Esophageal Perforation

صفرپناه مجید دکتر

• Esophageal perforation is an uncommon occurrence. This is fortunate, as it is a surgical emergency that is often difficult to manage, and has devastating sequelae if diagnosis and treatment are delayed.

• Historically, Hermann Boerhaave first described the entity of spontaneous esophageal rupture in 1723.

He documented the case of Baron Wassenaer, the Grand Admiral of Holland. In this case, the admiral self-administered emetics after a bout of overeating. This resulted in powerful vomiting which was soon followed by severe pain and subsequent death within 24 hours. Boerhaave performed the autopsy finding a ruptured esophagus and food contents within the chest.

• Esophageal perforation is a full-thickness injury to the esophagus that can occur during a number of situations, with the vast majority of injuries secondary to iatrogenic causes.

• However, other causes include spontaneous perforation, blunt or penetrating trauma, tumor rupture, injury from ingested foreign bodies, infection, and caustic injuries.

• Prior to the middle of the last century, esophageal perforation was a uniformly fatal entity. Advances in diagnosis, surgical therapy, antimicrobials, and intensive care now allow survival in the majority of cases diagnosed and treated in a timely manner.

• Etiology• In a collective review of 559 patients, iatrogenic injury

produced 59% of the esophageal injuries, followed by spontaneous perforations (15%), ingested foreign bodies (12%), trauma (9%), operative injury (2%), and tumor perforation (1%).

• The incidence of injury during flexible endoscopy is estimated at 0.03%. This risk is elevated slightly with the addition of bougienage and balloon dilatation. The incidence may approach or exceed 4% with the use of large pneumatic balloons to treat achalasia. Other infrequent sources include thermal injury during therapy for gastrointestinal bleeding, injury during sclerotherapy or ligation of esophageal varices, and perforation during photodynamic therapy or stent placement during the palliation of malignancy.

• Accidental perforation may also occur during the course of a surgical procedure, whether or not the esophagus is the organ of interest during the operation. This includes thyroidectomy, carotid procedures, tracheostomy, mediastinoscopy, cardiac valve repair, pneumonectomy or lung transplant, aortic aneurysm repair, cervical spine operations, and chest tube placement. Most frequently, injuries occur during operations directed at the esophagus or esophagogastric junction, such as anti-reflux operations, esophagogastric myotomies, and vagotomies.

• Spontaneous perforations are the result of barotrauma secondary to a rapid increase in intraluminal pressure leading to transmural injury. Any action which produces a ballistic increase in pressure may produce this injury, such as during hyperemesis, heavy lifting, or Valsalva during childbirth.

• Trauma-associated perforations are typically the result of penetrating injuries; however, perforation due to blunt force trauma, while rare (0.001%), is not unknown. Blunt injuries are most commonly the result of increased intraesophageal pressure leading to rupture. Patients with blunt esophageal injury often have several associated injuries, making diagnosis difficult and delays in treatment common.

• Foreign bodies result in perforations at points of physiological esophageal narrowing such as the cricopharyngeus or the aortic arch. These injuries may be the result of penetration from sharp objects (i.e., fish bones) or from gradual pressure necrosis and erosion of an impacted bolus.

• Ingestion of caustic material, particularly lye, results in liquefaction necrosis of the esophageal wall and delayed necrosis. These injuries occur in children or in those who have ingested material during suicide attempts.

• Medications may also cause injury resulting in perforations. Nonsteroidal anti-inflammatory drugs, etidronate, and potassium chloride are common culprits. Impaction secondary to motility disorders or prior stricture can be contributing factors.

• Clinical Presentation• The clinical presentation of esophageal perforation

depends on the location of the injury, the size of the injury, and the time interval since the occurrence of the injury. The lack of a true serosa makes the esophagus more susceptible to perforation. Extravasation of luminal contents leads to mediastinal contamination. The esophageal contents spread through the potential space of the prevertebral fascia. Saliva, gastric acid, bile, and foodstuffs cause a severe inflammatory reaction in the mediastinum and chest, leading to massive fluid sequestration. Bacteria are also carried into this space, leading to polymicrobial infection. Ultimately, if untreated, this leads to sepsis and ultimately cardiovascular collapse. The presenting symptoms may mimic a variety of pathologies such as myocardial infarction, aortic dissection, and pancreatitis, among others.

• A recent history of esophageal intubation should quickly raise the possibility of perforation and necessitates further inspection.

• Cervical injuries commonly present with subcutaneous emphysema, dysphagia or odynophagia, neck pain worsened with flexion, and bloody regurgitation. Symptoms may be initially relatively modest in comparison with more distal injuries.

• Thoracic injuries typically produce more immediate symptoms. There is usually free rupture of the visceral pleura, except in very localized perforations, resulting in extensive contamination of the pleural cavity as well as the mediastinum. Chest pain, fever, tachypnea, and tachycardia are common.

• Abdominal perforations produce signs or symptoms of an acute abdomen.

• Diagnosis• Early diagnosis of esophageal perforation, regardless of

the location of injury, has been clearly shown to reduce morbidity and mortality. As noted, the symptoms of perforation often mimic other pathologies, leading to unfortunate delays in diagnosis and treatment. Plain films of the neck, chest, or abdomen may show evidence of esophageal perforation. This may demonstrate free air within the neck, mediastinum, or abdomen. Pleural effusions or evidence of mediastinal widening may also be seen. If films are obtained soon after the onset of symptoms, radiographic findings may be absent or minimal.

• Plain films should be followed with a contrast esophagogram in the upright and lateral decubitus position. Gastrografin is advocated as the initial agent in suspected perforation because of the theoretical risk of inflammation due to extravasated barium. However, this risk has recently been called into question. Use of water-soluble agents will detect 50% of cervical injuries and 75% of thoracic perforations. Caution should be used with Gastrografin in patients at risk for aspiration, as it may lead to an intense pneumonitis. In these cases, or in cases of a negative study, dilute barium should be used. This results in detection of 60% of cervical and 90% of thoracic injuries confirmed with surgical exploration.

• Less frequently, CT may be useful. In patients with a negative esophagogram in whom there remains a high index of suspicion, this study may provide valuable information. Additionally, CTs can easily be obtained in the patient unable to undergo a standard esophagogram.

• Endoscopy may occasionally be useful in evaluating difficult-to-diagnose injuries or to rule out injury after penetrating trauma. Endoscopy is also useful in determining the exact level of injury and its extension and can be helpful during surgery when one is uncertain of the extent of the mucosal injury. It is reported to have 100% sensitivity and 83% specificity. However, caution is necessary, as air insufflation during examination may extend small tears, forcing operative intervention in a minor injury which otherwise could have been managed nonoperatively.

• Management• Nonoperative Management• Nonoperative management may be attempted in select

situations, such as in injuries that are small, contained, and without extensive contamination (i.e., no symptoms or signs of sepsis). Several series suggest that in carefully selected patients this approach can be used successfully. Cameron and associates and Altorjay and colleagues have established the following criteria for conservative management of these injuries: (1) early diagnosis with mild symptoms and absence of sepsis; (2) containment of leakage within the neck or mediastinum that drains back into the esophagus; (3) absence of distal obstruction or malignancy; and (4) availability of a surgeon experienced with esophageal disease.

• These patients receive broad-spectrum antibiotics, intravenous acid suppressors, and total parenteral nutrition. The patient should be frequently reassessed and the surgeon prepared to operate if it becomes necessary. Repeat imaging should be performed in any patient with clinical deterioration or signs of infection. Well-localized fluid collection can be managed with CT-guided percutaneous drainage if accessible. Serial esophagograms with water-soluble contrast are performed to evaluate healing. Oral restriction and intravenous antibiotics are continued for 7-14 days, depending on the serial imaging studies and the patient's clinical condition.

• There have been recent reports of the successful use of endoscopically placed self-expanding coated stents to seal the perforation.

• Operative Management• Cervical Perforations: Cervical perforations are

approached through an incision along the anterior border of the left sternocleidomastoid. The incision is carried down through the strap muscles and the omohyoid. Care is taken to identify the recurrent laryngeal nerve and to protect it. After division of the middle thyroid vein, the trachea and larynx are retracted medially and the carotid sheath laterally, followed by careful inspection of the esophagus circumferentially. Once the injury is identified the injury is debrided and closed with a single layer of absorbable material. A closed suction drain is then placed and the incision closed. In the event no perforation can be clearly identified, wide drainage should be employed.

• In either scenario, the patient is given antibiotics preoperatively and they are continued for at least 5 days. A contrast esophagogram is then obtained. If there is no evidence of a leak, the patient is started on clear liquids and observed. Persistent leak is managed with continued drainage and intravenous nutrition.

• Thoracic Perforations: These injuries are typically approached through a thoracotomy. The proximal and mid-esophagus are approached via a right thoracotomy and the distal esophagus via a left thoracotomy. The injured area needs to be identified (and if it is not clear, an intraoperative endoscopy may facilitate identification, location, and measurement of its extent). The esophagus is mobilized circumferentially with care not to injure the vagi and two Penrose drains are passed, one above and one below the injured area. This affords excellent exposure of the injury. Injuries identified within the first 24 hours are treated with mediastinal debridement, irrigation, and primary closure.

• The rent is carefully debrided; a small longitudinal myotomy is sometimes necessary to ensure identification of the extent of the mucosal injury. The mucosa is repaired with a single layer of absorbable suture. Most surgeons will reinforce the repair with a patch of pleura or intercostal muscle. A minimum of two large chest tubes are placed.

• One of the most common types of injuries is the perforation that occurs as a consequence of a pneumatic dilatation. In most instances the perforation manifests itself during the early stages and the great majority of these patients would benefit from an operative intervention.

• For injuries encountered after the first 24 hours, primary repair may be difficult, as the tissue is friable and any repair is at high risk for breakdown. In this situation a T-tube may be inserted and the perforation closed around it, creating an esophagocutaneous fistula.

• The tube can be left in place for 4-6 weeks and then can usually be pulled without difficulty. An alternative for the unstable patient with severe contamination and delayed diagnosis is esophageal exclusion and diversion. This consists of creation of a cervical esophagostomy, drainage of the mediastinum, placement of a gastrostomy, and a feeding jejunostomy. The patient then typically undergoes esophagectomy and reestablishment of gastrointestinal continuity with a conduit.

• For extensive injuries or in the case of perforation in the presence of malignancy, esophagectomy is an alternative if the patient is stable enough to undergo an operation. For cases with minimal contamination, transhiatal esophagectomy is a reasonable option. Patients with more extensive contamination are best approached via thoracotomy to ensure adequate debridement and drainage to control sepsis.

• Outcomes• The mortality associated with esophageal

perforations depends on the location of the injury and the interval between perforation and treatment.

• In a recent review by Brinster and associates of 397 patients from several series, mortality from cervical perforations averaged 6% (0-16%), that from thoracic injuries 27% (0-44%), and that from abdominal injuries 21% (0-43%).