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Esophageal Perforation: a Rare but Life-Threatening Complication of Esophageal Dilatation

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Esophageal Perforation: a Rare but Life-Threatening Complication of Esophageal Dilatation SL Gastroenterology Special Issue Article “Esophageal Dilation” Mini Review Esophageal Perforation: A Rare but Life-Threatening Complication of Esophageal Dilatation Julia Jougon1, Matthieu Thumerel2, Romain Hustache-Castain2, Benjamin Chevalier2, Arnaud Rodriguez2, Frédéric Delcambre2 and Jacques Jougon2* 1Resident in Gastroenterology 2Thoracic Surgeon ARTICLE INFO ABSTRACT Esophageal perforation is a rare but life-threatening complication of esophageal Received Date: October 10, 2019 Accepted Date: February 01, 2020 dilatation. Based on a retrospective review of patients treated in a tertiary center for Published Date: February 06, 2020 esophageal perforation, this study focused on perforation following esophageal KEYWORDS dilatation. A review of different treatments currently available is also presented. INTRODUCTION Esophageal dilatation Esophageal perforation Esophageal dilatation is the first-line treatment for symptomatic gastroesophageal Mediastinal abscess stenosis. It is a safe treatment that is recommended in most cases of benign Esophageal achalasia esophageal stenosis. Esophageal perforation following dilatation is a rare but life- Gastrointestinal endoscopy Esophageal stricture threatening complication of esophageal dilatation. Here, we performed a retrospective review of patients treated for esophageal perforation in a tertiary Copyright: © 2020 Jacques Jougon et thoracic surgery department at Bordeaux University Hospital with a focus on al., SL Gastroentrology. This is an open perforation occurring after esophageal dilatation. We also present a review of the access article distributed under the Creative Commons Attribution License, relevant literature. which permits unrestricted use, PATIENTS AND METHODS distribution, and reproduction in any medium, provided the original work is This study was performed using patient files collected in the Epithor clinical national properly cited. database. Only patients treated in our department for esophageal perforation between January 2010 and September 2019 were included in the study. Ethics Citation for this article: Julia Jougon, Matthieu Thumerel, Romain Hustache- approval for use of this database was obtained from the National Commission for Castain, Benjamin Chevalier, Arnaud Data Protection (Commission nationale de l’informatique et des libertés, CNIL, Rodriguez, Frédéric Delcambre and approval number: 1576793). All patients admitted to our department provided Jacques Jougon. Esophageal Perforation: A Rare but Life-Threatening Complication consent for inclusion in this database that is used for national institutional and of Esophageal Dilatation. SL individual surgeon accreditation. Therefore, there was no requirement for additional Gastroentrology. 2020; 3(1):129 patient consent for this study. Data were added prospectively to the database and more details if needed were obtained from the patient files. Corresponding author: RESULTS Jacques Jougon, During the study period, 17 patients (9 men and 8 women) with a mean age of 74 Department of Thoracic surgery, years (range 61 – 88) were treated for esophageal perforation in our department. Bordeaux University, CHU de Bordeaux, service de chirurgie thoracique et The causes of perforation were spontaneous (also called Boerhaave syndrome) in cervicale, transplantation pulmonaire et three cases, foreign body perforation in six cases, and iatrogenic in eight cases maladies de l’œsophage. France, Tel: +33 557656009; Fax: +33 (transesophageal echocardiography, n = 3; atrial fibrillation ablation therapy, n = 1; 557656021; and esophageal dilatation, n = 4). The latter four cases are described below. Email: [email protected] 01 Esophageal Perforation: A Rare but Life-Threatening Complication of Esophageal Dilatation. SL Gastroentrology. 2020; 3(1):129. SL Gastroenterology All of the 17 patients were cured with the exception of one that had been treated 10 years ago, followed by who died due to multiple organ failure after developing Waldenstrom disease and treatment for high blood pressure. Boerhaave syndrome. The clinical indicators of achalasia were dysphagia that had CASE 1 appeared more than 3 years previously, regurgitation, and This patient was a 72-year-old man undergoing treatment for weight loss of 8 kg. He weighed 86 kg and was 1.70 m in primary dissecting esophagitis revealed by dysphagia and height (BMI = 29.8; serum albumin, 41 g/L). Dilation had been weight loss. He had a history of meningitis in childhood, carried out with balloon inflation for a sequence of 30 s three deficiency encephalopathy, cumulative smoking history of 30 times from 8 to 10 PSI. pack years, and high blood pressure. He weighed 68 kg and Immediately on awakening after dilation, the patient presented was 1.62 m in height (Body Mass Index [BMI] = 25.91). He had chest pain and subcutaneous emphysema. A diagnosis of protidemia of 71 g/L. Two stenotic segments were identified suspected perforation was confirmed by CT. Broad-spectrum 25 and 30 cm from the dental arches. antibiotic therapy was initiated and the indication for surgery An endoscopic dilation program was underway with the first was retained. two sessions involving balloon dilations performed 5 months The surgical intervention was performed through the left and 2 months prior to presentation. Perforation occurred during thoracotomy approach and consisted of mediastinal and the third dilation session. Three hours after the third dilation, pleural lavage, suture of the esophageal tear, esophageal the patient developed fever at 39°C with chills. Clinical myotomy on the opposite circumference of the tear, and examination identified crackles in the two pulmonary bases, reversal plasty of the large gastric tuberosity on the area of cardiac arrhythmia that had not been present previously, and the esophageal suture (Dor’s fundoplication). saturation at 93% on skin oximetry. Thoracoabdominal Esophageal healing was favorable without fistula. The Computed Tomography (CT) confirmed the diagnostic suspicion postoperative course was marked by a segmental pulmonary of esophageal perforation showing pneumomediastinum embolism. The total period of hospitalization was 40 days, associated with right pleurisy. Broad-spectrum antibiotic after which the patient was transferred to a rehabilitation therapy was instituted and the patient was transferred to our center. department. The indication for surgery was retained. CASE 3 Preoperatively, exploratory esophageal endoscopy performed A 73-year-old woman was treated in a regional hospital for with a rigid tube identified an esophageal tear extending over severe esophageal stenosis associated with chest pain. 3 cm located 27 cm from the dental arches. Esophageal manometry identified severe motor disorders The surgical intervention was performed by two approaches: suggestive of scleroderma, although the diagnosis was not right thoracotomy to perform washing, suturing, and burial of confirmed. The patient was undergoing endoscopic treatment. the esophageal tear and drainage of the pleural cavity and Perforation occurred during the second dilation session, and mediastinum. Laparotomy was performed to perform gastric was quickly diagnosed at the end of the procedure. The drainage gastrostomy and jejunostomy for enteral feeding. patient was then transferred to our department. She had body The postoperative course was marked by a septic syndrome weight of 58 kg and height of 1.64 m (BMI = 21.6). The requiring respiratory assistance for 10 days. surgical procedure was performed via the left thoracotomy The patient was transferred to a convalescence center after a approach to perform pleural and mediastinal lavage, followed hospital stay of 15 days in the Intensive Care Unit (ICU) and by suturing of the esophageal tear and drainage. 15 days in the surgical department. Esophagography on postoperative day 7 showed a small CASE 2 drained esophageal leak that necessitated delaying of oral An 88-year-old man presented with perforation of the feeding until it had healed. However, the persistence of esophagus after endoscopic dilation for achalasia of the dysphagia and chest pain far from the perforation finally led esophagus. He was in remission from prostatic adenocarcinoma to esophageal resection, which was performed 3 years later. 02 Esophageal Perforation: A Rare but Life-Threatening Complication of Esophageal Dilatation. SL Gastroentrology. 2020; 3(1):129. SL Gastroenterology CASE 4 6% for achalasia vs. 0.09% – 2.2% for all other causes of A 71-year-old woman suffered from achalasia and was benign stenosis [3]. treated by dilation 2 years before the date of perforation. A Self-dilation is an alternative that is rarely used for caustic new program of dilation was proposed due to recurrence of stenosis [4]. Perforation rates of 3.4% after dilation for caustic symptoms. Dysphagia was responsible for weight loss of 9 kg stenosis and 1.1% after endoscopic resection of strictures have in 2 months and was associated with iron deficiency anemia. been reported (“). She weighed 53 kg and was 1.60 m in height (BMI = 20.7). A One of the main prognostic factors reported in most series of new dilation was carried out using the same technique as in the esophageal perforation is the delay between diagnosis and previous session using a balloon. treatment regardless of the method applied [5]. A long delay Immediately on awakening after the procedure, she presented increases the risk of chemical or infectious mediastinitis due to manifestations of perforation by chest
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