Despite advancements in diagnostic imaging, surgical technique, and postoperative care, open surgical repair for esophageal perforation continues to be associated with significant morbidity and mortality, particularly in cases of delayed presentation (>24 hours). Nonoperative management of esophageal perforation was classically reserved for poor surgical candidates due to associated comorbidities precluding surgical repair, or as palliation for perforations associated with malignant disease. The introduction of expandable bare-metal stents changed the management paradigm in this patient population; protocols of supportive care including nothing per mouth, drainage, broad-spectrum antibiotics, and total parenteral nutrition matured to include expeditious stent placement, early resumption of oral intake, and timely hospital discharge. These initial series were difficult to interpret; they included heterogeneous patient populations, a variety of stent types, and varying management protocols, although they uniformly demonstrated good success rates (60%–90%). Increased experience with stents led to expanded use in patients presenting with iatrogenic perforations, particularly after delayed presentation and in those with significant associated mediastinal/pleural contamination. Although their initial use was problematic due to difficulties associated with removal of uncovered metal stents (mucosal ingrowth), several small prospective series demonstrated the utility of stents as a primary treatment option for these patients. This indication has been expanded to included patients following early presentation who traditionally have reasonable outcomes with open surgical repair. The introduction of covered removable self-expanding stent technology, which are easily deployed, restrict mucosal ingrowth, and are adjustable if migration does occur, have led to widespread use by thoracic surgeons for both iatrogenic and benign esophageal perforations.
Although stent deployment for esophageal perforation is a less invasive model, appropriate use mandates equivalent management goals performed during open repair. Namely, rapid closure of the perforation, drainage of associated infection within the pleural space or mediastinum, and enteral access for nutrition during recovery are a necessity. Optimally, stent placement would minimize morbidity and mortality associated with thoracotomy and esophageal repair.
Freeman et al. managed 17 patients following iatrogenic intrathoracic esophageal perforation with silicone stent placement as initial therapy concurrently with mediastinal/pleural drainage by VATS or tube thoracostomy (in cases of delayed presentation or evidence of extraesophageal contamination). Leak occlusion was successful in 94% of patients, and 82% were able to initiate oral intake within 72 hours of stent placement. Only one patient was ineffectively controlled by stent placement and required operative repair. Stent migration required replacement or repositioning in three patients, and all stents were removed within 2 months without stent-related complications. Interestingly, this study included a significant number of sick patients; 65% displayed symptoms of mediastinitis, and 24% of sepsis. Average time from perforation to stent placement was 39 hours. These results are certainly impressive considering the delayed presentation of most patients and evidence of mediastinal contamination. Follow-up endoscopy revealed no evidence of postoperative stricture, likely due to the intrinsic properties of the stent that acts as a rapid manifold for tissue healing.17
In a subsequent assessment by Freeman et al. of 19 patients with spontaneous esophageal perforations (Boerhaave syndrome), also managed with silicone stent placement, leak occlusion was successful in 89% of patients, and 79% of patients initiated PO intake within 72 hours of stent placement. Mean time for onset of symptoms to stent placement was 22 hours. This study included patients without significant underlying medical problems but high rates of mediastinitis (68%), sepsis (16%), and obesity; contributing factors that increase risk for open surgical morbidity and mortality. Two patients with leaks at the gastroesophageal (GE) junction failed stent management and required operative repair. Four patients required repositioning or stent replacement due to migration. This migration rate was higher than Freeman's previous study, although not unexpected due to stent placement in proximity to the GE junction. Stent removal was individualized based on cause of perforation, anatomic location, patient's nutritional status, and resolution of any associated infection, and was completed in all patients within 1 month of placement with an overall success rate of 79%. Again, no postoperative strictures were reported. These results were surprisingly good considering the difficulty associated with placing/maintaining stent position in proximity to the GE junction.18
In a similar fashion, D'Cunha et al. managed 15 patients with silicone stent placement in lieu of surgical management for esophageal perforation. Almost 60% of patients were stented within 24 hours of diagnosis, and 45% of patients underwent drainage procedures for source control. Overall success was 60% with mean 27 days to resolution. Median time to return of PO intake was 3 days. All stents were removed without complication and no postoperative strictures were noted. Stent migration occurred in 13% of patients. Most notably an 88% success rate was achieved in their final 17 patients as the author's experience matured. In their final nine cases, all patients were successfully managed with stent placement after diagnosis, with resumption of PO intake by postoperative day 1.19
Fisher et al. managed 15 patients with spontaneous and iatrogenic esophageal perforations, placing self-expandable metal stents in both groups. Patients were stratified into two groups based on time to intervention: (1) those stented within 45 minutes of perforation (iatrogenic following endoscopic procedures) or (2) patients stented on average 123 hours following injury (Boerhaave's, laparoscopic fundoplication, esophageal diverticulectomy). Patients in the early treatment cohort were managed successfully with stent placement alone and were discharged by hospital day 5. Only one patient required a drainage procedure for fluid accumulation close to the perforation site. In the second group, postoperative management was complicated in some cases by sepsis and multiorgan failure, including one patient death, with an average length of stay of 44 days. Stent extraction was accomplished in 12 patients between 10 days and 8 weeks postoperatively.20
In our own institution, we treated a 63-year-old gentleman who underwent endoluminal stent grafting of a thoracic aortic aneurysm, complicated by an aortoesophageal fistula 4 weeks postoperatively. The patient underwent exploration and an isolated perforation in the esophagus was repaired primarily; buttressed with an intercostal muscle flap. In addition, latissimus dorsi was mobilized and ultimately interposed between the aneurysm sac and the esophageal repair. Postoperatively, the patient developed evidence of sepsis, renal failure, and respiratory failure requiring intubation. A gastrografin swallow demonstrated contrast extravasation from the esophagus (Fig. 48-12A). The patient was brought back to the operating room for endoscopic evaluation, stent placement, and mediastinal/pleural drainage (Fig. 48-12B). Postoperatively he responded to antibiotics, resumed oral intake, and ultimately was discharged to a rehabilitation facility. Contrast esophagram at 1 week demonstrated esophageal coverage and resolution of leak (Fig. 48-12C).
A. Contrast swallow of a 63-year-old gentleman 4 weeks after failed closure of an aortoesophageal fistula. B. The patient was brought back to the operating room for endoscopic evaluation, stent placement, and mediastinal/pleural drainage. C. Contrast swallow 1 week later confirms esophageal coverage and resolution of leak.
These studies demonstrated that esophageal stents are a viable primary treatment option for patients presenting immediately after esophageal perforation. Likewise, prolonged time to presentation following esophageal perforation and the presence of sepsis or shock from associated contamination does not preclude the use of esophageal stents as primary management. Drainage of associated contamination by VATS or percutaneous tube thoracostomy is suggested in these cases. The time point at which percutaneous or operative drainage is necessary has not been well defined. Because this is a vital component of therapy and ultimately impacts outcome, its use should be strongly considered in all patients with any evidence of contamination or for those presenting in a delayed fashion. Stent extraction after healing should always be performed due to complications associated with long-term treatment. This has been facilitated by the ease of removal inherent to covered/silicone stents. The potential for stent migration requires postoperative monitoring with chest x-ray to ensure adequate positioning; covered stents are inherently resistant to mucosal ingrowth and allow for repositioning or replacement without significant difficulty.
Mandatory to the successful management of esophageal perforation with stents is the fundamental premise that the goals achieved during open surgery are accomplished in an equivalent fashion: closure of the esophageal perforation, drainage of contamination, broad spectrum antibiotics, and prompt resumption of enteral nutrition to enhance healing. Stricture rates of 10% to 50% historically are noted following operative esophageal repair, necessitating further endoscopic procedures, dilatations, and risk. This is an obvious advantage of stent therapy. Success ultimately depends on a uniform approach that includes appropriate patient selection, experience with stent placement, and appropriate postoperative care. Endoscopy remains a critical component in the management of esophageal perforation: at presentation, to document leak resolution, and for follow-up evaluation.