TSRA Content:
Author: Rus Kanyongo, MD
This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by Kiran Lagisetty, MD, and Ian Makey, MD
Introduction
Esophageal perforations are one of the few surgical emergencies in thoracic surgery. Prompt diagnosis and treatment are necessary if major morbidity and mortality are to be avoided. The interval between insult and presentation, location of the injury, underlying etiology of the perforation, and clinical status of the patient are all important factors to consider when determining a treatment plan. Differences exist between etiology, presentation, acuity, and management of cervical and thoracic perforations, which are discussed separately in the following brief review.
Cervical Esophageal Perforation
The most common causes of cervical esophageal perforation are iatrogenic, occurring most commonly during an upper endoscopy. The risk of perforation is increased with instrumentation, such as dilation or transesophageal echocardiography. Operative trauma, another common cause of cervical perforation, can occur during any procedure in the neck or upper chest within close proximity to the esophagus, such as tracheostomy or cervical spine fusion. Rigid foreign body ingestion, caustic substance ingestion, and penetrating trauma are leading noniatrogenic causes, although much less common than iatrogenic etiologies. Most perforations in the cervical esophagus occur just proximal to the cricopharyngeus muscle, the narrowest region of the esophagus.
Patients most commonly present with the chief complaint of neck pain. Dysphagia and odynophagia are also frequently observed complaints. Patients who present late may complain of dyspnea, which can progress rapidly to airway compromise if not dealt with promptly. Fever and leukocytosis occur early and crepitus is often palpable in the neck on exam. In the setting of penetrating neck injuries, food debris and saliva coming out from the neck wound is pathognomonic of a pharyngeal or esophageal perforation.
During work-up, the patient should be monitored in a setting where airway and hemodynamics can be observed closely. AP and lateral CXRs should be the first diagnostic test. The presence of subcutaneous emphysema, pleural effusions, or pneumomediastinum is strongly suggestive of the diagnosis in patients with typical symptoms.
This is followed by a water-soluble contrast esophagram. If suspicion of a leak is high and the initial esophagram is negative, the study should be repeated with thin barium. It should be noted that false-negative rates of fluoroscopic studies are at least 20%. A CT scan of the chest is not necessary to diagnose cervical perforations but may be helpful if the esophagram is negative and suspicion remains high. The presence of peri-esophageal subcutaneous air, pneumomediastinum, and fluid collections on CT is likely enough to warrant treatment, except in the case of penetrating neck injuries. A combination of a contrast swallow and a flexible esophagoscopy in the aforementioned setting usually increases the diagnostic yield. Since most perforations in the cervical esophagus occur during upper endoscopy, it is rarely necessary to repeat the procedure. However, if there is a question of the exact location or extent of the injury, endoscopy may be considered.
Cervical perforations usually are best managed by immediate drainage of the retroesophageal space to avoid the development of descending mediastinitis and sepsis. Non-operative management may be attempted for perforations that do not demonstrate extravasation with contrast studies.
Exposure for drainage is essentially the same as the neck exposure performed for the cervical stage of an esophagectomy, which is described in a subsequent chapter. The perforation cavity should be irrigated, debrided, and drained, preferably with a closed-suction drain. Although primary repair is not necessary, it can be considered if the injury is easily visualized, and the wound edges are healthy. Most cervical perforations will heal spontaneously with proper drainage, antibiotics, nasogastric decompression, cessation of oral intake, and nutritional support.
Contrast esophagography is repeated after 5-7 days. If there is no evidence of a leak, a clear liquid diet is started, and the patient is monitored for 24-48 hours. The diet can then be advanced slowly as an outpatient and the drains removed in the office after an additional 1-2 weeks of observation.
Thoracic Esophageal Perforation
Intrathoracic perforations are of higher acuity than proximal injuries due to the greater risk of developing mediastinitis and pleural contamination. Mortality rates range from 10% to 50%. Primary repair is the main goal of treatment, but damage control procedures may be needed depending on the clinical status of the patient and the extent of the injury.
Like cervical perforations, the most common causes are iatrogenic, primarily from endoscopic instrumentation and operative trauma. Risk during endoscopy is significantly increased in the setting of achalasia, tight benign or malignant strictures, and bulky tumors. Surgical perforations occur most commonly during fundoplication and myotomy. Non-iatrogenic perforations occur from violent vomiting (Boerhaave's syndrome), ingested foreign bodies, and blunt or penetrating trauma.
Pain is the paramount complaint, typically located in the substernal or epigastric regions. Obtaining a detailed history is important, as this presentation can easily be confused with myocardial infarction, peptic ulcer disease, biliary disease, or pancreatitis. A perforation that is confined to the mediastinum may present with mediastinal emphysema and a "systolic crunch" (Hamman sign). Fever and leukocytosis are also common. Signs of sepsis and shock may be present if there has been a long delay between insult and presentation or if there is extensive contamination of the mediastinum and pleural space.
Work-up for thoracic esophageal perforations is essentially the same as for cervical perforations, with contrast esophagrams being the mainstay of diagnosis. Pneumothoraces and pleural effusions are more common with thoracic perforations. CT scans of the chest and abdomen, as well as upper endoscopy, are more helpful in thoracic perforations to locate the injury, if not clear on contrast esophagography. Identification of the exact location of the perforation is important, as this commonly dictates the choice of surgical approach.
Like cervical perforations, treatment for thoracic esophageal perforations always involves vigorous resuscitation, broad-spectrum antibiotics, and nutritional support. In contrast to cervical perforations, thoracic perforations require source control. This is because thoracic perforations are not confined like they usually are in the neck. The rapidity with which shock occurs varies with the extent of perforation. Treatment options include nonoperative treatment, primary repair, drainage alone, stenting, or resection.
Suggested criteria for nonoperative treatment of esophageal perforation include a contained perforation with ready drainage of contrast back into the lumen, stable physiology in a non-toxic patient, and the absence of treatable underlying esophageal pathology, such as a resectable tumor or other distal obstruction. Attempts at nonoperative treatment must be approached with caution and an "aggressive" conservative management plan is advised. This includes close monitoring of the patient, serial drainage of all effusions (pleural or peritoneal) and repeat imaging every 48-72 hours or sooner if the patient's clinical status worsens. Modalities like endoluminal esophageal vacuum associated closure systems can also be considered as part of the armamentarium of nonoperative management. Failure to improve or evidence of uncontrolled mediastinal or pleural contamination should lead one to proceed with operative intervention without delay.
Primary repair is best performed via thoracotomy, with care taken to preserve an intercostal muscle pedicle in case it is needed for coverage of the repair. Injuries to the proximal and middle third of the esophagus are best approached through the right chest, while distal injuries are better visualized from the left.
Alternatively, if there is evidence of rupture into the pleural cavity, it is best to approach the injury from that side to facilitate adequate drainage and decortication. Perforations of the intra-abdominal esophagus may be approached from the abdomen if there are no signs of intrathoracic contamination.
The mucosal injury commonly extends beyond that of the muscularis propria tear, which should be extended to visualize the entire length of the mucosal injury. The traditional repair is a hand-sewn closure in two layers (mucosa and muscularis propria); although, stapled closure of the mucosal defect has been described. Historically, the interval from insult to presentation and the mechanism of injury determined whether a patient was a candidate for primary repair. Patients presenting after 24 hours from perforation were typically treated with wide drainage alone, with a high incidence of stricturing once the perforation healed. However, recent evidence suggests that it is more important to evaluate the stability of the patient and the quality of tissue for repair before ruling a patient out for primary repair. Good results have been obtained even after more than 24-48 hours have elapsed from the time of injury.
Buttressing the repair with healthy, vascularized tissue is advisable, which should be sutured down to the esophageal wall rather than simply "tacked" over the closure. Alternatives to an intercostal muscle flap include pericardial fat, diaphragm, or omentum. In an early perforation, the pleura is not thickened sufficiently by inflammation to be an effective flap. If the perforation occurs in the intra-abdominal portion of the esophagus, coverage with the stomach wall (i.e. partial fundoplication) or omentum can be easily performed. Other measures that should be performed at the time of operation include pleural and mediastinal irrigation, lung decortication to allow full re-expansion of the lung and obliteration of any dead space, and wide drainage with multiple chest tubes and closed suction drains. One should consider a nasogastric tube to decompress the stomach and prevent reflux, as well as the placement of a jejunostomy feeding tube for distal enteral access.
Esophageal stenting for source control has recently gained popularity. The stents are typically covered, self-expanding metal stents that are placed endoscopically with or without fluoroscopy. However, stenting does not obviate the need for drainage and decortication. Reported benefits of stenting include an earlier return to oral intake and less stricture formation. Complications of stenting include migration, erosion, and food impaction. Stents are an excellent palliative option in patients with perforation in the presence of unresectable esophageal cancer.
Esophageal resection for perforation is reserved for situations in which source control cannot be obtained, such as extensive caustic ingestion injury with perforation or severe cases of penetrating trauma. Resection is also the treatment of choice in the setting of an obstructing esophageal cancer or refractory benign stricture, as a repair is unlikely to heal in the presence of distal obstruction. Mediastinal contamination is often severe enough that reconstruction must be delayed until the patient has fully recovered.
Proximal diversion is accomplished with an end cervical esophagostomy, leaving as much length as possible for later reconstruction. In stable patients, the distal esophagus is divided at the gastroesophageal junction and the body is resected. Gastric decompression and enteral access are necessary. In unstable patients, the body of the esophagus may be left in situ, but proximal and distal diversions should be carried out if possible. The esophagus can then be resected when the patient is more stable 24-48 hours later, as ongoing contamination will occur even with wide drainage. Leaving the perforated segment of the esophagus in situ is a suboptimal situation and should be avoided whenever possible.