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Ann Thorac Surg 2009;88:194-198. doi:10.1016/j.athoracsur.2009.04.004
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Esophageal Stent Placement for the Treatment of Spontaneous Esophageal Perforations

Richard K. Freeman, MD*, Jaclyn M. Van Woerkom, RN, BSN, Amy Vyverberg, RN, BSN, Anthony J. Ascioti, MD

Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana

Accepted for publication April 2, 2009.

* Address correspondence to Dr Freeman, 8433 Harcourt Rd, Indianapolis, IN 46260 (Email: rfreeman{at}corvascmds.com).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent.

Methods: During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram.

Results: Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 ± 15 days after placement. Hospital length of stay was 9 ± 12 days.

Conclusions: Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Spontaneous perforation of the esophagus, also known as Boerhaave syndrome or barogenic rupture, is most commonly the result of a full-thickness longitudinal tear in the esophageal wall associated with emesis. The perforation most often occurs just above the esophageal hiatus of the diaphragm in the intrathoracic esophagus [1]. The result is an esophageal perforation that is often associated with a significant delay in diagnosis and continued oral intake resulting in mediastinal contamination [2].

The main treatment for spontaneous esophageal perforations besides supportive care has most commonly involved primary surgical repair, exclusion and diversion, or esophagectomy. However, despite significant advances in critical care, antimicrobial therapy, diagnostic imaging, and surgical technique, spontaneous esophageal perforations continue to be associated with excessive rates of morbidity and mortality. Our experience treating iatrogenic esophageal perforations and esophageal fistulas using a hybrid approach of endoluminal esophageal stent placement and less invasive surgery led us to investigate this technique in patients with spontaneous perforations of the esophagus [3, 4].


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
A nonrandomized, prospective, observational study of all patients referred to the thoracic surgery service at a tertiary care medical center for spontaneous esophageal perforation was conducted during a 48-month period. All patients with a documented esophageal leak without an antecedent endoscopy, esophageal instrumentation, or operation close to the esophagus who were candidates for surgical repair were offered participation in an Institutional Review Board-approved protocol using an endoluminal esophageal stent to treat their esophageal perforation. Patients gave informed consent for the study as well as the procedure. Exclusion criteria were an esophageal perforation from another cause, an esophageal malignancy, and previous operative repair of an esophageal perforation with a subsequent leak.

The presence of an esophageal perforation resulting in the extravasation of oral contrast into the mediastinum, pleural space, or peritoneum was documented and localized by Gastrografin (Bracco Diagnostics Inc. Princeton, NJ) or barium esophagram, or both, before any treatment (Fig 1). All patients being considered for stent placement also underwent computed tomography imaging of the neck, chest, and abdomen (Fig 2).


Figure 1
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  		Fig 1. Contrast esophagram shows a distal esophageal perforation with extravasation of contrast into the left pleura space.

 

Figure 2
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  		Fig 2. Computed tomography imaging of the chest shows pneumomediastinum, bilateral pleural effusions, and contrast from a preceding esophagram in the left pleural space.

 
All esophageal stents were placed in the operating room using general endotracheal anesthesia and fluoroscopy by a thoracic surgeon after flexible esophagoscopy (Fig 3). During endoscopy, factors were sought that would preclude treatment of the perforation using an endoluminal stent, such as extension of the perforation onto the stomach, a perforation too long to be occluded by a single stent, or obvious circumferential necrosis of the esophagus. A percutaneous endoscopic gastrostomy was placed immediately before esophageal stent placement in patients to allow for enteral nutrition and gastric drainage. Adequate drainage of infected areas was also simultaneously achieved.


Figure 3
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  		Fig 3. Endoscopic view shows a large esophageal perforation with contamination of the mediastinum and pleural space.

 
Occlusion of the esophageal perforation was confirmed by contrast esophagram a minimum of 48 hours after stent placement or when the patient was able to participate in the examination (Fig 4). In the absence of a continued leak, a soft mechanical diet without bread or meat was initiated and advanced as tolerated to a postgastrectomy diet.


Figure 4
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  		Fig 4. Contrast esophagram shows that the previous distal esophageal perforation has sealed after esophageal stent placement.

 
It was the intention to remove all esophageal stents after a sufficient amount of time to allow closure of the perforation. This was individualized by the cause of the perforation, anatomic location, nutritional status of the patient, and the resolution of all associated infectious or septic events, but was not less than 14 days after the initial stent placement. Stent removal also occurred in the operating room under general anesthesia. Flexible esophagoscopy was performed before and after stent removal as well.

An esophagram was obtained 24 hours after stent removal to exclude recurrent leak. Patients were followed up until their stent had been removed and they were tolerating oral nutrition. All patients were assessed at least 3 months after stent removal for dysphagia. Continuous data for this investigation are expressed as the mean ± the standard deviation of the mean, except where otherwise indicated.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
During the 48-month study period, 23 patients were evaluated for a perforation of the esophagus without an antecedent history suggestive of an iatrogenic etiology. Two patients had a previously undiagnosed malignancy of the esophagus associated with the perforation, and 1 patient had either a foreign body or perforation of the intrathoracic stomach. These 4 patients were excluded from this investigation. Nineteen patients met the investigation's inclusion criteria and gave informed consented to participate (Table 1). Their mean age was 48 ± 18 years (range, 26 to 67 years). Eight patients were seen in consultation as inpatients or in the emergency department, and 11 patients were transferred from other hospitals.


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  		Table 1 Patient Outcomes
 
The 19 patients in this series had the onset of chest or abdominal pain with or without shortness of breath after an episode of emesis. Nine (47%) recalled significant alcohol ingestion within 8 hours of emesis. In 13 patients (68%), mediastinitis was evident at the initial evaluation by a thoracic surgeon, as defined by chest pain, fever, leukocytosis, and dyspnea. Three other patients (16%) displayed findings consistent with sepsis, defined as hypotension requiring treatment other than volume resuscitation, bacteremia, and end-organ dysfunction when evaluated. Preexisting comorbidities are reported in Table 2. No patient had any known preexisting esophageal disorders. Follow-up was complete in all 19 patients for the study period.


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  		Table 2 Patient Demographics
 
The mean time from the onset of symptoms associated with an episode of emesis to stent placement was 22 ± 33 hours (range, 6 to 78 hours). At the time of stent placement, all 19 patients underwent additional endoscopic procedures, and a surgical procedure was also done in 9 (Table 3), the most common of which was for percutaneous gastrostomy placement and video-assisted thoracoscopic decortication, respectively. Each patient received a Polyflex stent (Boston Scientific; Natick, MA) sized to produce sufficient radial force in the esophagus to promote occlusion of the perforation with a length long enough to minimize migration.


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  		Table 3 Associated Procedures
 
Mean days from stent placement until repeat esophagram was 3 ± 5 days (range, 2 to 11; median, 3 days). The most common reason for delay of the esophagram beyond 48 hours was the need for mechanical ventilation. In such patients, evidence of a persistent leak was investigated with a modified esophagram in which contrast was delivered through a nasogastric tube. Occlusion of the esophageal perforation occurred in 17 patients (89%) as demonstrated by an esophagram. Two patients (11%) with a perforation involving the gastroesophageal junction experienced a continued leak after stent placement and underwent a transabdominal operative repair. Fifteen patients (88%) treated with stent placement were able begin an oral intake regimen, 14 (82%) within 72 hours of stent placement. One patient (5%), despite having a percutaneous gastrostomy placed, was not able to receive enteral feedings because of a prolonged ileus and was maintained on parenteral nutrition for 6 days before resuming an oral diet.

Stent migration requiring repositioning (n = 4) or replacement (n = 2) occurred in 4 patients (24%). Polyflex stents were removed in all 17 patients without residual esophageal leak at a mean of 20 ± 15 days (range, 14 to 32 days). No patients required stent replacement or further procedures for the esophageal perforation. Hospital lengths of stay varied because of associated complications and preexisting comorbidities. The mean was 9 ± 12 days (range, 5 to 38 days).

All stent placements occurred without intraoperative complication. Morbidities in the study population included respiratory failure in 1, prolonged ileus in 1, and deep venous thrombosis in 2 patients, both of which were related to peripherally inserted central catheters. Gastroesophageal reflux despite proton-pump inhibitor therapy was a complaint in 9 patients (53%) but resolved in each patient to preperforation levels after stent removal. No symptomatic esophageal strictures developed after stent removal during the follow-up period. No patients died.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Spontaneous perforation of the esophagus was first reported in 1724 by Herman Boerhaave, professor of medicine at Leyden University. The previous October 29, 1723, he had been called to urgently evaluate Baron Jan von Wasseaer, high admiral of the Dutch Fleet, who attempted to induce emesis after a large meal. Upon vomiting, the Baron experienced severe chest and epigastric pain. After his death 18 hours later, an autopsy found subcutaneous emphysema and a tear in the posterior wall of the intrathoracic esophagus near the diaphragm. Gastric contents were also found within the left pleural space [5].

Subsequent investigations have found that spontaneous perforation of the esophagus most often results from a sudden rise in the intraluminal esophageal pressure [2]. Such barotrauma has been reported after childbirth, defecation, seizures, and blunt trauma but has most commonly been associated with an increase in intraabdominal pressure combined with failure of the upper esophageal sphincter to relax or more distal esophageal spasm during emesis. This postemetic esophageal perforation is most often longitudinal, is located in the left posterolateral wall of the esophagus, and can be caused by as little as 5 pounds per square inch of intraluminal pressure in cadaveric studies [1].

Compared with other causes of esophageal injury, spontaneous perforation of the esophagus traditionally has been associated with higher rates of morbidity and mortality. Overall rates of mortality are reported to be between 16% and 24% in such patients [6–9]. Several factors that critically influence prognosis in these patients are beyond the control of the surgeon and include preexisting comorbidities, esophageal disease, and delay in diagnosis, which appears to be the most significant.

Traditional, modern therapy for patients with a spontaneous esophageal perforation has focused on the goals of resuscitation and supportive care, antimicrobial therapy, drainage of all contaminated areas, and closure of the perforation while maintaining foregut continuity, when possible. The latter two goals of therapy are most frequently accomplished by means of a thoracotomy or celiotomy, or both, with primary repair of the esophagus when possible, or exclusion and diversion or esophagectomy. Despite significant advances in the medical and surgical care of these patients, however, spontaneous esophageal perforation continues to be associated with excessive rates of morbidity and mortality, especially when the diagnosis is delayed more than 24 hours or when gastrointestinal continuity must be subsequently reestablished, or both [10, 11].

A superior treatment for any perforation of the esophagus, including spontaneous perforations, would be one that minimized the negative effect of the treatment itself on the patient by avoiding thoracotomy and or celiotomy while fulfilling the traditional goals of therapy. Such a hybrid treatment approach would hold promise for effectively treating these patients while minimizing their recuperation time, morbidity, and mortality. A principle component of such a hybrid model has been missing: the ability to consistently close the esophageal perforation without surgical repair.

Our previous experience using an endoluminal esophageal stent to seal iatrogenic esophageal perforations, esophageal fistulas, and perforations of the esophagus associated with malignancies has been encouraging [3, 4]. Esophageal stent placement has resulted in a high rate of closure of these forms of esophageal leak while avoiding thoracotomy or celiotomy. Percutaneous endoscopic gastrostomy placement for enteral nutrition combined with minimally invasive surgical techniques to drain intrathoracic and intraabdominal contamination, when required, and standard supportive care has resulted in significantly lower rates of reoperation, exclusion and diversion, esophagectomy, and morbidity and mortality than those reported for standard surgical treatment. This is especially true when subsets of patients in whom the diagnosis of an esophageal perforation has been significantly delayed are analyzed.

Realizing that spontaneous esophageal perforations differ in location, cause, frequency of delay in diagnosis, contamination of the mediastinum, and patient population from our previously reported experience, this investigation sought to focus exclusively on patients with a spontaneous esophageal perforation to evaluate the safety and effectiveness of a hybrid operative and endoscopic treatment strategy. As in our previous treatment protocols, the placement of a removable endoluminal esophageal stent to seal the esophageal perforation was combined with percutaneous gastrostomy to provide enteral nutrition and gastric drainage as well as simultaneous minimally invasive surgical treatment of empyema or mediastinitis, when present. The placement of an esophageal stent in the distal esophagus requiring the gastroesophageal junction to be crossed with the possibility of significant rates of pyrexia and stent migration were of specific concern in this patient population.

Several results of interest to the surgeon caring for patients with spontaneous esophageal perforations were observed in this investigation. Our experience confirms that of others who found a high rate of synchronous alcohol consumption and delay in diagnosis of patients with a spontaneous esophageal perforation and a low rate of preexisting esophageal disease. Also found were higher rates of mediastinitis or sepsis and associated obesity, but a lower rate of comorbid disease, in this patient population than in reports of esophageal perforations resulting from other causes.

Endoluminal esophageal stent placement was highly effective in rapidly sealing spontaneous esophageal perforations even in the more distal locations encountered in these patients. This allowed earlier oral intake and a decrease in hospital stay compared with our experience and published reports after operative repair [12, 13]. Stent migration requiring repositioning or replacement was higher in this series of patients than in the our previously reported experiences, likely due to the distal placement required, but was treatable in all cases endoscopically. Furthermore, only 2 patients (11%) in this series required operative repair of their esophageal perforation. No patient required esophagectomy or esophageal diversion despite the significant delay in diagnosis, in contrast to other published reports.

Many of the benefits realized by patients treated by endoluminal stent placement in this investigation are a consequence of the favorable characteristics of the stent used. The Polyflex is a nonpermeable, silicone-coated polyester stent. When slightly oversized in diameter, it delivers sufficient radial force to occlude most esophageal perforations. Our experience has been that these stents, unlike some others, do not degrade when exposed to acid or bile reflux, do not fracture, and are easily removed even after migration.

Lastly, although there were significant morbidities in the study population, they occurred less frequently than reported in patients treated with operative esophageal repair after esophageal perforation [14, 15]. Furthermore, no patients died, despite a significant delay in the diagnosis of esophageal perforation in most. This is certainly in contrast to published series of patients whose esophageal perforation was treated surgically and could be the result of the ability to effectively treat most of these patients without thoracotomy or celiotomy. This effect is likely only magnified when patients undergoing esophagectomy, exclusion and diversion, or reoperation for a failed repair or fistula after a spontaneous esophageal perforation are considered.

Integral to whatever success we may have achieved in caring for these challenging patients is the commitment to achieve the same goals one would entertain if operative repair were performed. Every patient underwent at least one simultaneous endoscopic or surgical procedure to accomplish these goals. In our opinion, this global approach to these patients can only be provided with the involvement and preferably under the direction of a thoracic surgeon.

Endoluminal esophageal stent placement for the treatment of spontaneous esophageal perforation appears to have distinct advantages compared with operative repair, but this investigation has some weaknesses. Although this study included a large number of spontaneous esophageal perforations treated in this manner, a patient population of 19 remains a small number even for a relatively uncommon condition. Furthermore, we did not compare endoluminal therapy with operative therapy in a prospective or retrospective fashion. Our current experience of treating a variety of esophageal conditions with endoluminal stent placement raises the question of whether sufficient equipoise exists to serve as a basis for a prospective investigation. Instead, future investigations will focus on an analysis of the difference in resource consumption between the two approaches.

In conclusion, this series demonstrates the safety and effectiveness of an occlusive esophageal stent in treating patients with a spontaneous esophageal perforation when used as part of a hybrid treatment plan to achieve the traditional goals of operative therapy. Endoluminal stent placement provided rapid closure of the perforation even when deployment in the distal esophagus was required. Along with the associated procedures performed, esophageal stent placement resulted in earlier oral nutrition, relatively little morbidity, and no deaths, even when the diagnosis was significantly delayed. Because of the encouraging results of this investigation, we believe consideration should be given to endoluminal stent placement in patients with a spontaneous perforation of the esophagus as part of a hybrid treatment strategy in which thoracotomy and celiotomy are not routinely required.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Mackler S. Spontaneous rupture of the oesophagus Surg Gynecol Obstet 1952;95:344-356.
  2. Muir AD, White J, McGuigan JA, McManu KG, Graham AN. Treatment and outcomes of oesophageal perforation in a tertiary referral centre Eur J Cardiothorac Surg 2003;2:799-804.
  3. Freeman RK, Van Woerkom JM, Ascioti AJ. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation Ann Thorac Surg 2007;83:2003-2008.[Abstract/Free Full Text]
  4. Freeman RK, Ascioti AJ, Wozniak TC. Postoperative esophageal leak management with the Polyflex esophageal stent J Thorac Cardiovasc Surg 2007;133:333-338.[Abstract/Free Full Text]
  5. Boerhaave H. Atrocis, nec descripti prius, morbid historia secundum artis leges conscripta, lugduni batavorum, bontes teniana Medici 1724;60.
  6. Bufkin BL, Miller JI, Mansour KA. Esophageal perforation: emphasis on management Ann Thorac Surg 1996;61:1447-1452.[Abstract/Free Full Text]
  7. Kotsis L, Kostic S, Zubovits K. Multimodality treatment of esophageal disruptions Chest 1997;112:1304-1309.[Abstract/Free Full Text]
  8. Bladergroen MR, Postlethwait RW. Diagnosis and management of esophageal perforation and rupture Ann Thorac Surg 1986;42:235-239.[Abstract/Free Full Text]
  9. D'Journo BX, Doddoli C, Avaro JP. Long-term observation and functional state after primary repair of spontaneous esophageal rupture Ann Thorac Surg 2006;81:1858-1862.[Abstract/Free Full Text]
  10. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation Ann Thorac Surg 2004;77:1465-1483.[Abstract/Free Full Text]
  11. DiPierro FV, Rice TW, DeCamp MM, Rybicki LA, Blackstone EH. Esophagectomy and staged reconstruction Eur J Cardiothorac Surg 2000;17:702-709.[Abstract/Free Full Text]
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  13. Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS. Esophageal perforation: a therapeutic challenge Ann Thorac Surg 1990;50:45-51.
  14. Salo JA, Isolauri JO, Heikkila LJ, et al. Management of delayed esophageal perforation with mediastinal sepsis Esophagectomy or primary repair? J Thorac Cardiovasc Surg 1993;106:1088-1091.[Abstract]
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