Ann Thorac Surg 2006;81:472-473
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Jonathan C. Nesbitt, MD
St. Thomas Medical Building, Cardiovascular Surgery Associates, PC, Suite 501, 4230 Harding Rd, Nashville, TN 37205
(Email: jcnesbitt{at}msn.com).
Although several treatment methodologies have been used to manage esophageal perforations, there is no absolute standard of care. Surgical intervention has been the traditional and most popular management approach. It is well known that early intervention provides the best outcome. Mortality for patients with iatrogenic or spontaneous perforations ranges from 0% to 11%. Delays in treatment are associated with heightened complications and with mortality that can exceed 50%. Leak rates after surgical repair are common, ranging from 0% to more than 50% for patients who have delays in treatment, particularly in barogenic perforations.
The past 2 decades have witnessed tremendous growth in the indications for and the usage of stents for a wide variety of anatomic locations, including the esophagus. The article by Fischer and colleagues [1] reports their experience with 15 consecutive patients who had benign esophageal disease and who sustained iatrogenic or spontaneous perforations and were managed by covered, expandable metallic stents. The 7 patients (all with iatrogenic perforations) who were managed early (within 24 hours; average, 45 minutes) had complete sealing of the leak and were discharged from the hospital with an average stay of only 5 days. All stents were extracted uneventfully.
Of the remaining 8 patients, 5 sustained spontaneous perforations and the remaining 3 occurred after esophageal operations. The median delay for treatment was more than 5 days. Two patients had incomplete sealing of their leaks and required wide surgical drainage. Seven patients required tube thoracostomy for empyemas. The average hospital stay was 44 days. One patient died from aspiration pneumonia.
This review is an important contribution and highlights an evolving technique for managing a challenging and potentially life-threatening problem. The primary objective of treatment in this series was the sealing of the leak as quickly as possible to curtail mediastinal contamination. Minimal intervention with esophageal stent placement was safe and quick. In every case of early perforation, closure of the leak was accomplished with an excellent outcome. In cases of late perforations, the leak rate and ultimate outcome were similar to historical data.
These results for managing early, iatrogenic perforations with covered, expandable stents are impressive and compelling. In delayed perforations the evidence reveals the fact that simple coverage of the leak is insufficient and that adequate drainage of the mediastinum and chest are essential. The results certainly warrant further investigation and careful consideration for the usage of these stents as primary treatment, at least for early perforations when minimal soilage of the mediastinum has occurred.
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References
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- Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents Ann Thorac Surg 2006;81:467-473.[Abstract/Free Full Text]
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