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Esophageal Perforation: Review of Outcomes From a Single-Institution SeriesHugo Santos-Sousa, Tiago Bouca-Machado, Attila Dubecz, André Gonçalves, John Preto,José Barbosa, José Costa-Maia

Background: Esophageal perforation is an important therapeutic challenge. The aim of thisstudy was to review the outcomes of esophageal perforations treated by a specialized unitin esophageal surgery. Methods: We performed a retrospective review of 52 consecutivepatients with non-neoplasic esophageal perforation, between January 1991 and December2008. Demographics, cause and location of perforation, time of diagnosis, managementresults and outcomes were evaluated. The management and outcomes trends over time wereevaluated. For that, the cases were catalogued in three groups of 6 consecutive years. Results:Spontaneous perforation occurred in 9 (17,3%) patients. Iatrogenic perforations were presentin 15 (28,8%) patients and 28 (53,8%) patients had traumatic perforations. In half of thepatients diagnosis was done in the first 24 hours. The perforation's location was cervical in14 (26,9%) cases, thoracic in 31 (59,6%) and abdominal in 7 (13,5%). The traumaticperforations were diagnosed significantly later than the other causes (p=0,02). In 9 patients(17,3%) the treatment was non-operatively. For the patients submitted to surgery (82,7%),a primary repair was done in 23 cases (53,5%), a bipolar exclusion was performed in 18(41,9%) and a conservative operative approach (drainage only) performed in 2 (3,8%).There were significant differences in the type of operative treatment according to the location(p=0,035) [thoracic perforations were more times treated with bipolar exclusion]. In theanalysis of the trends over time, there were significant differences in the location (p=0,027)and the type of management (p=0,012) [more patients treated surgically with primary repairin the last periods]. The morbidity and mortality rates were 46,2% and 13,5%, respectively.There were significant differences in morbidity according to the cause of perforation (p=0,047) [the iatrogenic perforations had less morbidity] and the type of management (p=0,041) [the patients treated conservative either operatively or non-operatively had lowermorbidity rate], but only the type of management was an independent risk factor in thelogistic regression analysis (OR 0,071, CI95% 0,007-0,696, p=0,003). There were significantdifferences in mortality according to the age (p=0,022) [older patients with higher mortalityrate] and age was an independent risk factor in multivariate analysis (OR 1,095, CI95%1,003-1,196, p=0,005). There weren't significant differences in morbidity and mortality rateover time. Conclusion: An approach to esophageal perforation based on injury severity andthe degree of mediastinal and pleural contamination is of paramount importance. Althoughoperative management remains the standard in the majority of patients with esophagealperforation, non-operative management may be successfully implemented in selected patientswith a low morbidity rate.

Tu1771

Comparative Manometric Characteristics of 3 Anti-Reflux OperationsAlia Qureshi, Ralph W. Aye, Brian E. Louie, Alexander S. Farivar, Ariel Knight, Lee L.Swanstrom

Background: The impact of antireflux operations on esophageal motility and lower esophagealsphincter characteristics is incompletely understood. Comparing the manometric featuresof various repairs may provide insight through differences and similarities. Materials andmethods: 153 patients with gastroesophageal reflux and/or hiatal hernia underwent one of3 laparoscopic operations at 2 institutions through 1 of 2 IRB-approved prospective protocolsevaluating Nissen fundoplication (NF), Hill repair (HR), or a combination of Nissen plusHill hybrid repair (NH). Clinical and objective testing and quality of life metrics wereadministered preoperatively and at 6-12 month follow-up. Ninety patients underwent pre-and post-operative manometry (NF=27; HR=37; NH=26). Results: Manometric results arelisted in the table. Post-operative lower esophageal sphincter pressure (LESP) was increasedsignificantly for NF and NH but not HR; residual LESP was highest in NF. DeMeester scoreswere equivalent, NF=6.58; HR=10.89, NH=7.3. Postoperative quality of life scores wereequivalent, NF=6.24; HR=6.24; NH=6.69; Postoperative dysphagia scores were better forNH, 43.0 vs NF=37.2 and HR=38.1 (p=0.019). Postoperative medication use was less forNH, 2.4% vs NF=19.5% and HR=17.0%. Conclusions: Combining NF and HR in oneoperation results in manometric lower esophageal sphincter characteristics that are similarto the individual component repairs, with low medication use and reduced long-termdysphagia. This suggests that theremay be benefit to intra-abdominal fixation of the gastroeso-phageal junction Further study of the relative contributions of the fundoplication and thediaphragmatic repair are warranted.Trivariate Manometric Comparisons

S-1095 SSAT Abstracts

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The Influence of Postoperative Complications on Recurrence and Long-TermSurvival After Esophagectomy for Esophageal CancerArzu Oezcelik, Shahin Ayazi, Steven R. DeMeester, Joerg Zehetner, Jeffrey A. Hagen, TomR. DeMeester

BACKGROUND: The aim of this study was to identify factors associated with postoperativecomplications and to evaluate whether the severity of postoperative complications as classifiedusing the Clavien classification was associated with cancer recurrence and survival.METHODS: The records of all patients who underwent an esophagectomy for cancer between2002 and 2007 were reviewed. Postoperative complications were graded using the ClavienClassification, and scored from minor (GradeI) through the most serious (GradeIV). Wedefinedmajor complications as those≥Grade IIIb. RESULTS: The study population consistedof 422 patients with a median age of 63 years. Neoadjuvant therapy was given in 94 patients(22%). En bloc, transhiatal and minimally invasive esophagectomies were performed. Post-operative complications occurred in 191 patients (45%). Complications were consideredminor (Clavien Grade I-IIIa) in 116 (27%) and major (Grade IIIb or IV) in 75 (18%). Onmultivariate analysis, increasing age, stage, blood transfusion and Clavien classification ≥Grade IIIb complications were independent negative predictors of survival. Factors associatedwith cancer recurrence included tumor stage, blood transfusion and major postoperativecomplications. Factors associated with Clavien Grade IIIb or higher complications includedincreasing age and blood transfusion. Neoadjuvant therapy, tumor stage and type of resectionwere not associated with postoperative complications. CONCLUSION: The study suggeststhat in addition to known prognostic factors such as tumor stage, the occurrence of majorcomplications are associated with a higher frequency of recurrence and decreased survivalafter esophagectomy for cancer. Esophagectomy should be done in experienced centerswhere major complications are minimized.

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Fully Covered Self Expanding Removable Metal Stents are Effective forEsophageal Fistulas, Leaks, Perforations and Benign StricturesJennifer L. Kramer, Alexander S. Farivar, Eric Vallières, Ralph W. Aye, Brian E. Louie

Purpose: Expandable plastic stents are the only stent approved for benign esophageal disease.However these stents are prone to migration and inadequate leak control. The self-expandingdesign of fully covered metal stents (CS), approved for malignancy only, is ideally suitedfor benign esophageal disease. Not only are they removable, but the continued radial forcemay reduce migration, result in durable stricture resolution and effect control of fistulas,leaks and perforations. We reviewed our experience with CS in 2 groups: benign stricturesand fistulas/leaks/perforations to evaluate our outcomes and define the role of CS in thetreatment algorithms these complex problems. Methods: Chart review of all stents insertedfor fistulas, leaks, perforations, and benign strictures from 2005 to 2011. Results: A totalof 56 CS were placed in 39 patients. Indications were stricture (14), anastomotic leak (12),perforation (4), staple line leak (4), fistulas (4) and other (1). There was no proceduralmortality. There were complications in 32%: 10 stent migrations, 3 upper GI bleeds, 4impactions and 1 erosion. Benign Stricture Group: Strictures had been previously dilated amedian of 2.5 times prior to stenting in 13/14 patients. Stents were removed at a mean of25 days. At a mean of 219 days of follow up, strictures remained patent. Eleven patientswere managed with a single stent but 3 patients required sequentially larger stents toachieve patency. Adjunctive intralesional steroids were used in 11/14 patients. Fistula/Leak/Perforation Group: Control of the disruption was achieved in 79% of patients with fistulas(3/4), leaks (12/16) and perforations (4/4), but needed to be combined with drainage, VATSor laparoscopy in 12/24 leaks. All disruptions healed but 13/24 had to remain NPO duringthis time. Stents were removed at a mean of 42 days in this group. Conclusions: CS areeffective in the management of benign refractory strictures, fistulas, leaks, and perforations.A CS with intralesional steroids is an alternative to serial dilations for stricture. Whereasfistulas, leaks and perforations when combined with minimally invasive drainage, may avoidopen repair or even salvage a prior open repair. CS are well tolerated and removable, withacceptable complication rates and have a low migration rate.

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