Antifungal prophylaxis for esophageal perforation: what’s the evidence?

Elsayed H, et al. The impact of systemic fungal infection in patients with perforated oesophagus. Ann R Coll Surg Engl. 2012 Nov;94(8):579-84.

“Some authors have concluded that antifungal prophylaxis could reduce mortality by 25% in non-neutropaenic critically ill patients and should be given prophylactically to patients at increased risk of invasive fungal infections.24 Patients with oesophageal perforation, the majority of whom are managed initially on critical care units, have several factors that increase their risk of secondary candidal infection including prolonged antibiotic use, surgery and being on total parental nutrition as well as a possible higher rate of candidal colonisation. As a result, this makes them ideal candidates for empirical antifungal therapy from diagnosis. This is the routine practice in our hospital now.

Until a randomised study comparing administration of antifungal versus no antifungal therapy proves empirically that there is no benefit of adding this medication, antifungal prophylaxis should be standard in patients with a ruptured oesophagus once diagnosed. We appreciate the limitation of this study in terms of the number of patients (27) but as a ruptured oesophagus is a rare presentation, it would be difficult to have a randomised study with a large number of patients.” (p. 583)

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Article of interest: Assessment of morbidity and mortality after esophagectomy using a modified frailty index

Hodari A, et al. Assessment of morbidity and mortality after esophagectomy using a modified frailty index. Ann Thorac Surg. 2013 Oct;96(4):1240-1245.

Full-text for Emory users.

Results: A total of 2,095 patients were included in the analysis. Higher frailty scores were associated with a statistically significant increase in morbidity and mortality. A frailty score of 0, 1, 2, 3, 4, and 5 had associated morbidity rates of 17.9% (142 of 795 patients), 25.1% (178 of 710 patients), 31.4% (126 of 401 patients), 34.4% (48 of 140 patients), 44.4% (16 of 36 patients), and 61.5% (8 of 13 patients), respectively. A frailty score of 0, 1, 2, 3, 4, and 5 had associated mortality rates of 1.8% (14 of 795 patients), 3.8% (27 of 710 patients), 4% (16 of 401 patients), 7.1% (10 of 140 patients), 8.3% (3 of 36 patients), and 23.1% (3 of 13 patients), respectively. When using multivariate logistic regression for mortality comparing age, functional status, prealbumin, emergency surgery, wound class, American Society of Anesthesiologists score, and sex, only age and frailty were statistically significant. The odds ratio was 31.84 for frailty (p = 0.015) and 1.05 (p = 0.001) for age.

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Management of Nonvariceal Upper Gastrointestinal Bleeding

Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019 Dec 3;171(11):805-822.

Full-text for Emory users.

Recommendations: 

Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease.

Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers.

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Management of Esophageal Perforation

Lindenmann J, Matzi V, Neuboeck N, et al. Management of esophageal perforation in 120 consecutive patients: clinical impact of a structured treatment algorithm. J Gastrointest Surg. 2013 Jun;17(6):1036-43.

Full-text for Emory users.

Click to enlarge.

Results: Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave’s syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave’s syndrome (p = 0.005), initial sepsis (p = 0.002), pleural effusion/empyema (p = 0.001), mediastinitis (p = 0.003), peritonitis (p = 0.001), and redo-surgery (p = 0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave’s syndrome 33.3 %.

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Dor versus Toupet fundoplication after laparoscopic Heller myotomy

Torres-Villalobos G, et al. Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry. J Gastrointest Surg. 2018 Jan;22(1):13-22.

Full-text for Emory users.

Surgical data table

Results: Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months.

Conclusion: There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.


More PubMed results on Dor vs.Toupet fundoplication after Heller myotomy.

Article of interest: Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia

One discussion this week included a question about the patient outcomes of those undergoing the POEM procedure.


Werner YB, Hakanson B, Martinek J, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019;381(23):2219–2229.

Full-text for Emory users.

Results: A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor’s fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], −8.7 to 11.4; P=0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, −0.75 mm Hg; 95% CI, −2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, −4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%.

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Upper GI bleeding: CTA prior to flouroscopic angiography?

A discussion this week included a diagnostic CTA prior to flourscopic angiography.


Reference: Wells ML, et al. CT for evaluation of acute gastrointestinal bleeding. RadioGraphics. 2018 Jul-Aug;38(4):1089-1107. doi:10.1148/rg.2018170138

Summary: “Teaching point: CT angiography is gaining popularity for use in emergent evaluations of acute GI bleeding. It has potential for use in the first-line evaluation of acute LGIB and the evaluation of UGIB after failed or nondiagnostic endoscopy.”

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