Esophageal Perforation - Types and Surgical Management

Introduction:

Several esophageal injuries include esophageal trauma, perforation (hole), foreign body absorption, and caustic ingestion (accidental ingestion of strong chemical acids). These wounds can cause issues either due to injury of immediate organs or infection of surrounding organs when the esophagus wall is damaged.

What Is Esophageal Perforation?

A hollow tube called the esophagus, also known as the food pipe, carries food and liquids from the mouth to the stomach. The esophagus travels through the neck, thorax, and abdomen and is surrounded by major organs. Adults with esophageal perforation (hole) experience high rates of disease and death.

What Are the Causes of Esophageal Perforation?

Following are the causes of esophageal perforation:

• Iatrogenic (due to medical therapy or examination).

• External injury.

• Caustic fluid (like cleaning solutions and battery liquids) consumption can induce esophageal perforation.

What Are the Symptoms of Esophageal Perforation?

Following are the symptoms of esophageal perforation:

• Back pain or left shoulder ache radiates from the chest.

• Vomiting.

• Respiration difficulty.

• Subcutaneous emphysema (air getting into tissues under the skin).

• Issues with the voice.

• Problems swallowing.

• Epigastric pain (abdominal pain).

• Hematemesis (blood vomiting).

How Is Esophageal Perforation Diagnosed?

Diagnosis of esophageal perforation is done in the following ways:

• On a plain chest X-ray, perforation-related indirect symptoms can be seen.

• A chest X-ray does not detect the location of the perforation; a computed tomography scan (CT scan) of the chest and abdomen does.

• When there is no visible perforation on the X-rays, but there is still a suspicion, an upper endoscopy is performed. It provides clear visualization of the stomach and esophagus.

What Are the Types of Esophageal Perforation?

It can be broadly divided into three types based on the anatomic location of the perforation in the esophagus:

1. Cervical Esophageal Perforation: The first part of the esophagus is called the cervical segment. A perforation in this area is termed cervical esophageal perforation. Esophagus perforations in this location can be uncommon and dangerous to an individual's life.

Causes - The main cause for the tear at this site is due to iatrogenic action, which may be surgeries relating to the thyroid, cervical spine, or endoscopic procedures.

Symptoms

1. Pain in the neck.

2. Weakness and fever.

3. Redness of the skin.

4. Voice disorder.

5. Joint and bone crackling sounds during the movement of the neck.

Diagnosis - Complications underlying this cause can be minimized by early diagnosis through CT scan, endoscopy, and X-rays at regular intervals in series post swallowing.

Treatment - Drainage of the neck, antibiotics, natural supplements, and endoscopic stents of the esophagus are all included in the treatment.

2. Thoracic Esophageal Perforation: Following the cervical segment is the thoracic segment. Perforation in the thoracic segment of the esophagus is called thoracic esophageal perforation. Perforation at this esophagus site is dangerous compared to thoracic and abdominal sites, and has high morbidity rates.

Causes

1. Iatrogenic perforations at this site are small and can be diagnosed early.

2. Spontaneous perforations, such as Boerhaave syndrome, rupture the esophagus because of vomiting-induced pressure.

Treatment

1. Strict fasting is advised.

2. Antibiotic intake is continued.

3. Endoscopic stents are placed.

4. Drainage of the infectious site.

5. Primary closure of the wound is done surgically.

6. Esophageal exclusion, a process where the damaged esophagus is removed, is also done.

3. Abdominal Esophageal Perforation: The last segment of the esophagus is called the abdominal segment. A perforation in this segment is called abdominal esophageal perforation. Rupture at this esophageal site is very rare. In most cases, it is managed along with the perforation of the thoracic esophagus

Causes

1. Perforation of the instruments.

2. Spontaneous perforation.

3. Faulty techniques lead to forceful dilation (enlargement).

Symptoms

1. Pain in the upper abdomen.

2. Vomiting.

3. Discomfort in the abdomen.

4. Weakness and discomfort in breathing.

Diagnosis

1. Radiological examinations.

2. Upper abdomen CT scan.

Treatment

1. Drainage of the infected fluid and food.

2. Endoscopy and placement of a stent.

3. Repair of the perforation.

4. Esophagectomy (removing a part of the esophagus) when a repair is impossible.

How Is Esophageal Perforation Managed?

Esophageal perforation management and identification pose a significant issue.

Early diagnosis reduces the chances of fatality (death) compared to late diagnosis.

Treatment also depends upon the location of the perforation, the patient's condition, the condition of the esophagus, and the extent of harm.

A healthy esophagus requires a different approach than an esophagus with a disease.

Initial Medical Care:

• Nil per mouth (food is avoided through the mouth).

• Fluids are continuously administered intravenously.

• Pain treatment.

• Antibiotics with a broad range are infused intravenously (IV).

• Monitoring is done for oxygen saturation levels.

• Surgery, if required, would come next.

• Patients with iatrogenic (unknown etiology) conditions have primarily chosen non-operative treatment.

• In addition to fundoplication, a surgical treatment termed myotomy is used to treat holes caused by various reasons.

Surgical Management:

The surgical management of esophageal perforation plays a very important role.

• Primary closure is done by bringing the wound edges together.

• Buttressing (strengthening) primary closure of damage with pleural flap, pericardial fat pad (fat pad around the heart).

• Grafts like the diaphragmatic pedicle graft and omentum flap from one area are brought to another, maintaining the blood supply.

• Certain muscles can also be used as a graft.

• Draining of the site if there is the presence of any infection.

• Primary closure with esophagectomy (removing some or most parts of the esophagus) combined with either immediate or delayed reconstruction.

• T-tube drainage (Placing a T-tube for diversion).

• Esophageal stenting (a small metal tube inserted to keep the passage open in the esophagus).

• Application of fibrin glue (a surgical formulation that helps adjoining tissues together.

• Endoclip application (it is a device used to close any openings without surgery).

Conclusion:

Treatment for perforated esophagus is subjected to multiple factors. It depends on the severity of the injury, its location, and various causes of the injury. These variables determine the treatment method and may involve non-operative care, minimally invasive and endoscopic procedures, primary repair with tissue support and esophageal division.

All thoracic surgeons should be proficient in treating esophageal perforation, a crucial but difficult expertise. In addition, to achieve positive outcomes in this challenging clinical presentation, the thoracic physician must be skilled in precise tests, effective resuscitation techniques, and quick but skillful repair.