

Postoperatively, the patient was on gastrostomy feeding, and attempts to restart oral feeding failed due to continued dysphagia. A repeat esophagoscopy showed a long stricture in the distal third of the esophagus. While attempting to balloon dilate this stricture, the patient developed acute chest pain, and a chest roentgenogram showed a left-sided pneumothorax. A subsequent gastrografin swallow confirmed a midthoracic esophageal perforation. Via a right posterolateral thoracotomy, the perforation was localized to the left side of midthoracic esophagus. Because the patient was explored within 2 hours of perforation with minimal inflammation, a primary repair was performed in two layers reinforced with an intercostal muscle flap. A gastrografin swallow performed on postoperative day 7 did not reveal an esophageal leak. The patient tolerated an oral liquid diet and was discharged.

The patient was readmitted 5 days after discharge with fever and pneumonia. A chest computed tomographic scan showed empyema with consolidation of the right lower lung lobe. A gastrografin swallow confirmed an esophageal leak into the chest distal to the carina (Fig 1). The patient refused esophageal diversion, and was reexplored to drain the abscess cavity and attempt esophageal repair. The first intercostal muscle flap was necrotic, and a new intercostal muscle flap was fashioned to cover the esophageal perforation as a patch. A gastrografin swallow obtained on the 7th postoperative day showed a persistent, but fairly well-contained, esophageal fistula.

View larger version (67K): [in this window] [in a new window]   Fig 1. Gastrografin swallow obtained after the second repair showing a persistent thoracic esophageal leak.

Six weeks after discharge, she was readmitted with an episode of hematemesis. Endoscopy showed gastric erosion caused by the distal stent impinging on the gastric mucosa. The distal stent was removed at laparotomy by opening the stomach and without dislodging the proximal stent that had sealed off the perforation. A postoperative gastrografin swallow revealed an intact proximal stent in satisfactory position and with no reflux or leak (Fig 2). At 1-year follow-up, the patient was tolerating a regular oral diet with no evidence of esophageal leak or gastroesophageal reflux.

View larger version (111K): [in this window] [in a new window]   Fig 2. Lateral chest roentgenogram showing the esophageal stent in satisfactory position.

	Comment

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A primary surgical repair and, when needed, additional reinforcement or buttressing of the repair by well-vascularized autologous tissue such as gastric fundus, pleural flap, pedicled muscle flap taken from the diaphragm, intercostals, chest wall musculature, pericardium, and omentum remains the treatment of choice for esophageal perforations [3]. A useful alternative to surgical repair in cases of esophageal perforation and fistulae associated with inoperable malignant disease has been the availability of a variety of esophageal tubes and, more recently, self-expanding coated stents [4]. The recently developed, self-expanding, partially coated stents allow satisfactory anchorage into the esophageal wall, and, at the same time, the coated area of the stent seals the perforation.

Our case report illustrates a complex situation where the use of immunosuppression, including steroids, and the presence of cytomegalovirus esophagitis with distal stricture may be among other factors responsible for failure of the surgical repair. Furthermore, in our critically ill patient with sepsis, multiple comorbidities, and previous multiple abdominal operations, further surgical options to control the mediastinitis were also limited. Although Cameron and associates [5] proposed nonoperative therapy in the management of esophageal perforation, these were only in carefully selected cases with a contained perforation and without evidence of septic deterioration.

At this point, deriving experience from management of malignant esophageal stricture and perforations, and hoping to reduce further patient morbidity, we opted to try an esophageal stent. In our patient, the use of esophageal stent provided a valuable salvage option and the patient remains well at 1-year follow-up. Similar experiences in a small number of case report studies shows that stents may be a useful salvage option in the management of such inveterate perforations associated with benign esophageal disease [6–8]. In a patient with blunt trauma to the chest reported by Pajarinen and associates [6], and presenting with rib fractures and hemothorax, the diagnosis of esophageal perforation was delayed until after two thoracotomies had been performed for recurrent empyema. The patient’s condition improved after placement of a self-expandable coated stent. Serna and colleagues [7], in a critically ill human immunodeficiency virus patient, treated a thoracic esophageal perforation that had not improved after 14 days of nonoperative therapy by placing a 10 x 2 cm partially coated stent.

In summary, this case report and a review of the literature shows that self-expanding coated stents may be a valuable and life-saving salvage option in the immediate management of old or recurrent esophageal perforations associated even with benign disease. Careful follow-up of this group of patients is mandatory as stent migration and erosion through the wall of the esophagus remains a potential complication.

	References

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1. Chen L., Duranceau A. Esophageal perforation. In: Cameron J.L., ed. Current surgical therapy. St. Louis, MO: Mosby, 1998:8-15.
2. Jones W.G., Ginsberg R.J. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534-543.[Abstract/Free Full Text]
3. Gouge T.H., Depan H.J., Spencer F.C. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus. Ann Surg 1989;209:612-619.[Medline]
4. Morgan R.A., Ellul J.P., Dento E.R., et al. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprosthesis. Radiology 1997;204:527-532.[Abstract/Free Full Text]
5. Cameron J.L., Kieffer H.F., Hendrix T.R., et al. Selective non-operative management of contained intrathoracic esophageal disruptions. Ann Thoracic Surg 1979;27:404-408.[Abstract/Free Full Text]
6. Pajarinen J., Ristkari S.K., Mokka R.E. A report of three cases with an esophageal perforation treated with a coated self-expanding stent. Ann Chir Gynaecol 1999;88:332-334.[Medline]
7. Serna D.L., Vovan T.T., Roum J.H., Brenner M., Chen J.C. Successful nonoperative management of delayed spontaneous esophageal perforation in patients with human immunodeficiency virus. Crit Care Med 2000;28:2634-2637.[Medline]
8. Segalin A., Bonavina L., Lazzerini M., et al. Endoscopic management of inveterate esophageal perforations and leaks. Surg Endosc 1996;10:928-932.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hamid Mumtaz Aytekin Ozdemir Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mumtaz, H. Articles by Ozdemir, A. Search for Related Content PubMed PubMed Citation Articles by Mumtaz, H. Articles by Ozdemir, A. Related Collections Esophagus - other