Personal management of 57 consecutive patients with esophageal perforation

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.     

Esophageal perforation following external blunt trauma

Esophageal perforation from external blunt trauma is an exceedingly rare injury. Since 1900, including our five cases, we found 96 reported cases. The most common cause was violent vehicular trauma. The cervical and upper thoracic esophagus was the site of perforation in 82%. In 78% of the cases, there were findings consistent with esophageal injury, but there was a delay in diagnosis in two thirds of these. The diagnostic difficulty was due to lack of a specific symptom complex for esophageal perforation. Often esophageal perforation was not suspected and the symptoms were attributed to the more common injuries, or the diagnostic workup was incomplete. There were 24 (38%) infectious complications directly related to the esophageal perforation. In 21 of these, there was a delay in diagnosis. There were five (9.4%) deaths due to sepsis from the esophageal perforation.     

Management of thoracic esophageal perforations

Objective: To assess our results of a prospective algorithm applied to patients with thoracic esophageal perforation. Methods: A retrospective review of a prospective algorithm. Patients with esophageal perforation underwent an esophagram. If there was a contained esophageal perforation they were admitted, kept nothing by mouth, and restudied in 3–5 days. If the leak was not contained, they underwent operative repair. Results: From 1/1998 to 6/2009 there were 81 patients. The gastrograffin swallow showed 56 patients had contained perforations and 25 did not. Twenty-two of the 25 patients with noncontained perforation underwent immediate operative repair (one patient refused surgery, two were not stable enough for the operating room); their morbidity was 68% and there were six (24%) operative mortalities. Median hospital length of stay (LOS) was 11 days (range, 2–120). Of the 56 patients with contained perforations, 26 were managed successfully without surgery. However, 30 of the patients initially treated nonoperatively eventually required operations due to new pleural effusion, mediastinal abscess, or conversion to noncontained perforation. Their morbidity was 41% and there were three operative mortalities (5%). On univariate analysis, these patients were more likely to have undergone previous esophageal procedures (surgical or dilation) (p = 0.03), had new or increased pleural effusion (p = 0.04), and had greater than 24 h between diagnosis and treatment (p = 0.02). Only greater than 24 h between diagnosis and treatment remained a significant predictor on multivariate analysis. Their median hospital LOS was 21 days (range, 7–77). Conclusion: Contained thoracic esophageal perforations can usually be safely managed nonoperatively without significant morbidity or mortality. However, careful in-hospital monitoring is needed if surgery is not chosen.     

Esophageal perforations after anterior cervical surgery

An esophageal perforation after anterior cervical surgery is an uncommon but well recognized complication. During the past 25 years, 44 patients have presented to Craig Hospital (Rocky Mountain Regional Spinal Injury Center) with esophageal perforations; this is the largest series reported to date. There were 34 patients whose esophageal injury was related to the operations performed for cervical fractures, of which 28 patients had plate and screw fixation. The most frequently occurring clinical symptoms were that of neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. The most common clinical findings were an elevated temperature, localized induration and neck tenderness, crepitus or subcutaneous air in the neck and anterior chest wall, an unexplained tachycardia, and blood in the nasogastric tube. Imaging studies indicated an esophageal injury in only 32 (72.7%) patients. Twenty-two patients experienced cervical osteomyelitis or an abscess of the neck. Nonoperative treatment is fraught with a high mortality, and 42 patients required surgical repair of their esophageal injury. The length of hospital stay averaged 253 days. Successful management of esophageal perforations depends on the physicians' awareness of the causes, prompt recognition of the symptoms and clinical findings, and immediate institution of treatment.     

Esophageal perforation: a continuing challenge.

Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.     

Options in the management of perforations of the esophagus

A study of 90 cases of esophageal perforation in the antibiotic era emphasizes individualized treatment and options of therapy based on a fundamental understanding of modifying pathophysiologic factors. If the patient is seen during the first 24 hours, surgical repair and irrigating tube drainage continue to be the treatment of choice in the thoracic and abdominal regions, with certain exceptions. The exceptions include small perforations proved by a thin media esophagram or esophagoscopy without pleural involvement or constitutional symptoms. Such patients may be treated nonoperatively, with gastric drainage, antibiotics, and parenteral alimentation. However, for large perforations with extensive contamination of the mediastinum and pleura, an esophageal exclusion operation may be life saving. In the cervical region, irrigating tube drainage may be just as effectual as repair and drainage. In patients seen after 24 hours, size of the perforation and the amount of mediastinopleural infection, rather than the time that has elapsed, dictate optimal treatment.     

Esophageal perforation in the neonate: an emerging problem in the newborn nursery

We report 11 cases of esophageal perforation in the neonate, in whom no surgery was performed for repair of the perforation, nor was any cervical or mediastinal drainage carried out. The perforation was in the cervical esophagus in all cases where an esophagram was performed. Nine were in premature babies (580 to 1,350 g), and two were full-term babies. There were two deaths in small prematures (580 and 935 g), from extreme prematurity and intraventricular hemorrhage, with no morbidity or mortality related to the esophageal perforation. The babies presented as esophageal atresia, or pneumothorax with the feeding tube in the right chest, or an abnormal right upper extrapleural air collection with infiltrate. Barium esophagram showed a classic "double esophagus" configuration. Two babies were mistakenly operated on, one with a diagnosis of esophageal duplication, and one had a gastrostomy for a diagnosis of esophageal atresia. Esophageal perforation in the neonate is an iatrogenic disease that may mimic esophageal atresia, and may be managed without surgical intervention.     

Esophageal perforation: a therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.     

Transesophageal irrigation for the treatment of mediastinitis produced by esophageal rupture

Esophageal rupture in the thorax, unless small and contained, is followed by the early onset of fulminant mediastinitis. When the rupture occurs in the cervical esophagus, mediastinitis will also occur if cervical drainage is delayed and the infection is allowed to spread along the periesophageal planes towards the mediastinum. The purpose of this article is to report the good results obtained in the treatment of life-threatening sepsis from esophageal rupture with the combination of continuous per oral transesophageal irrigation of the mediastinum and drainage of the irrigating fluid by accurately positioned chest tubes connected to a wall-suctioning system. When the patient cannot swallow, mediastinal irrigation is accomplished via a nasogastric tube positioned by the upper esophagus proximal to the perforation. Irrigation by mouth was also used for the treatment of cervical perforations with the drainage tubes positioned in the neck. With this method in eight patients, sepsis has invariably been controlled, and in six cases, in which no irreversible damage to the esophagus existed, the perforations have healed spontaneously. There was no death resulting from mediastinitis, which is most often the lethal factor in esophageal rupture.     

Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.     

Esophageal Perforation

Esophageal perforation can be caused by any instrument, device, or foreign body reaching the hypopharynx. Diagnosis remains difficult. If esophageal perforation is suspected, Gastrografin (meglucamine diatrizoate) swallow study, eventually followed by barium swallow study, is the most useful diagnostic test. Absolute rules cannot be made about the selection of nonoperative or surgical treatment. If diagnosed early, cervical or thoracic esophageal perforations can sometimes be treated conservatively if there are no signs of systemic sepsis. Recurrent leakage after surgical closure is not unusual. Local tissue flaps can reinforce the closure, particularly after delayed operation, thereby often avoiding the necessity for a reoperation or an esophageal exclusion.     

Stented esophageal transfixion injury

Esophageal perforation is a rare, but life-threatening condition with a mortality rate ranging between 10% and 40%. It can happen at the level of the cervical, intrathoracic, or intra-abdominal segment. It usually occurs as a result of iatrogenic injury after endoscopic procedures or as a spontaneous rupture. It is seen less frequently in trauma after gunshot or stab wounds. Stenting of the esophagus after iatrogenic perforation is well documented in the literature, but yet it is to be published for management of penetrating injury. We report a case of esophageal perforation with a wooden fence post treated successfully with a covered esophageal stent.     

Detection of esophageal perforation using intraesophageal dye injection

OBJECTIVES: Esophageal perforation complicating anterior cervical spine surgery is a potentially fatal complication. Early identification and immediate treatment may lower adverse effects for the patient. The purpose of this study is to assess the efficacy of intraesophageal dye injection to detect an esophageal injury and to test two novel techniques. METHOD: Ten cadaveric specimens were dissected using an anteromedial Smith-Robinson approach. Each was sequentially tested by a control and three dye injection techniques: technique A: nasogastric tube alone; technique B: nasogastric tube plus a distally placed Foley catheter; technique C: proximal plus a distally placed Foley catheter. Each technique was tested against esophageal perforations created by needle puncture (21-gauge, 18-gauge, and 14-gauge) and by a 2-mm high-speed burr. Dye visualization was independently graded as present or absent by two authors. RESULTS: In the control trial, no dye leak was visualized in any of the 10 specimens. In technique A, 0 of 10 21-gauge perforations, 1 of 10 18-gauge perforations, 2 of 10 14-gauge perforations, and 6 of 10 burr perforations were visualized. In technique B, 1 of 10 21-gauge perforations, 8 of 10 18-gauge perforations, 9 of 10 14-gauge perforations, and 9 of 10 burr perforations were visualized. In technique C, 0 of 10 21-gauge perforations, 9 of 10 18-gauge perforations, 10 of 10 14-gauge perforations, and 7 of 10 burr perforations were visualized. CONCLUSIONS: The study suggests that intraesophageal dye injection via nasogastric tube alone should not be relied upon to exclude the presence of esophageal perforation. Two novel techniques showed an improved, though limited, capability of detecting esophageal perforations.     

Combination of a free jejunal flap and a Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report

Pneumatic perforation of the esophagus caused by blast injury is very rare. Our patient presented with esophageal stricture in the context of a previous reconstruction of an esophageal rupture secondary to a distant air-blast injury. The ruptured esophagus was initially reconstructed with a left pedicled colon interposition in an antiperistaltic pattern. However, dysphagia developed 4 years later because of severe reflux-induced stenosis at the junction of the cervical esophagus and the left pedicled colon segment. A free isoperistaltic jejunal flap was performed to replace the cervical esophagus, with an anti-reflux Roux-en-Y colojejunostomy between the caudal segment of the left pedicled colon and the jejunum. The patient was discharged uneventfully 29 days later with smooth esophageal transit and no further reflux, as shown by scintigraphic scan. Esophageal reconstruction in an isoperistaltic pattern using a free isoperistaltic jejunal flap combined with an anti-reflux Roux-en-Y colojejunostomy has never been reported in the literature and appears to be an effective method to provide smooth passage of food and prevent restenosis of the esophagus.     

Nonoperative management of esophageal perforations. Is it justified?

OBJECTIVE: Experiences obtained with nonoperative treatment (NOT), i.e. total prohibition of per oral food intake for a minimum of 7 days, administration of combinations of broad-spectrum antibiotics, and parenteral hyperalimentation, are described in the management of esophageal perforations. SUMMARY BACKGROUND DATA: The place, value, and indication of NOT in the management of esophageal perforation has not yet been unequivocally defined. As a result, contradictory data have been published regarding the outcome of NOT. METHODS: During the past 15 years (1979 to 1994), 20 of 86 patients (23.3%) with esophageal perforation have been treated nonoperatively from the outset. In this group, perforations were located to the upper, middle, and lower third of the esophagus in 50%, 30%, and 20%, respectively. In the operative management group (OT)--in which conservative (drainage, endeprothesis), reconstructive (suture, reinforced suture), and radical (resection) surgical methods were applied--lesions were preponderantly located in the lower one third of the esophagus (56.1%--37/66). As to the interval between the perforation and the onset of treatment, 14 patients had been diagnosed within 24 hours, whereas in 6 cases treatment had been begun beyond 24 hours. RESULTS: NOT could be successfully carried out in 16 patients; the decision to use NOT had to be revised in 4 other cases (Table 1). Two patients were lost; the mortality rate was 10% (2 of 20). The rate of complications was lower in the NOT group (20%, or 4 of 20) than in the OT group (50%, or 33 of 66). CONCLUSIONS: NOT can be suggested for the treatment of intramural perforations. In the case of transmural perforation, this approach should be taken into consideration if the esophageal lesion is circumscribed, is not in neoplastic tissue, is not in the abdominal cavity, and is not accompanied by simultaneous obstructive esophageal disease; in addition, symptoms and signs of septicemia should be absent.     

Esophageal Perforation: An Increasing Challenge

Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation.The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.     

Ischemic esophageal necrosis secondary to traumatic aortic transection

Esophageal necrosis with perforation secondary to traumatic aortic transection is extremely rare but usually fatal. A 47-year-old man complained of sudden swallowing difficulty 6 days after blunt trauma. Computed tomography showed a ruptured aorta and the midesophagus shifted to the right side with luminal obliteration because of the ruptured aorta. After primary repair of the partially transected aorta, unexpected mediastinitis because of esophageal perforation was noted. Upper endoscopy showed midesophageal ulceration, necrosis, and perforation. Biopsy samples were consistent with ischemia. The possibility of direct esophageal trauma or intraoperative esophageal injury was ruled out. Esophageal exclusion with thoracoscopic decortication and multiple antibiotics were ineffective, and the patient eventually died. Ischemic esophageal necrosis caused by mechanical compression can occur in a traumatic aortic transection. Dysphagia, when present with radiologic signs, indicates a displaced and compressed esophagus. In spite of aggressive surgical and medical treatment for a perforated esophagus, the prognosis remains poor.     

Esophageal perforation. A rare complication after operation of degenerative and traumatic pathology of the cervical spine]

Esophageal perforation is a rare complication in the surgical treatment of diseases of the cervical spine. Following cervical discectomy for degenerative arthritis at the C6/C7 level, a 42-year-old male patient experienced a progressive dislocation of a PMMA-implant with impending esophageal perforation. Neurological symptoms including dysphagia worsened and a new fusion had to be performed 3.5 months after initial surgery. On the 2nd postoperative day, a laceration of the esophagus was diagnosed clinically and on esophagogram. After drainage, the perforation healed under antibiotic treatment and enteral nutrition through a percutaneous endoscopic gastrostomy within 5 weeks.     

Pharyngoesophageal perforation after blunt neck trauma

Pharyngoesophageal perforation secondary to blunt neck trauma is an uncommon injury that can cause serious morbidity and mortality if not recognized and treated. Pharyngeal perforation secondary to blunt trauma sustained while boxing is reported. Review of the world literature found 10 cases of pharyngoesophageal perforation secondary to blunt neck trauma. Analysis of these cases indicates that perforations less than 2 cm and limited to the pharynx may be treated medically with close observation. Large perforations and those perforations that extend to the esophageal inlet or involve the esophagus exclusively are best treated surgically.