Transcript Esophageal Perforation

Esophageal Perforation
‫دکتر مجید صفرپناه‬
• 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 antireflux 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 CTguided 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%).