Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation

Chien-Hung Chiu; Osbert Qi Yao Leow; Yu-Chao Wang; Wei-Hsun Chen; Hsin-Yueh Fang; Yin-Kai Chao; Jules Lin

doi:10.21037/jtd-22-1316

Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation

J Thorac Dis. 2023 Mar 31;15(3):1228-1235. doi: 10.21037/jtd-22-1316. Epub 2023 Mar 10.

Authors

Chien-Hung Chiu¹, Osbert Qi Yao Leow¹, Yu-Chao Wang², Wei-Hsun Chen¹, Hsin-Yueh Fang¹, Yin-Kai Chao¹, Jules Lin³

Affiliations

¹ Division of Thoracic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan.
² Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan.
³ Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Abstract

Background: Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations.

Methods: We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material.

Results: There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation.

Conclusions: A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Keywords: Esophageal stenting; delayed esophageal perforation; esophageal perforation; spontaneous esophageal perforation.