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.     

Pharyngeal perforation masquerading as esophageal atresia

We present a case of pharyngeal perforation from a nasogastric tube mistakenly diagnosed as esophageal atresia with tracheoesophageal fistula in a full term infant female. The correct diagnosis was identified with rigid bronchoscopy and esophagoscopy immediately prior to the planned thoracotomy which was aborted. After one week of oral restriction and antibiotics, the healed perforation did not demonstrate leakage on a contrasted pharyngoesophagogram and bottle feeds were initiated. The infant was discharged to home on day of life 13 without any further complications.     

Esophageal atresia, duodenal atresia, and unilateral lung agenesis: a case report

The association of pure esophageal atresia, duodenal atresia, and unilateral lung agenesis has not been reported previously. Here the authors present a case of a newborn with this constellation of anomalies that underwent staged repair. The primary principle guiding treatment was the avoidance of iatrogenic injury to the single lung. Therefore, the order of operations proceeded as follows: (1) placement of a decompressing gastrostomy tube, (2) repair of the duodenal atresia, and (3) repair of the esophageal atresia. The congenital closed loop obstruction caused by the esophageal and duodenal atresias was beneficial in that it resulted in growth by stretching of the distal esophagus, allowing a tension-free primary repair of the esophageal atresia.     

Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.     

食管破裂诊断及外科手术方式的选择——附36例临床分析

目的探讨食管破裂的诊断与手术方式。方法 1980-01—2012-06间共收治36例食管破裂与穿孔患者。保守治疗2例,手术治疗34例。单纯食管破裂修补术、食管破裂修补加肋间肌瓣、膈肌瓣、带蒂大网膜覆盖破裂口8例;破裂食管切除、Ⅰ期食管胃胸内或颈部吻合术3例;纵膈引流、胸腔引流或食管"T"管引流加空肠造瘘6例;食管旷置或颈部食管造瘘,加纵膈、胸腔引流及空肠造瘘,Ⅱ期消化道重建2例,其中1例为经胸骨后管状胃与颈部食管吻合;颈部食管旁切开引流术及食管支架置入术各1例。贲门失弛缓症、食管癌、食管癌术后吻合口狭窄扩张或支架置入时破裂5例:姑息性食管癌切除、吻合口狭窄部切除再游离胃行颈部吻合术4例,食管破裂修补术加破裂食管对侧Heller手术1例。合并多发性肋骨骨折肺深部裂伤、脾破裂胃破裂、车祸胸部贯通伤伴胸壁皮肤Ⅱ度烧伤各1例:行肺裂伤修补,胸腹联合切口行脾切除胃破裂修补术加胃空肠造瘘,1例伤后6d,确诊食管破裂,行食管破裂修补及肋间肌瓣加固。1例食管异物40 d,致食管-主动脉瘘(AEF),左心转流下阻断主动脉,修补主动脉破口,切除胸段食管行颈部食管胃吻合,获成功。食管胸中段化学性烧伤致穿孔1例,I期行胸段食管切除食管胃颈部吻合术。食管破裂修补术后再瘘3例:行胸腔廓清、上下胸腔引流及空肠造瘘。结果治愈27例,其中3例并吻合口狭窄,经扩张后好转。死亡9例。结论选择合理方式治疗食管破裂至关重要。要综合考虑食管破裂的原因、部位、时间、大小、原发疾病、并发症、纵隔及胸腔感染情况。     

Membranous type of esophageal atresia at the cardiac end of the esophagus: a case report

An 8-day-old female neonate was referred to pediatric surgical services for regurgitation of feeds since birth. Plain x-ray of the chest and abdomen with Ryle's tube in situ and contrast study confirmed the diagnosis of esophageal atresia at the cardiac end of the esophagus. The membrane at the cardiac end of the esophagus was excised employing a thoracoabdominal approach. This is the first case report of membranous type of esophageal atresia at the cardiac end of the esophagus to be reported in the English literature.     

High-grade congenital esophageal stenosis owing to a membranous diaphragm with tracheoesophageal fistula

Gross E-type congenital esophageal atresia associated with congenital esophageal stenosis is extremely rare. In a male infant born at 36 weeks of gestation, bubbly vomiting was noted after birth. X-ray films of the chest and abdomen showed coil-up sign of the nasogastric tube and gas in the stomach and small intestines were recognized, so gross C-type esophageal atresia was suspected and surgery was performed on the first day of life. Surgery revealed the presence of a tracheoesophageal fistula in the upper esophagus and membranous stenosis on the distal side.     

Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery

Background: This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention. Methods: Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports. Results: Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%. Conclusion: Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anethesiologist and safe techniques of dilator insertion.     

Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality

OBJECTIVE: To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation. SUMMARY BACKGROUND DATA: The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress. METHODS: From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement. RESULTS: Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2. CONCLUSIONS: Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.     

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.     

Traumatic pharyngo-oesophageal perforation in the newborn: a condition mimicking oesophageal atresia

Two newborn infants with traumatic perforation of the pharyngo-oesophageal region are presented. This injury was induced by pharyngeal suction catheters and/or vigorous attempts at nasogastric or tracheal intubation during resuscitation of the newborn. The true nature of this condition remained unrecognized and the babies were thus referred with a tentative diagnosis of oesophageal atresia. The perforation itself could be treated successfully without surgery, despite a severe complication in one infant resulting from inadvertent use of barium sulphate contrast medium. Raising awareness of the possibility of this injury should help in avoiding this complication by gentle and skilful action during newborn resuscitation, particularly in the premature infant.     

Penetrating wounds of the cervical esophagus

To determine trends in management, twenty-two years' experience with penetrating wounds of the cervical esophagus in thirty-nine patients has been evaluated. There were three deaths, all as a result of delayed operative repair. Experience gained from the earlier years of this study led to a marked reduction in mortality in the later years as a result of an increased index of clinical suspicion, coupled with an aggressive operative approach with primary closure and adequate drainage. A nonoperative approach has been suggested by others for small esophageal perforations after endoscopy and perforation from foreign objects. For penetrating injuries of the esophagus, operation and definitive repair is mandatory.     

Heterotopic gastric mucosa of the upper esophagus following repair of esophageal atresia with tracheoesophageal fistula

A term female newborn underwent uncomplicated repair of esophageal atresia with tracheoesophageal fistula (type C) then coarctation of the aorta. Subsequently, she developed symptomatic esophageal strictures, which required serial dilations. In addition, she suffered feeding intolerance from esophageal dysmotility and gastroesophageal reflux disease, necessitating Nissen fundoplication with gastrostomy. At 6 years of age, surveillance esophagogastroduodenoscopy revealed mild stenosis and heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis. This is the second report of heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis following repair of esophageal atresia with tracheoesophageal fistula.     

Three cases of esophageal bleeding after cardiovascular surgery

Three patients after cardiovascular surgery developed severe esophageal bleeding. All had been diagnosed as having an aberrant subclavian artery (ASCA). ASCA is the commonest congenital anomaly of the aortic arch, which arises from the proximal portion of the descending thoracic aorta and runs across the back side of the esophagus. The patients were intubated with a tracheal, nasogastric or ileus tube for a long time after surgery because of low output syndrome (LOS), delayed awareness, or ileus. The ASCA was compressed by the nasogastric or ileus tube in the esophagus and the patients developed an ASCA-esophageal fistula and bleeding. It should be noted that patients with an ASCA may suffer from esophageal bleeding due to the prolonged use of a nasogastric tube. Prevention is the best way to avoid this serious complication.     

Double esophageal perforation by ingested foreign body: Endoscopic and surgical approach. A case report.

IntroductionEsophageal perforation in adults is most frequently caused by ingested foreign bodies. They can migrate through the esophageal wall, damaging the nearby organs such as the aorta or the trachea, with fatal outcome. After the diagnosis, the viable treatments for extracting the foreign body and repairing the perforation are several. The appropriate treatment, may be endoscopic, surgical or combined, depending on the level of the perforation, on the co-morbidities of the patient and on the available resources.Presentation of caseThis paper describes a case of a 68 years old patient with a double EP caused by a meat-bone that perforated the thoracic esophageal wall, approaching the aorta on the left side and the azygos vein on the right side.DiscussionBecause of the double transfixion and the position near the aorta and the azygos, it was not possible to remove safely the bone during the endoscopy. The management required a combined endoscopic and surgical approach. This way it was possible to detect easily the location of the perforation, to remove safely the foreign body, to repair the perforation both from the outside and from the inside, and to place the nasogastric tube under direct vision.ConclusionEven when the type of esophageal perforation requires surgical treatment, the simultaneous use of endoscopy proved to be an advantage in order to extract the foreign body safely, to perform a double repair of the perforation and to place the nasogastric tube under direct vision.     

Membranous atresia of esophagus associated with pyloric stenosis

Membranous atresia of the esophagus without tracheoesophageal fistula (TEF) is very rare, only four cases have been reported since 1928. We present a case in whom a thick membrane was present 2 cm proximal to the diaphragm. The membrane was resected and the longitudinal esophagotomy wound was closed transversely. The postoperative course was complicated with hyperbilirubinemia and hypertrophic pyloric stenosis (HPS). The problems of the feeding tube used for diagnostic evaluation of this rare esophageal anomaly are discussed. In spite of its low incidence, the potentiality of HPS as a cause of postoperative vomiting in esophageal atresia should be borne in mind in order to avoid delay in diagnosis.     

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.     

Congenital stenosis of the esophagus. A rare diagnosis in children and adults]

The authors report about 3 cases of congenital stenosis of the upper third of the esophagus. This is an exceptional condition, for which 3 main types are described: a mucous diaphragm, to be compared with membranous atresia, fibrous stenosis and stenosis caused by bronchial heterotopy. The location of the stenosis in the upper third of the esophagus is extremely rare. It results from a disorder in the revascularization of the esophageal tube. The diagnosis is established in the newborn, and less frequently in children and adults, in cases of vomiting, regurgitation or dysphagia. It is based on esograstroduodenal follow-through and fiberendoscopy, which allows ruling out other causes of benign narrowing. The treatment resorts to endoscopic dilatations and to surgery, which remains the safest method.     

Management of pediatric esophageal perforation

Esophageal perforation is a serious complication necessitating immediate therapy. In a retrospective study we have evaluated the results in 13 children treated for esophageal perforation. Eleven of 13 perforations could be managed conservatively. In one child with extrapleural effusion, tube drainage was performed. The only death in this series occurred in a child who was brought for treatment after a 60-hour delay. Thoracotomy and multiple abscess drainage eventually proved unsuccessful. On the basis of our experience with children with esophageal perforation or with complications after esophageal atresia repair, we conclude that management of esophageal perforation in children differs substantially from therapy in adults and necessitates restrictive treatment guided by clinical symptoms.     

Selective nonoperative management of contained intrathoracic esophageal disruptions.

Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).