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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Instrumental perforation of the esophagus

and .

Helsinki University Central Hospital, Department of Thoracic and Cardiovascular Surgery, Helsinki, Finland

Instrumentation is the most common cause of esophageal perforation. The diagnosis is often delayed, but should be suspected in all patients who have pain after esophageal instrumentation. Early diagnosed small lesions can successfully be treated conservatively, but in other cases operative treatment is the method of choice. The prognosis depends mostly on the diagnostic delay, but also on the location and cause of perforation, and on the patients age.

Causes

The most common cause of esophageal perforation is instrumentation of the esophagus during endoscopy, e.g. dilation of esophageal stricture or achalasia, removal of foreign bodies or application of esophageal endoprostheses (1). The prevalence of perforation during diagnostic endoscopy is about 0.05% and 2.6% following instrumentation (2).

Pathogenesis

After perforation, bacteria and digestive juices have easy access to the mediastinum because the esophagus is surrounded by loose areolar tissue. This leads to the development of severe mediastinitis and sepsis, which often leads to multiorgan failure and death (3).

Prognosis

The prognosis of esophageal perforations is still serious. early diagnosis is often missed because of the rarity of condition and failure even to consider the possibility of oesophageal perforation.

Today mortality in early diagnosed cases is often less than 10%, but diagnostic delay significantly increases mortality.

With treatment delay mortality, rises from 40% up to 66% after 24 hours (4). Other factors influencing outcome are the patient's age, the location, and cause of perforation and associated oesophageal pathology. Cervical perforations have the best prognosis.

Diagnosis

In early cases, the classical findings - chest pain, fever, subcutaneous emphysema and pneumothorax - are often absent and the condition may be confused with myocardial infarction, aortic dissection, pneumothorax or perforation of a peptic ulcer. Even pancreatitis is a possible misdiagnosis because of the frequently increased serum amylase levels (5). Thus, one has to be highly suspicious to early diagnose an esophageal perforation. Pain, the most common symptom, occurs in 70–90% of the patients. If a patient complains about pain after any kind of esophageal instrumentation, a perforation should always be suspected. Subcutaneous emphysema, which is easily ascertained by palpation, confirms the diagnosis in these patients. Fever, pleural effusion combined with pneumothorax and mediastinal emphysema are often late findings. Laboratory findings, e.g. white blood cell count or C-reactive protein, remain mostly normal for several hours after the perforation.

An esophagogram performed with a water-soluble contrast agent in supine position is the most reliable diagnostic tool. Because its diagnostic accuracy is usually less than 90% the examination should be repeated if necessary. The computed tomography patterns of esophageal perforation include extraluminal air, periesophageal fluid, esophageal thickening, and extraluminal contrast. In some cases peroperative esophagoscopy in connection with negative laparotomy or thoracotomy may lead to diagnosis.

Treatment

The rarity of esophageal perforation and, mostly, very limited personal experience make it difficult to find a uniform method of management. Until now there have been no prospective randomised studies about the results of different therapies. In addition, most published series are small, without any statistical significance, containing only few patients being treated for long periods of time, so that reliable conclusions about the efficacy of different therapies cannot be made.

The level of evidence concerning the efficacy of different treatment modalities, especially in delayed cases, is very low. The recommended treatment modalities vary according to subjective personal likings.

Time is of critical importance in managing instrumental perforations of the esophagus and must be taken into account when various types of treatment are proposed (6).

Additionally, treatment should be individualised according to the findings of each patient. Patients showing persistent pain after esophageal instrumentation should neither fed nor given medications orally; intravenous infusions and antibiotics (i.e. imipenem) should be started and continued until perforation is excluded. Small perforations with a diameter of a few millimetres without diagnostic delay or septic symptoms can be successfully treated according to the above-mentioned conservative methods. The healing of the lesion is confirmed by esophagograms repeated at intervals of several days. However, for perforations larger than some millimetres surgery may be safer. Treating esophageal perforations one should keep in mind that insufficient control of mediastinal sepsis and concomitant multiorgan failure is the principal cause of death of patients with esophageal perforation, not the operation (thoracotomy) itself.

Primary repair by thoracotomy is mostly considered to be the method of choice in early cases demanding surgery. The disrupted edges of the mucosa are identified, and debridement of necrotic mucosa and muscle layer is performed. During the exploration the muscular layer should be opened long enough for exposure of both edges of the rupture, because a seemingly small perforation may involve a much longer segment of esophageal mucosa. Repair should consist of a separate closure of mucosal and muscular layers using a 4/0 absorbable monofilament suture or stapler. Due the risk of disruption it is often advised that the suture line should be buttressed with viable tissue. Left thoracotomy is advantageous in cases of distal perforations. More orally located perforations are better operated by right thoracotomy. Gastrostomy and nasogastric suction are discussed controversially. Most cases with neither diagnostic delay nor mediastinal sepsis successfully heal with few complications after primary repair (7). However, the presence of pre-existing oesophageal disease requires management concomitant with primary repair.

The challenging problem is a septic patient with a late intrathoracic perforation. After 24–48 hours the esophageal wall in the perforated area is often inflamed and fragile making primary closure often not successful because of possible fistula formation. Infection has usually spread widely in the mediastinum during this time. For these patients various treatments such as drainage (8), primary repair of the esophagus (9, 10), insertion of a T-tube through the perforation (11), cervical esophagostomy with seclusion of the distal esophagus (12), and esophageal resection (4) have been advocated. In addition, transesophageal irrigation of the mediastinum through the rupture has been successfully performed (13). The authors who are familiar with the above-mentioned techniques have demonstrated acceptable results with all these methods, but the reported numbers of these severely ill patients are rather small, rarely containing more than ten patients with delayed esophageal perforation and mediastinal sepsis.

Among the above-mentioned techniques, subtotal esophagectomy with cervical esophagostomy, gastrostomy and irrigation of the mediastinum with antibiotics is the procedure we prefer in delayed perforations with mediastinal sepsis. Esophagectomy can be performed either transthoracally or transhiatally. However, in delayed cases the transthoracal approach may be preferable because it allows a more efficient mediastinal cleansing and exact positioning of the irrigation tubes after opening the mediastinum. Mediastinal irrigation should be continued, until two consecutive bacterial cultures give a negative result. In addition, one advantage of esophagostomy is the avoidance of fistula formation. In severe septic mediastinitis staged esophageal resection with later restoration of the digestive continuity is safer, because it avoids anastomotic disruption. Restoration of the digestive continuity using the colon or the stomach can be performed three to six months after healing of the mediastinitis and after improvement of the catabolic nutritional state.

Primary reconstruction of the digestive continuity (mostly using the stomach) can be performed in cases where the mediastinitis is not severe.

The instrumental perforation of an esophageal malignancy is a serious complication. The curative surgery (esophageal resection) is seldom possible, or has often a survival of only several months. In these patients the endoscopic placement of coated self-expanding esophageal stents, especially in cases with fistula formation between the esophagus and the airways, may be the best alternative.

References

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Quine MA, Bell GD, McCloy RF (1995) Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England. Br J Surg: 530–533 . [PubMed: 7613903]
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Orringer M B, Stirling M C. Esophagectomy for esophageal disruption. Ann Thorac Surg. (1990);49:35. [PubMed: 2297275]
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DeMeester T R. Perforation of the esophagus. Ann Thorac Surg. (1986);42:231. [PubMed: 3753069]
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7.
Salo J A, Isolauri J O, Heikkilä L J, Markkula H T, Heikkinen L O, Kivilaakso E O. et al. Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair? J Thorac Cardiovasc Surg. (1993);106:1088. [PubMed: 8246543]
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Frink N W. Spontaneous rupture of the esophagus: Report of a case with recovery. J Thorac Cardiovasc Surg. (1947);16:291. [PubMed: 20242217]
9.
Barrett N R. Report of a case of spontaneous perforation of the esophagus successfully treated by operation. Br J Surg. (1947);35:216. [PubMed: 20271775]
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Whyte I R, Iannettoni M D, Orringer M B. Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg. (1995);109:140. [PubMed: 7815790]
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Abbott O A, Mansour K A, Logan W D, Sympas P N. A traumatic so-called spontaneous rupture of the esophagus: A review of 47 personal cases with comments of a new surgical therapy. J Thorac Cariovasc Surg. (1970);59:67. [PubMed: 5409955]
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Urschel H C, Razzuh M A, Wood R E. Improved management of esophageal perforation: Exclusion and diversion in continuity. Ann Surg. (1974);179:587. [PMC free article: PMC1356028] [PubMed: 4207349]
13.
Santos G H, Frater R W. Transesophageal irrigation for the treatment of mediastinitis produced by esophageal rupture. J Thorac Cardiovasc Surg. (1986);91:57–62. [PubMed: 3941560]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6892

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