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Instrumental perforation of the esophagus in benign disease
1Thoracic Surgical Unit, Royal Devon and Exeter Hospital, England.
Abstract:
Over a period of seven years, a total of 1,831 endoscopic procedures were performed in patients with benign esophageal disease. These comprised flexible esophagoscopy (848), flexible esophagoscopy and dilation (924), pneumatic dilation (29), and rigid esophagoscopy (30). There were 14 episodes of perforation: 1 was cervical, 2 were abdominal, and 11 were perforations of the intrathoracic esophagus (7 occurred at or immediately above a stricture). The diagnosis was made immediately in 9 and within six hours in all but 1 patient. Treatment was emergency surgery in 12 patients, 2 of whom died. The major cause of death was respiratory failure. The overall incidence of perforation was 0.76%. The incidence of perforation was 0.35% (3/848) for flexible esophagoscopy alone, 0.38% (3/792) for dilation with Maloney mercury-weighted bougies, and 3.8% (5/132) for dilation with other bougies. Our experience indicates that instrumental perforation in benign esophageal disease carries a considerable mortality rate in spite of prompt recognition and surgical treatment. Successful dilation with mercury-weighted bougies can be achieved in 86% of benign strictures with an incidence of perforation similar to that for flexible esophagoscopy alone. Difficult strictures and the use of other bougies are associated with a tenfold higher incidence of perforation.
Insights
Esophageal perforation during endoscopic procedures for benign esophageal disease is rare (0.76%) but carries significant mortality. Maloney mercury-weighted bougies offer safe and effective dilation for most benign strictures.
Area of Science:
- Gastroenterology
- Gastrointestinal Endoscopy
- Surgical Complications
Background:
- Benign esophageal disease often requires endoscopic intervention, including dilation.
- Esophageal perforation is a serious complication of these procedures.
- Understanding perforation risks associated with different endoscopic techniques is crucial.
Purpose of the Study:
- To evaluate the incidence and outcomes of esophageal perforation during endoscopic procedures for benign esophageal disease.
- To compare the perforation rates of various endoscopic techniques, including different dilation methods.
Main Methods:
- Retrospective analysis of 1,831 endoscopic procedures over seven years.
- Categorization of procedures: flexible esophagoscopy, esophagoscopy with dilation, pneumatic dilation, and rigid esophagoscopy.
- Detailed review of perforation episodes, diagnosis, treatment, and mortality.
Main Results:
- Overall perforation incidence was 0.76% (14/1831).
- Perforation rates varied: flexible esophagoscopy alone (0.35%), Maloney mercury-weighted bougies (0.38%), other bougies (3.8%).
- Mortality rate for perforation was 14.3% (2/14), with respiratory failure as the primary cause.
Conclusions:
- Instrumental esophageal perforation, despite prompt diagnosis and surgery, has a considerable mortality rate.
- Maloney mercury-weighted bougie dilation is safe and effective for benign strictures, with low perforation risk.
- Difficult strictures and non-mercury bougies significantly increase perforation risk.