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1. Impact of Endoscopic Assessment and
Treatment on Operative and Non-
operative Management of Acute
Oesophageal Perforation
M.K.Kuppuswamy , C.Felisky ,et al.
Department of Surgery and Gastroenterology, Virginia Mason Medical Center , Seattle
, Washington ,USA.
Presenter : Dr. Sumit Sudhir Hadgaonkar
Moderator : Dr. A.D. Sharma

2. Introduction
• Oesophageal perforation is a complex and highly
morbid emergency.
• Mortality rate range from 6 to 65 percent.
• Recent publications show improved mortality rate
in specialized centers.
• Improvement reflects new approaches to
diagnosis and assessment such as CT
scan, Interventional radiology techniques and
minimally invasive surgical techniques.

3. • Upper gastrointestinal endoscopy for diagnosis and
management of acute oesophageal perforation has not
been typically used.
• Endoscopic techniques now form a recognized
component in the management of oesophageal
perforation.
• But in many centers their use is confined to initial
assessment or any endoscopic therapy only.
• This study assessed the evolution of endoscopic
approaches and their effect on outcome over time in acute
oesophageal perforation.

4. Materials and methods:
Enrollment of patients:
All patients presenting or referred to Virginia Mason
Medical Centre, Seattle. between April 1990 to May
2009 with esophageal perforation.
It was done prospectively in Institutional review board
approved data base.

5. Study population:
• All patients of esophageal perforation in
whom endoscopy was used.
1. As primary diagnostic technique
2. In conjunction with surgical therapy
3. To provide primary non-operative treatment
Study type: Descriptive

6. Inclusion criteria:
• All patients with spontaneous or iatrogenic
esophageal perforation.
Exclusion criteria:
• Patients with fistulation secondary to esophageal
cancer.

7. Statistical analysis:
• Group characteristics were compared using ANOVA
and Pearson’s X2 test.
• SPSS version 18 was used.
• Descriptive methods were used to evaluate clinical
characteristics , management and outcome.

8. Results:
• 81 patients having perforation were treated between
April 1990 to May 2009.
• 52 had endoscopy, 12 as diagnostic and 40 as
therapeutic.
• 29 did not undergo endoscopy.
• 48 patients undergone surgical treatment.
• 33 patients were managed without surgery.

9. Patient characteristics
All perforation Endoscopy No endoscopy P value
1. No. of 81 52 29
patients
2. Age 63.7 63.6 63.9 0.94
3. ASA grade III 55 37 18 0.402
- IV
4. Time to 29.6 31.2 26.2 0.690
treatment
(hours)
5. Time to
diagnosis 0.564
< 24hours 64 41 23
>24hours 17 11 6
6. Length of 19.7 18.9 21 0.6
stay(days)

10. Presenting characteristics of patients who had
endoscopy
No. of patients (52)
1. Cause
a. Iatrogenic 26
b. Barogenic 19
c. Other 07
2. Location
a. Distil third and GE junction 35
b. Proximal third 09
c. Middle third 08
3. Size
a. <1cm 12
b. >1-≤3 15
c. >3 10
d. Unknown 15

11. Surgical group:
• 28 patients out off 48 who had surgical treatment
endoscopy was used.
• 19 out off 28 patient’s endoscopy assessment took
place in OT immediately before surgery.
Non-surgical group:
• In 24 out off 33 patients endoscopy was used.
• 15 patients out off 24 had primary endoscopic
therapy.
• 9 were managed without endoscopic or surgical
intervention.

12. Impact of endoscopy
No. of patients (21)
1.Additional secondary pathology 10
a. Additional perforation 2
b. Distal benign stricture 6
c. Undiagnosed cancer 2
2.Treatment of secondary pathology 6
a. Balloon dilatation 4
b. Stent placement 2
3. Stent and drain management 6
a. Nasomediastinal drain 2
b. Nasojejunal tube placement 2
c. Previous stent removal 2
4. Change in the initial treatment plan 5
a. No repair 3
b. Resection 1
c. Diversion 1

13. • Compared with rest of the surgical group , patients
undergoing intra-operative endoscopy had a significantly
higher rate of primary repair (16 of 19 versus 19 of 29
;p=0.003) and shorter mean length of stay.
• There were 2 deaths at 30 days or at any time in hospital
among 52 patients who had endoscopic assessment and
management .
• Mean length of stay improved from 21.8 days in initial 5
years to 13.4 days in final 5 years.
• No recognized complication was directly associated with
endoscopic assessment or treatment.

14. Discussion
• Initial perception that endoscopy increases
mediastinal contamination has never been
documented.
• Also its widely considered irrelevant when
procedural rules are accepted.

15. Discussion (cont.)
General points emerged during study
evolution:
1. When done with surgical repair endoscopic
assessment best done after GA induction.
2. Air insufflation minimal but visibility is also
critical.
3. Endoscopic viability of mucosa is more
important than 24 hour time frame.

16. 4. Endoscope if left in place after initial
assessment can guide intraoperative therapy
such as;
a) suitability for stents, clips and transesophageal
drainage.
b) guide towards mucosal perforation when managing
delayed perforation.
c) can guide repair suture
d) can be used to insufflate esophagus to test primary
repair.

17. Limitations of study:
• Patients with endoscopy had higher ASA and
more likely had delayed management – not
used for straight forward cases.
• Statistical p value given only in surgical group.
• Non uniform use of endoscopy over 19 years (
4 of 13 in first 5 years to 20 of 24 in last 5
years)

18. Conclusion:
• Endoscopy will be used increasingly in assessment
and primary management.
• Its safe and provides additional information that
modifies treatment.
• Wider use should result in improved outcome.

19. Thank you