Benign Esophageal Perforations: Better Keep a Surgeon in the Toolkit

Transcription

1 Benign Esophageal Perforations: Better Keep a Surgeon in the Toolkit Bryan F. Meyers MD MPH Patrick and Joy Williamson Professor of Surgery

2 Background Esophageal perforation is a difficult problem to characterize, because the presentation can be so variable: Post-emetic mediastinal air Injury in healthy person with foreign body Iatrogenic perforation Boerhaave s classic rupture Variations in size, location, time since injury, involvement of cavities, sepsis, co-morbidity

3 Result of Variability Mortality reports range from 5-89% Post-emetic perforation has a higher reported mortality; it has been reported to occur at 2% per hour If treatment is instituted within 24 hours of symptoms, mortality is 25%; rates are 65% after 24 hours and 75-89% after 48 hours Some believe that if treatment is more than 24 hours after the perforation, the mode of treatment does not influence the outcome and can be conservative, tube thoracostomy (drainage), repair, or diversion.

4 Treatment Options Observation Antibiotics NPO, +/- feeding tube Stent Interventional radiology tube drainage Surgeon tube drainage VATS debridement Thoracotomy/laparotomy: decort, repair Diversion

5 Problems Interpreting Data No classification system of benign esophageal perforations or leaks No registry No trials Problem of publication bias Problem of recall bias

6 Recall Bias We have not done a head-to-head comparison, but it would certainly seem, in our experience, that hospital stays are shorter. Richard Freeman at the GTSC on YouTube

7 Issues with Using Stents Stents don t always unfurl properly Problems with very high and very low placement Often migrate distally Many patients still get surgery: VATS, thoracotomy, feeding tube placement, etc Must be removed, or they will cause a perforation or fistula!

8 Are Stents Necessary? Wake up the grey-haired thoracic surgeon dozing next to you to learn what they did prior to 1999! Miraculously, patients still survived with the limited options of observation, antibiotics, feeding tubes, VATs, thoracotomy, repair or diversion!

9 When are stents appropriate? Recent admissions for benign leaks: 1, Hyperemesis on wedding day with mediastinal and cervical air. 2. Empyema and upper abdominal abscess after sleeve gastrectomy and failed stents. 3. Empyema with leak after failed PEH 4. Leak and sepsis after ILE with excellent chest tube in place

10 When are stents appropriate? Recent admissions for benign leaks: 1, Hyperemesis on wedding day with high WBC and mediastinal/cervical air. Neg swallow, fed and sent on honeymoon. 2. Empyema and upper abdominal abscess after sleeve gastrectomy and failed stents. Thoracotomy, Decort, laparotomy, G-tube, j-tube 3. Empyema with leak after failed PEH. Thoracotomy, decort, revise/repair leak. 4. Leak, respiratory failure and sepsis after ILE with excellent chest tube in place. Tracheostomy, antibiotics, vent wean, no surgery, no stent, resolved.

11 Biggest Selling Point Often, the strongest reason to use a stent is to return to oral intake ASAP However, in many elective cases (i.e. esophagectomy), many enlightened practitioners are slow to feed, even in the absence of a known leak.

12 American College of Gastroenterology Guideline In conclusion, in selected cases, SEMSs and SEPSs can be considered in the treatment of esophageal perforation. However, the quality of evidence for the use of esophageal stenting in the management of esophageal perforations, leaks and fistulas is very low and the strength of recommendation is weak. ACG Clinical Guidelines

13 Strength of recommendation Strength of recommendation using the GRADE classification and implications for patients, clinicians, and policy makers Strong recommendations For patients: Most individuals in this situation would want the recommended course of action and only a small proportion would not. Formal decision aids are not likely to be required to help individuals make decisions consistent with their values and preferences For clinicians: Most individuals should receive the intervention. Adherence to this recommendation according to the guidelines could be used as a quality criterion or performance indicator For policy makers: The recommendation can be adapted as policy in most situations Weak recommendations For patients: The majority of individuals in this situation would want the suggested course of action, but many would not. Decision aids may be useful in helping individuals make decisions consistent with their values and preferences For clinicians: Examine the evidence or a summary of the evidence yourself For policy makers: Policy making will require substantial debates and involvement of many stakeholders

14 Quality of evidence definitions and determinants Grade High Definition Further research is very unlikely to change our confidence in the estimate of effect Underlying methodology: randomized controlled trials Moderate Low Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Underlying methodology: downgraded randomized controlled trials or upgraded observational studies Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Underlying methodology: well-done observational studies with control groups Very low Any estimate of effect is very uncertain Underlying methodology: case reports or case series

15 Summary Stenting for esophageal perforations has been enthusiastically described in case reports and case series It is potentially useful, particularly in cases where conservative therapy has been successful in the past Stent use is often accompanied by revision, and other surgical procedures Stents, in general, could be harmful if stent use keeps surgeons away from patients that need surgery Early return to oral intake is over-rated.

16 ARS Question #1: What is the main limitation to the evidence surrounding the use of stents for esophageal leaks? A. The existing trials are underpowered. B. The results of trials are mixed. C. Economic analyses of trials are not provided to demonstrate cost-effectiveness. D. Only case reports and case series exist as evidence.

17 ARS Question #1: What is the main limitation to the evidence surrounding the use of stents for esophageal leaks? A. The existing trials are underpowered. B. The results of trials are mixed. C. Economic analyses of trials are not provided to demonstrate cost-effectiveness. D. Only case reports and case series exist as evidence.

18 ARS Question #2: After receiving a dilation of a distal esophageal peptic stricture, a patient had pain and mediastinal air on CXR. What is the best argument against a stent? A. It is not certain it is required. B. The esophageal stricture makes it hard to oversize the stent at the neck. C. It will straddle the GE junction. D. It will stent the mucosal defect open.

19 ARS Question #2: After receiving a dilation of a distal esophageal peptic stricture, a patient had pain and mediastinal air on CXR. What is the best argument against a stent? A. It is not certain it is required. B. The esophageal stricture makes it hard to oversize the stent at the neck. C. It will straddle the GE junction. D. It will stent the mucosal defect open.