INTRODUCTION
Esophageal perforation is a dangerous problem with a high mortality rate (9%–36%), as reviewed by Bufkin and associates. Early diagnosis and management is key to improved outcomes. Thus, it is important to appreciate those circumstances in which esophageal perforation might occur and to have a high index of suspicion in such instances.
CAUSES
Usually results from some form of trauma
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Forceful retching or vomiting (Boerhaave’s syndrome) .
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Penetrating trauma
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Foreign body ingestion
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Usually, ingested foreign objects that are smaller than 2 cm pass through the normal adult esophagus without causing perforation.
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Eighty to ninety percent of ingested foreign objects pass through the esophagus and eventually the rest of the gastrointestinal tract without the need for intervention.
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The remainder of these patients who do mandate intervention most often are treated with endoscopic techniques, with less than 1% needing to go for surgery.
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Chemical or caustic perforation: three phases :
Initial phase
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Inflammation, edema, and necrosis occurring days after injury.
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Next, there is sloughing of the esophagus and development of mucosal ulceration
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Second phase
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Esophageal wall is weakest and prone to perforation.
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Granulation tissue
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Collagen deposition
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Re-epithelization lasting about 3 weeks to 4 weeks
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Third phase
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Damaged and destroyed esophageal submucosa and muscularis are replaced with scar tissue.
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Stricture formation
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Mechanism of injury:
Alkaline
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More esophageal than gastric injury. Produces liquefactive necrosis, resulting in a deep injury
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Induces pylorospasm, thus resulting in reflux back into the esophagus
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Cricopharyngeal muscle spasm also occurs and forces the refluxate back into the stomach.
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Hence, alkali causes both esophageal and gastric burns.
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Acid
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More gastric than esophageal injury; produces coagulative necrosis, and forms an eschar, which, in turn, limits tissue penetration
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Acid passes through the esophagus faster than alkaline substances.
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Acid will also trigger pylorospasm, pooling the acid in the distal antrum and producing severe gastritis.
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May progress to full-thickness gastric necrosis and perforation within 24 hours to 48 hours.
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Iatrogenic
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Traumatic intubation
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Nasogastric tube placement
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Following endoscopic procedures
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Esophagogastroduodenoscopy
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Dilation
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Transesophageal Echo (TEE)
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Sclerotherapy
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Endoscopic retrograde cholangiopancreatography
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Postoperatively following surgery
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Any esophageal operation
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Myotomy or achalasia
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Esophageal leiomyoma enucleation
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Collis gastroplasty
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Esophageal diverticula
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Fundoplication
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Vagotomy
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Hiatal hernia repair
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Lung transplantation
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Pneumonectomy
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Thyroid resection
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Tracheostomy
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Thoracic aneurysm repair
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Mediastinoscopy
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Cervical spine surgery
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Clinical Features
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The primary symptoms include
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Acute chest pain—the most common symptom (71%)
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Fever (51%)
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Dyspnea or shortness of breath (24%)
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Crepitus (22%)
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Dysphagia
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Odynophagia
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Epigastric pain
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Productive cough
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The clinical presentation in delayed presentations may be more advanced, with the patient showing signs of toxicity and shock.
DIAGNOSIS
Chest Radiography
Radiography is essential in the diagnosis of esophageal perforation.
Cervical Esophageal Perforation
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Lateral neck radiograph is recommended as it may demonstrate air in the prevertebral facial planes.
Thoracic and Abdominal Esophageal Perforation
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Posterior and lateral chest radiographs as well as upright abdominal films are recommended ( Figs. 58-1 and 58-2 ). Radiographic findings include
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Pneumomediastinum—generally takes 1 hour or more after injury to be readily identified on CXR.
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Subcutaneous emphysema
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Mediastinal air-fluid levels or pleural effusions
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Effusion is generally on the right with perforation of the midesophagus.
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Effusion is generally on the left with perforation of the distal esophagus.
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Hydropneumothorax
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Mediastinal widening
Figure 58-1
Chest radiograph showing right pleural effusion.
Figure 58-2
Computed tomography scan reveals pleural effusion and pneumothorax in a patient with esophageal perforation.
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Computed Tomography
Computed tomography (CT) scanning is also valuable in defining the extent of the infective process and allows a serial measure of progress in therapy. CT findings include
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Pneumomediastinum
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Extraluminal air
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Esophageal thickening
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Pleural effusion
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If prolonged, an abscess cavity may be present.
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Communication of the esophagus with pleural cavity or an adjacent mediastinal air-fluid collection
Esophagoscopy/Endoscopy
Esophagography aids in diagnosing as well as localizing the leak ( Fig. 58-3 ).
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Has a false-negative rate of 10%.
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Esophageal perforation may be preceded by inflammation and edema, and hence, have no evidence of extravasation. However, the leak may later develop as the esophageal wall breaks down and perforates.
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Rigid esophagoscopy
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Flexible esophagoscopy
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Although esophagography is effective at detecting perforation, there still exists the risk of converting a mucosal or submucosal injury into a perforation during air insufflation. Based on this problem, some authors advise against the use of esophagoscopy in the diagnosis of esophageal injuries.
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MANAGEMENT
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The usual therapy includes
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Broad-spectrum antibiotics
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Early, aggressive surgical intervention
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Drainage, débridement and control of the perforation site to prevent or treat sepsis.
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Several surgical approaches are available for the management of esophageal perforation. The options include
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Débridement and primary closure
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Possible use of autogenous tissue flap reinforcement.
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Placement of an esophageal T-tube
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Exclusion-diversion
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Mediastinal drainage and esophagectomy.
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The choice of approach is based on
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Cause and duration of the perforation
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Degree of surrounding tissue inflammation and injury
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Clinical condition of the patient
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As expertise is gained in video-assisted esophageal surgery, minimally invasive surgical approaches to esophageal perforations and leaks have been developed and have become the preferred approach in many situations. Nguyen and coauthors summarize the main goals in the minimally invasive approach to esophageal perforations, which are the same principles held with open repair, namely
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Identification of the esophageal perforation
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Débridement of ischemic and necrotic tissue
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Myotomy with exposure and identification of mucosal edges of the defect
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If possible, closure of defect in two layers
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Control of the leak (primary closure or T-tube placement)
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Wide drainage of the mediastinum
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In upper esophageal injuries
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Usually occur secondary to trauma (gunshot wounds, difficult intubations) or may occur post-operatively following an esophagectomy
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Aided by gravity, as well as negative intrathoracic pressures, organisms and pus may rapidly accumulate in the deep cervical and mediastinal fascial planes, accounting for mortality rates as high as 30% to 40%.
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Transcervical drainage is a highly effective means of controlling hypopharyngeal and proximal esophageal perforations.
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This approach allows adequate exposure to control and repair perforations and leaks extending into the upper mediastinum down to the level of the carina.
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Transcervical drainage is also useful in treating descending cervical mediastinitis, which may be odontogenic, peritonsillar, cervicofacial, or esophageal in origin, as discussed by Kiernan and Wheatley and their associates.
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Esophageal leaks after esophagectomy may be managed in most instances by opening the neck incision and packing the wound.
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Cervical exploration through this wound allows access to the upper mediastinum, facilitating assessment of the leak, the condition of the gastric tube, and esophagogastric anastomosis.
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It also permits adequate exposure for débridement and drain placement.
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Mid-distal esophageal perforations
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Typically require transthoracic drainage
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Some authors advocate the routine use of thoracotomy to provide maximal exposure in order to carry out a thorough débridement, repair, or drainage.
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Increasingly, thoracoscopy is being used in place of thoracotomy when conditions are favorable for video-assisted thoracic surgery (VATS), as reviewed by Chung and colleagues.
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Scott and Rosin were the first to report a minimally invasive repair of esophageal rupture secondary to Boerhaave’s syndrome.
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The usual thoracoscopic approach employs three to four trocars positioned conventionally via a right-sided approach through the chest.
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A left-sided VATS, as described by Ikeda and coworkers, or transabdominal approach, as advocated by Landen and coauthors, can be employed in distal esophageal perforations, or when the leak is demonstrated by esophagram to extend into the left chest.
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Surgical Management
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The initial step is retraction of the lung and evacuation of fibrinous debris and purulent exudates.
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Intraoperative endoscopy is performed to assist in identifying the site of perforation.
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The suspected region can be submerged under irrigation during endoscopic insufflation to pinpoint the precise location of perforation.
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Once identified, the devitalized margins of the perforation are débrided,
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Myotomy with exposure and identification of mucosal edges of the defect
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A decision is made whether to attempt a primary closure, depending on the degree of surrounding tissue injury as well as the clinical condition of the patient.
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If the defect is small (<1 cm) and surrounded by viable tissue, a primary closure can be performed with interrupted sutures in two layers.
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An important caveat to remember in delayed presentation (i.e., those presenting after 24 hours of perforation), is that the leak rate after repair remains very high.
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Even with the use of reinforced primary esophageal repair, an esophageal leak can occur in 83% of these patients.
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In the case of larger injuries or perforations surrounded by severely inflamed tissue in which repair is not possible, or in hemodynamically unstable patients who cannot tolerate definitive esophageal repair, wide drainage is performed with placement of a T-tube to control the leak.
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Wide defects may allow direct placement of a T-tube through the perforation site.
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For smaller holes, a loop wire can be inserted transthoracically through the perforation defect. Endoscopy is performed to retrieve the loop wire, which is then brought back through the mouth. The end of a T-tube is sutured to the loop wire, and the wire or T-tube is pulled transorally down the esophagus and out through the chest, with the T-tube tip positioned intraluminally at the perforation site. Final positioning of the T-tube can be confirmed by endoscopy.
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Jackson-Pratt drains as well as a 28 to 32 French chest tube are positioned strategically to provide wide drainage of the mediastinum and chest.
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Identification and elimination of any distal obstruction, such as a stricture.
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There are unusual and rare circumstances encountered during esophageal perforation that call for creative and safe surgical approaches to this serious problem.
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Perforations involving an esophageal diverticulum can be managed by minimally invasive diverticulectomy and drainage, as reported by Tinoco and colleagues.
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Perforation of the distal esophagus after esophageal dilatation for achalasia can occur with a frequency of 0 to 15%.
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The location of the perforation is typically the left posterior esophagus.
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Full-thickness perforations tend to begin within a centimeter of the squamocolumnar junction, and extend proximally from a few millimeters to as much as 10 cm.
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These perforations can usually be repaired using a thoracoscopic or transabdominal laparoscopic technique with suture closure of the perforation, contralateral Heller myotomy, and Toupet posterior fundoplication, as summarized by Nathanson and associates and Bell.
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A contralateral myotomy is performed extending 5 cm along the length of the esophagus and extending 1 cm onto the surface of the stomach, with care taken to spare the vagus nerves.
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A posterior fundoplication is then performed in the manner of Toupet, suturing the edges of the myotomy to the edges of the plicated stomach over a length of 4 cm.
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This technique has the advantage of covering the closed esophageal perforation with a gastric serosal patch, while at the same time treating the underlying motility disorder.
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A closed suction drain is placed into the mediastinum.
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Early recognition, and prompt surgical intervention allow primary closure in the majority of circumstances without the need for muscular flaps or esophageal exclusion.
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Although the most common surgical approach is transthoracic, the excellent visualization of the distal 6 to 7 cm of thoracic esophagus is amenable to a transabdominal laparoscopic approach, as advocated by Swanstrom and Pennings.
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Definitive treatment of achalasia is obtained by performance of a myotomy with a fundoplication to help diminish the risk of postmyotomy reflux.
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A transthoracic approach should probably be used if the tear extends more than 5 cm proximally, or if there is gross extravasation of contrast into the left pleural space, as summarized by Laisaar.
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The location of the tear on the circumference of the esophagus is not a significant issue in deciding on this approach, because adequate visualization of the entire circumference of the esophagus is possible by gentle rotation.
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Advantages of a minimally invasive approach include
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Excellent, magnified view of the entire thoracic cavity
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Ability to achieve adequate débridement and drainage of the mediastinum and pleura, as summarized by Roberts and coworkers.
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Using VATS, either primary closure or an esophageal T-tube with drainage can be used to control the esophageal leak in the same manner as is done with open thoracotomy.
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If any difficulties arise, it is always possible to convert to open thoracostomy.
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By avoiding thoracotomy, however, the patient experiences less postoperative pain, a decrease in wound-related complications and a faster postoperative recovery.
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Nonoperative Management
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Considered in highly selected, healthy, nontoxic patients with well-contained perforation and minimal to no mediastinal contamination. Management consists of :
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Keeping the patient on nothing by mouth (NPO)
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Antibiotics
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Total parenteral nutrition (TPN)
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Drainage of fluid collections
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It must be stressed that up to 20% of patients undergoing nonoperative management require surgical intervention within 24 hours, and lack of improvement or worsening and deterioration requires timely surgical intervention.
Esophageal Stent
Management of early esophageal perforation using esophageal stents is an emerging modality. It has also been used in the management of esophageal perforation due to TEE and endoscopic instrumentation such as esophageal dilation, postoperative leak, foreign body ingestion, and Boerhaave’s syndrome.
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