Esophagus—Esophageal Perforation
Concept
Potentially lethal condition that may be spontaneous (Boerhaave’s syndrome), result of trauma, swallowed for- eign bodies, ingestion of caustic substances, malignancy, or iatrogenic (NGT/endoscopy). Most common cause today is iatrogenic related to endoscopic maneuvers (biopsy/dilatations/cautery).
Way Question May be Asked
“28 y/o male presents to ED with acute onset of epigas- tric/chest pain after several episodes of vomiting from alcohol abuse.” Could also see after dilatation of stricture, achalasia, biopsy for Barrett’s, dysplasia, or malignancy.
You’ll be lucky if they mention to you any of the follow- ing: crepitance in the suprasternal notch, diminished breath sounds in the left chest, a left pleural effusion or air in the mediastinum on CXR, or triad of vomiting/low tho- racic pain/cervical emphysema.
How to Answer?
As usual, history and physical exam, but make assessment of stability of the patient. A patient in shock needs urgent treatment.
History
Previous esophageal disorders Any history of ulcer disease Pancreatitis
Heart disease Ingestions
Timing of pain to vomiting
Complete Physical Exam
Vital signs
Cervical exam (SQ emphysema=more with cervical perforations),
Diminished breath sounds in left chest
Appropriate Studies
Full labs (amylase to r/o pancreatitis), EKG (r/o MI),
CXR (pleural effusion, hydropneumothorax, mediasti- nal air),
Lateral neck x-ray (SQ emphysema)
Gastrografin swallow should identify leak. If not, may then get barium swallow.
No endoscopy!
Treatment should also be stepwise with consideration given to:
Time since perforation
Location/size of the perforation Pt’s overall clinical status Degree of contamination
Underlying esophageal disorder (Barrett’s/malignancy) All pts:
NPO, broad spectrum Abx, NGT
Non-operative therapy only for pt with walled-off small perforation, minimal symptoms, no sepsis, with fre- quent reassessments and low threshold to take to OR Once taken OR, all pts get same basic plan:
Debridement
Closure (of perforation) Drainage
62
Part 1.qxd 10/19/05 2:51 AM Page 62
(1) If within 24 h of perforation, attempt primary repair
(a) for perforations in upper two thirds of esopha- gus, right thoracotomy, debridement of all non- viable tissue, myotomy to define extent of mucosal injury, closure in two layers over NGT, cover with tissue flap (pleural/pericardium/inter- costal muscle), and place chest tube. Pt is then kept NPO, on TPN or enteral feeds through J- tube, and continue abx.
(b) for perforation in lower third of esophagus, left thoracotomy and same procedure as above with ability to now cover repair with Thal patch, diaphragm muscle, fundoplication
(c) for perforation in abdominal esophagus, upper midline with low threshold to making left tho- racotomy (make sure to prep left chest) and cover repair with fundoplication
(d) for cervical perforation, incision in left neck along SCM
(2) If after 24 h unstable, perform esophageal exclusion (a) debridement of mediastinum/esophagus/lung (b) establish effective drainage with two chest tubes (c) leave esophagus open
(d) ligate GEJ with 2 ties of #2 chromic (e) place NGT above perforation (f) high volume irrigation through NGT (g) NPO/TPN or J-tube feeds/abx (c) or segmental esophagectomy (d) gastrostomy/J-tube
(e) cervical esophagostomy (f) NPO/TPN or enteral feeds/abx
(3) Esophageal resection is appropriate if there exists pathology in the esophageal wall, this is delayed if
the pt is unstable, or can be performed immediately with stomach and a left cervical anastomosis Post-op UGI with gastrografin prior to feeding once resolution of sepsis and repair has chance to heal!
Common Curveballs
No leak seen on gastrografin swallow CXR/neck x-ray will be negative Pt will be unstable
Location of the leak will change after you suggest an algorithm
Time to detection of the leak will change after you sug- gest an algorithm
Examiners pushing you towards non-operative therapy Nonoperative therapy will fail
Pt will have leak after your repair (esophageal diversion) Pt will have perforation during dilatation of achalasia
or during examination of Barrett’s (esophagectomy appropriate here)
Management late stricture
Strikeouts
Performing endoscopy to identify leak (and spread infection/create tension pneumothorax)
Not performing water soluble contrast enema
Attempting to perform immediate resection/reconstruc- tion with unprepped colon
Not ruling out distal obstruction
Not attempting primary repair on early perforation Not r/o MI/pancreatitis/perforation PUD/aortic
dissection
Strikeouts 63
Part 1.qxd 10/19/05 2:51 AM Page 63
