A Case of Esophageal Perforation Presenting as Cavitary Pneumonia: Diagnostic and Therapeutic Challenges

Esophageal perforation, a rare condition, can arise from iatrogenic, traumatic, or spontaneous origins. Even when therapy is initiated within the first 24 hours, it is associated with a mortality rate of up to 25%. Due to the varied initial presentation, treatment may be delayed, leading to poorer outcomes. Here, we present a unique case of a 27-year-old schizophrenic patient who initially presented with acute respiratory failure and septic shock and was ultimately diagnosed with cavitary pneumonia secondary to esophageal perforation.

How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience

BACKGROUND Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition.The optimal management strategy is still unclear.AIM To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks.METHODS A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023.Clinical outcomes were analyzed,and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus,when feasible.RESULTS Among the whole series of 60 patients,an urgent surgery was required in 8 cases due to a septic state.Fifty-six patients were managed by endoscopic or hybrid treatments,obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus.The mean time to resolution was 54.95±52.64 days,with a median of 35.5 days.No severe complications were recorded.Ten patients out of 56(17.9%)developed pneumonia that was treated by specific antibiotic therapy,and in 6 cases(10.7%)an atrial fibrillation was recorded.Seven patients(12.5%)developed a stricture within 12 months,requiring one or two endoscopic pneumatic dilations to solve the problem.Mortality was 1.7%.CONCLUSION A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.

Bedside ultrasound-guided water injection assists endoscopically treatment in esophageal perforation caused by foreign bodies: A case report

BACKGROUND Fishbone migration from the esophagus to the neck is relatively uncommon in clinical practice.Several complications secondary to esophageal perforation after ingestion of a fishbone have been described in the literature.Typically,a fishbone is detected and diagnosed by imaging examination and is usually removed by a neck incision.CASE SUMMARY Herein,we report a case of a 76-year-old patient with a fishbone in the neck that had migrated from the esophagus and that was in close proximity to the common carotid artery,and the patient experienced dysphagia.An endoscopically-guided neck incision was made over the insertion point in the esophagus,but the surgery failed due to having a blurred image at the insertion site during the operation.After injection of normal saline laterally to the fishbone in the neck under ultrasound guidance,the purulent fluid outflowed to the piriform recess along the sinus tract.With endoscopic guidance,the position of the fish bone was precisely located along the direction of liquid outflow,the sinus tract was separated,and the fish bone was removed.To the best of our knowledge,this is the first case report describing bedside ultrasound-guided water injection positioning combined with endoscopy in the treatment of a cervical esophageal perforation with an abscess.CONCLUSION In conclusion,the fishbone could be located by the water injection method under the guidance of ultrasound and could be accurately located along the outflow direction of the purulent fluid of the sinus by the endoscope and was removed by incising the sinus.This method can be a nonoperative treatment option for foreign body-induced esophageal perforation.

Delayed esophageal perforation occurring with endoscopic submucosal dissection:A report of two cases

We report two cases of delayed esophageal perforation occurring with endoscopic submucosal dissection. Our cases involved delayed perforation after 10 d in case 1 and after 6 d in case 2. Both cases were related to solid food. We performed subtotal esophagectomy with gastric tube reconstruction of the esophagus via the subcutaneous route anterior to the thoracic wall without conservative treatment because both cases involved chest pain and major leakage of food into the mediastinum. Postoperative complications were a local factor(including suture failure and esophageal stricture) in case 1, and we performed endoscopic balloon dilatation five times for esophageal stricture. There was no intrathoracic and mediastinal infection in either case. Surgical treatment for delayed esophageal perforation can be performed safely and surely if diagnosis and assessment are not delayed.

Delayed presentation of intrathoracic esophageal perforation after pneumatic dilation for achalasia

Pneumatic dilation(PD)is considered to be a safe and effective first line therapy for achalasia.The major adverse event caused by PD is esophageal perforation but an immediate gastrografin test may not always detect a perforation.It has been reported that delayed management of perforation for more than 24 h is associated with high mortality.Surgery is the treatment of choice within 24 h,but the management of delayed perforation remains controversial.Hereby,we report a delayed presentation of intrathoracic esophageal perforation following PD in a 48-year-old woman who suffered from achalasia.She completely recovered after intensive medical care.A review of the literature is also discussed.

Circumferential mucosal dissection and esophageal perforation in a patient with eosinophilic esophagitis

A young man with a previous history of episodes of mild solid food dysphagia was admitted with a total dysphagia. The esophagogastroduodenoscopy (EGDS) showed an extensive disruption of mucosal layer with a cul-de-sac in the lower part of the esophagus. Soon after the procedure, the patient suffered from an acute chest pain and subsequent CT scan demonstrated an intramural circumferential dissection of thoracic esophagus, and a mediastinal emphysema. An emergency right thoracotomy was performed, followed by a total esophagectomy with esophagogastroplasty and jejunostomy. The histopathology confirmed that mucosal and submucosal layers were circumferentially detached from muscular wall and showed an eosinophilic infiltration of the whole organ with necrosis and erosions of mucosal, submucosal and muscular layers. The diagnosis was esophageal perforation in eosinophilic esophagitis.

Esophageal perforation caused by fish vertebra ingestion in a seven-month-old infant demanded surgical intervention: A case report

A seven-month-old infant was admitted to our hospital with a 1-wk history of shortness of breath, dysphagia, and fever. Diagnosis of esophageal perforation follow- ing fish vertebra ingestion was made by history review, pneumomediastinum and an irregular hyperdense lesion noted in initial chest radiogram. Neck computed tomo- graphy (CT) confirmed that the foreign body located at the cricopharyngeal level and a small esophageal tra- cheal fistula was shown by esophagogram. The initial re- sponse to treatment of fish bone removal guided by pan- endoscopy and antibiotics administration was poor since pneumothorax plus empyema developed. Fortunately, the patient’s condition finally improved after decortica- tion, mediastinotomy and perforated esophagus repair. To our knowledge, this is the first case report of esopha- geal perforation due to fish bone ingestion in infancy. In addition to particular caution that has to be taken when feeding the innocent, young victim, it may indicate the importance of surgical intervention for complicated esophageal perforation in infancy.

Esophagectomy for a traumatic esophageal perforation with delayed diagnosis

Esophageal perforations are rare,and traumatic perforations are even more infrequent.Due to the rarity of this condition and its nonspecific presentation,the diagnosis and treatment of this type of perforation are delayed in more than 50% of patients,which leads to a high mortality rate.An 18-year-old male patient was brought to the emergency room with a penetrating neck injury,caused by a gunshot wound.He was taken to the operating room and underwent surgical exploration of the neck and a chest tube was inserted to treat the hemo-and pneumothorax.During the procedure,a 2 cm lesion was detected in the esophagus,and the patient underwent a primary repair.A contrast leakage into his right hemithorax was noticed on the 4th postoperative day;he was submitted to new surgery,and a subtotal esophagectomy and jejunostomy were performed.He was discharged from the hospital in good condition 20 d after the last procedure.The discussion around this topic focuses on the importance of the timing of diagnosis and the subsequent treatment.In early diagnosed patients,more conservative therapeutics should be performed,such as primary repair,while in those with delayed diagnosis,the patient should be submitted to more aggressive and def initive treatment.

Diaphragmatic hernia complicated with intestinal obstruction with colon perforation after surgery for esophageal cancer:a case report

We reported a case of diaphragmatic hernia complicated with intestinal obstruction with colon perforation after surgery for esophageal cancer. In this case, the conservative treatment took too long, which delayed the diagnosis and treatment and resulted in colon perforation. After computed tomography confirmed the diagnosis, an emergency operation was performed. During the operation, we found colon perforation. Because pollution of thoracic cavity was serious, we performed proximal end colon neostomy. The patient recovered and discharged with active treatment 35 days after operation. We consider surgical repair of the diaphragmatic hernia is recommended to avoid the potentially disastrous complications, such as strangulation or perforation of the herniated contents, which can threaten the life of the patient if diagnosis is delayed.

Surgical Treatment of Perforation with Esophageal Carcinoma

OBJECTIVE To determine the ideal method of surgical preoperative treatment for perforation with esophageal carcinoma.METHODS 36 cases of perforation with esophageal carcinoma were treated surgically in this series.Perforations occurred into the right lung in 14 cases.the mediastinum in 17 cases and treachea in 5 cases.Open thoracic surgery was performed in 34 cases.in which the right thoracic approach using a 3-incision method was applied in 16 cases,and operation by stages in 15 cases.Of the 34 cases.retrosternal substitution of the esophagus with stomach or colon was performed in 26 cases.RESULTS Surgery was successful in 31 cases and operative death occurred in 3 cases.The postoperative follow up study was from 3-72 months.Of these cases 15 were alive 15 7-12 months,2 at 24 months.and 1 at 72 months.The results can be considered satisfactory.CONCLUSION The therapeutic results of surgical treatment of perforation with esophageeal carcinoma were markedly superior to that of conventional conservative treatment.The authors suggest that surgical interventionwithout delay should be undertaken for patients having a perforation with carcinoma of the esophagus.A right thoracic approach with a 3-incision method（retrosternal replacement of esophagus with stomach or colon0or operation by stages is preferable.

Presentation of Boerhaave's syndrome as an upper-esophageal perforation associated with a right-sided pleural effusion:A case report

BACKGROUND Spontaneous esophageal rupture or Boerhaave’s syndrome is a rare and acute disease with a high incidence of misdiagnosis and mortality.Here,we aimed to explore the clinical characteristics,diagnosis,treatment,and prognosis of spontaneous esophageal rupture,and to analyze the causes of misdiagnosis during the treatment of spontaneous esophageal rupture.CASE SUMMARY The clinical features of the patient with spontaneous esophageal rupture misdiagnosed earlier as pleural effusion were retrospectively analyzed and the reasons for misdiagnosis are discussed based on a current review of the literature.The patient was admitted to a local hospital due to shortness of breath accompanied by vomiting and abdominal distension for five hours.Based on the computed tomography(CT)scan analysis,clinically,right pleural effusion was diagnosed.However,the patient was unwilling to undergo right closed thoracic drainage.The patient also had intermittent fevers against infection,and during the course of treatment,he complained of chest pain,following which,he was transferred to our hospital.Grapefruit-like residue drainage fluid was observed.Re-examination of the chest CT scans suggested the presence of spontaneous perforation in the upper left esophagus.Therefore,the patient underwent an urgent esophageal hiatus repair.Unfortunately,the patient died of infection and respiratory failure due to progressive dyspnea after surgery.CONCLUSION Spontaneous esophageal rupture is a rare disease associated with high fatality.The patients do not present typical clinical symptoms and the disease progresses rapidly.This case report highlights the importance of a dynamic review of chest CT scan,not only for the initial identification of segmental injury but also for prioritizing subsequent treatment strategies.Moreover,we have presented some clues for clinicians to recognize and diagnose spontaneous esophageal rupture at rare sites(upper-esophageal segment)through this case report of spontaneous esophageal rupture that caused the patient’s death.We have also summarized the reasons for the misdiagnosis and lessons learned.

Huoxue Tongjiang decoction-resisted reflux esophagitis by activation stem cell factor/c-kit/interstitial cell of cajal pathway and regulating the T-helper 17/regulatory T-cells balance in rats

Background:Huoxue Tongjiang decoction(HXTJD)is an effective prescription for treating reflux esophagitis(RE).We investigated the effects of HXTJD on esophageal motility and mucosal inflammation in a rat RE model.Methods:Chemical composition of HXTJD was analyzed by ultrahigh-performance liquid chromatography Q-Orbitrap mass spectrometry(MS).The change rates of mean contraction tension forces,mean amplitudes,and mean frequencies for the lower esophageal sphincter(LES)were recorded using the isolated tissue bath system,mechanical tension transducer,and PowerLab physiological recorder.After weighing the stomach,the phenol red labeling method was used to measure the gastric emptying rate.The LES ultrastructure was observed through transmission electron microscopy.Immunofluorescence and western blotting were used to detect the number of interstitial cells of Cajal(ICC)and the expression levels of c-kit protein,connexin43(Cx43),and stem cell factor(SCF).Flow cytometric analysis and enzyme-linked immunosorbent assay were conducted to detect the percentages of T helper 17(Th17)cells and regulatory T(Treg)cells and the serum concentrations of interleukin 6(IL-6),interleukin 17(IL-17),and interleukin 10(IL-10)in the rats.Results:We identified 28 chemical constituents in HXTJD.Regarding esophageal motility,we revealed that HXTJD increased the mean contraction tension forces,mean amplitudes,and mean frequency change rate of LES and the gastric emptying rate;decreased stomach weight;and improved the LES ultrastructure.Additionally,HXTJD increased the number of ICC-positive cells,and c-kit,Cx43,and SCF expression levels.Regarding esophageal inflammation,HXTJD significantly decreased the percentage of Th17 cells,and IL-6 and IL-17 concentrations,and increased the percentage of Treg cells and IL-10 concentration.Conclusion:HXTJD was found to be efficacious in the rat RE model.It may promote esophageal motility and alleviate the inflammatory response by activating the SCF/c-kit/ICC pathway and regulating the Th17/Treg cell balance.

Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma

AIM To identify the risk factors and clarify the subsequent clinical courses.METHODS This study retrospectively analyzed consecutive patients with esophageal squamous cell carcinoma( ESCC) treated using endoscopic submucosal dissection(ESD) between April 2008 and October 2012. We divided the ESCC lesions into perforation cases and non-perforation cases, and compared characteristics and endoscopic findings between the two groups. "Intraoperative perforation" was defined as the detection of a perforation site during ESD and the presence of mediastinal emphysema.RESULTS In total, 147 patients with 156 ESCC lesions were treated by ESD. Intraoperative perforation was recorded for nine lesions(5.8%) from nine patients. Multivariate analysis identified mucosal deficiency larger than 75% of the circumference of the esophagus as an independent risk factor for intraoperative perforation(OR = 7.37, 95%CI: 1.45-37.4, P = 0.016). The predominant site of perforation was the left wall [6/9(67%)]. Six of nine perforation sites were successfully closed by clips during the procedures. Two of nine cases required drainage for pleural effusions; however, all nine cases recovered with conservative treatment and without surgical intervention. At the median follow up of 42 mo after ESD, no cases of local recurrence or distant organ metastasis had been observed.CONCLUSION This study suggests that mucosal deficiency larger than 75% of the luminal circumference is a risk factor for intraoperative perforation during ESD for ESCC.

predictors for failure of stent treatment for benign esophageal perforations- a single center 10-year experience

AIM: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).

Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction

Iatrogenic perforation of esophageal cancer or cancer of the gastroesophageal(GE)junction is a serious complication that,in addition to short term morbidity and mortality,significantly compromises the success of any subsequent oncological therapy.Here,we present an 82-year-old man with iatrogenic perforation of adenocarcinoma of the GE junction.Immediate surgical intervention included palliative resection and GE reconstruction.In the case of iatrogenic tumor perforation, the primary goal should be adequate palliative(and not oncological)therapy.The different approaches for iatrogenic perforation,i.e.surgical versus endoscopic therapy are discussed.

Esophageal Perforation in Children: Experience in Kurdistan Center for Gastroenterology and Hepatology/Iraq

Background: Esophageal perforation is a rare, but potentially life threatening injury. The etiology and management of this condition have changed overtime. Iatrogenic causes are increasingly recognized and management is evolving towards more conservative approaches. Objective: To review our experience in the management of esophageal perforation in pediatric patients. Patients and methods: This retrospective study was conducted in the Kurdistan center for gastroenterology and hepatology in Sulaimani city. Review of records for cases of esophageal perforation during the period from January 2006 to October 2013 was performed. Results: Ten cases were found to have esophageal perforation. The causes of esophageal perforation were complications of endoscopic dilation for esophageal stricture (n = 7), button battery ingestion (n = 2), complication of esophagoscopy for corrosive injury (n = 1). The mean age was 42 months (range, 18 - 75 months). The diagnosis was made during the procedure in 6 cases, within 12 hours in 2 cases and late in the two cases of battery ingestion. Subcutaneous emphysema and respiratory distress were the main presenting features. The location of perforation was thoracic in 9 cases and cervical in 1 case. Conservative management was successful in 7 patients and surgical closure was done in two patients. One death has been reported. Conclusion: Iatrogenic causes were the most common causes of esophageal perforation. Conservative management with interventions guided by clinical response can have a favorable outcome and may become the best initial treatment strategy in the future. Further larger scale studies are recommended to establish the best protocol for conservative management.

Vertebral body infection due to esophageal perforation caused by ingestion of fishbone:a case report

Background:Esophageal injury is a common complication of foreign bodies in the upper gastrointestinal tract,but bilateral pleural effusion or vertebral infection is a rare condition due to a swallowed fishbone.It is considerably difficult for a physician to diagnose quickly because of incomplete patient history of foreign bodies ingestion and/or insufficient experiences.Patient concerns:We describe the case of a 56-year-old man who was admitted to an emergency medical department owing to a low to moderate fever for 7 days.After a series of examinations,the patient was diagnosed with esophageal perforation(EP)caused by a fishbone that was swallowed half a month ago.Diagnoses:About 12 days after the onset of fever,he was diagnosed with EP based on the gastric endoscopic images combined with histological section and sufficient history of the disease.About 2 months later,the patient has obvious back pain and lack of strength in two legs and was diagnosed with vertebral body infection.Interventions:Antibiotic therapy,multi-disciplinary team(MDT),and surgical intervention had been exerted.Outcomes:It is very fortunate for this patient to have a good prognosis due to a timely diagnosis and proper management.Muscle power has attained level 5.Lessons:Several lessons can be learned from this case;for example,physicians should be alerted to the EP,endoscopic intervention should be prompt,antibiotics should be used regularly,and so on.

Esophageal Perforation Management: A Single-Center Experience

Background: Esophageal perforation is a rare and potentially life-threatening condition requiring urgent management. Successful therapy depends on the underlying etiology, clinical presentation, the time between rupture and diagnosis, the extent of the rupture and the underlying health of the patient. Method: From 2005 to 2012, the author retrospectively analyzed 36 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, comorbidities, the method of diagnosis, delay in diagnosis, therapeutic regimen, complications, hospital stay, follow-up and mortality. Results: The cause of perforation were iatrogenic in 14 cases (38.8%), foreign body ingestion in 11 (30.5%), spontaneous in 9 (25%), chest trauma in 1 (2.8%) and esophageal cancer in 1 case (2.8%). The most frequent signs and symptoms were chest pain in 27 cases (75%), fever in 15 (41.6%), dysphagia in 11 (30.5%), mediastinitis in 9 (25%) and vomiting in 8 (22%). The treatment included surgery in 26 cases (72.2%) which consists of thoracotomy (right or left), with or without esophageal suturing, washing, drainage with three chest tubes, jejunostomy and gastrostomy. The second group were patients treated medically in 10 cases (27.8%), medical treatment includes nil per os (NPO), parenteral nutrition, intravenous antibiotics and observation. Complications include fever (n = 14), auricular fibrillation (n = 7), esophageal fistula (n = 3), reoperation (n = 2), renal failure (n = 2), cerebrovascular accident (n = 1), pulmonary embolism (n = 1), pneumonia (n = 1) and deep vein thrombosis (n = 1). The average hospital stay for patients treated surgically was 36 days and for patients treated medically was 14.2 days. The overall mortality was 25% involving 8 patients treated surgically and 1 patient treated medically. Conclusion: The treatment method still must be chosen on an individual basis. Rapid diagnosis of this often life threatening condition is critical for expediting the choice of an optimal treatment strategy, whether surgical or non-surgical.

Treatment of esophageal rupture or perforation

Esophageal rupture or perforation is a serious emergent disease.Without accurate diagnosis and effective treatment in time,it’s life-threatening.Esophageal rupture or perforation can be caused by:iatrogenic endoscopy examination and treatment,ligation and sclerotherapy of esophageal variceal,dilation of esophageal stricture,operative injury and so on; Spontaneous perforations; foreign body ingestion; trauma; tumor; calculus and ulcer of esophagus and so on.The key-point for the treatment of this disease lies in early diagnosis and accurate effective treatment.

ESOPHAGUS-STOMACH-ABDOMINAL WALL DRAINAGE FOR DELAYED INTRATHORACIC ESOHPAGEAL PERFORATION

Objective To design a technique of esophagus-stomach-abdominal wall drainage for the de-layed intrathoracic esophageal perforation and to improve the therapeutic results. Methods Four patients were treated by this simplified technique. There were 1 case of lower intrathoracic esophageal perforation to the left thorax , 1 high and 2 middle perforation to the right. This technique used two plastic tubes (chest tube) in a diameter about 1 .2cm . One tube served as an intercostal drainage tube to drain purulent effusion , the other was inserted abdominally through stomach to the esophagus about 10cm above the esophageal perforation. Results The four patients were treated successfully by the esophagus-stomach-abdominal wall drainage. There was no mortality or severe morbidity or complication. Hospitalizations were shortened. Conclusion This technique is simple, safe and effective. It may provide a more promising alternative method of treatment for delayed esophageal perforation, especially in the critically ill patients. The procedure can also be extended to deal with esophagus-stomach anastomotic leak.