Esophageal Perforation

Esophageal Perforation

INTRODUCTION

Esophageal perforation is a diagnostic and therapeutic challenge because of the rarity of the condition and the variability in presentation. Surgical management is primarily based upon small retrospective studies and expert opinion. The following basic principles are applied to the management of a patient with an esophageal perforation:

Rapid diagnosis

Appropriate hemodynamic monitoring and support

Antibiotic therapy

Restoration of luminal integrity

Control of extraluminal contamination

Restoration of enteral alimentation

The etiology and surgical management of a perforation to the cervical, thoracic, and abdominal esophagus will be reviewed here. The risk factors, clinical presentation, diagnosis, and nonoperative management of an esophageal perforation are discussed elsewhere.

ANATOMY 

The esophagus has three anatomical points of narrowing, the cricopharyngeus muscle, the broncho-aortic constriction, and the esophagogastric junction (figure 1) (Cook & Lau, 2008). Perforation may occur anywhere along the esophagus, but there is a predilection for rupture at these key anatomic areas. As an example, iatrogenic injuries to the cervical esophagus can occur during endoscopy at Killian's triangle (figure 2), an area lacking a posterior esophageal muscularis and bordered by the horizontal cricopharyngeus muscle inferiorly and the oblique inferior constrictor muscles superiorly.

ETIOLOGY 

Increased intraluminal pressure at the anatomic sites of narrowing, as well as sites narrowed by a malignancy, foreign body, or physiologic dysfunction, can lead to rupture of the esophagus.

More than one half of all esophageal perforations are iatrogenic and most of these occur during endoscopy. The rate of esophageal perforation during diagnostic and therapeutic esophageal endoscopy is discussed separately.

Other causes of esophageal perforation include (Brinster et al, 2004; Helton et al, 2011; Marchea et al, 2010):

Spontaneous perforation (Boerhaave's Syndrome): 15 percent

Foreign body ingestion: 12 percent

Trauma: 9 percent

Intra-operative injury: 2 percent

Malignancy: 1 percent

PRIMARY MANAGEMENT

The major principles of the primary and immediate management of an esophageal perforation include prompt diagnosis, stabilization of the patient, and assessment for operative or nonoperative management.

Regardless of etiology, an esophageal perforation is a surgical emergency(Curci & Horman, 1976; De Schipper et al, 2008). Leakage of esophageal and gastric contents into the mediastinum creates a necrotizing inflammatory process that can lead to sepsis, multiorgan failure, and death (Shaker et al, 2010; Vallböhmer et al, 2010). The near doubling of overall mortality from 14 to 27 percent with a delay in diagnosis greater than 24 hours after perforation emphasizes the importance of a prompt diagnosis and treatment (figure 3) (Brinster et al, 2004). The diagnostic studies performed to confirm the clinical suspicion of esophageal perforation are discussed in detail elsewhere.

The rarity of the diagnosis and the variability in clinical presentation often lead to diagnostic treatment delays. This is especially true of spontaneous perforation, in contrast to iatrogenic perforation, where the clinical suspicion is low, which often leads to the evaluation of more common medical conditions such as myocardial infarction, pneumonia, and peptic ulcer disease.

Initial management 

Once the diagnosis is suspected, treatment is started immediately:

Patient is made NPO (nothing per oral).

A large bore intravenous line is started and fluid resuscitation is performed with isotonic saline solution or lactated ringers ...