Emergency Management of Spontaneous Esophageal Perforation

Introduction

The esophagus travels across the neck, thorax, and abdomen region and is enclosed by the vital organs at each level. The esophagus encounters injuries either by foreign body ingestion, caustic ingestion, perforation, or trauma. These injuries can lead to further complications as the esophageal wall is breached, causing digestive contamination of surrounding vital organs. Being a rare, life-threatening surgical emergency, esophageal perforation should be suspected in all patients suffering from lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms.

What Causes Esophageal Perforations?

Iatrogenic esophageal perforations caused by therapeutic endoscopic procedures are the most commonly encountered perforations. The etiological factors can be classified into:

1. Iatrogenic:

• Diagnostic endoscopy.

• Endoscopic biopsy.

• Variceal sclerotherapy.

• Endoscopic laser therapy.

• Endoscopic photodynamic therapy.

• Endoscopic stent placement.

• Nasogastric tube placement.

• Endotracheal intubations.

• Transesophageal echocardiography.

• Minitracheostomy.

2. Traumatic:

• Penetrating traumas like gunshot and stab injuries.

• Blunt trauma like motor vehicle accidents.

• Sword swallowing.

3. Foreign Bodies:

• Bones.

• Dentures.

• Button batteries.

4. Caustic Agents: Acidic and alkali agents.

5. Spontaneous or Boerhaave’s Syndrome.

6. Infective Causes:

• Candida.

• Herpes.

• Syphilis.

• Tuberculosis.

• Immunocompromised conditions.

7. Non- Non-esophageal Surgery Causes:

• Thyroid tumors.

• Lung tumors.

• Spine tumors.

• Mediastinal tumors.

What Implications Occur Following Esophageal Perforation?

Pathophysiology:

• The cervical esophagus at the level of the cricopharynx happens to be the commonest site of injury when the diagnostic endoscopy is performed.

• The pharyngoesophageal junction is the weakest point, and piercing or shearing action caused by the endoscope leads to perforation.

• Owing to complex anatomic morphology and the location of the esophagus, bacteria, and digestive enzymes tend to get access to the mediastinum, causing severe mediastinitis, empyema, sepsis, and multiple organ dysfunction syndromes.

What Are the Clinical Features of Esophageal Perforations?

The clinical features occur depending upon the perforation site. Some of the major clinical features following esophageal perforations include,

• Pain.

• Vomiting.

• Hematemesis.

• Dysphagia (difficulty in eating).

• Tachypnea (abnormally fast breathing).

• Cough.

• Fever.

• Acute or severe epigastric pain.

• Tachycardia (increased heart rate).

• Hypotension/ shock.

• Subcutaneous emphysema (air being trapped within the tissues of the skin).

• Pneumothorax (air being trapped in the space called pleura, which covers the lungs) and hemothorax (leaking of blood into the space called pleura, which covers the lungs).

• Spontaneous esophageal perforation includes the Mackler triad of symptoms consisting of vomiting, chest pain, and subcutaneous emphysema.

• Neck stiffness.

• Mediastinitis (inflammation of the mediastinum- a space in the chest that houses the heart and other important organs in that region )

• Peritonitis (inflammation of the peritoneum space covering the abdomen).

• Gross sepsis.

• Multiple organ dysfunction syndrome.

How Are Esophageal Perforations Diagnosed?

• The main diagnostic key lies in the careful evaluation of history and clinical features.

• The suspicion of esophageal perforation should be ruled out if the patient presents with pain, fever, forceful vomiting, or a history of esophageal instrumentation.

• A lateral neck X-ray is beneficial in the case of cervical esophageal perforation as it can reveal air in the prevertebral facial planes.

• Posterior and lateral chest X-rays and upright abdominal series for detecting thoracic or intra-abdominal esophageal perforation reveal pneumomediastinum, subcutaneous emphysema, mediastinal widening, or a mediastinal air-fluid level.

• A contrast esophagogram is advised once esophageal perforation is suspected in the chest X-ray.

• Barium study followed by contrast esophagography using a water-soluble agent is useful in locating the perforation.

• A dilute barium study reveals whether the perforation is limited to the mediastinum or communicates freely with the pleural or peritoneal cavities, and the primary area of leakage can be determined.

• A contrast-enhanced CT scan of the chest is advised in detecting mediastinitis when a contrast esophagogram cannot be obtained or in case of a negative result in spite of strong clinical suspicion.

• Findings like mediastinal air, extravasated luminal contrast, peri esophageal fluid collections, pleural effusions, or actual communication of an air-filled esophagus with an adjacent mediastinal air-fluid collection suggest perforation.

• Other diagnostic procedures like MRI (magnetic resonance imaging) can be used to rule out dissection of the aorta, ventilation-perfusion (V/Q) scan and CT (computed tomography) scan can be investigated to rule out pulmonary embolism and ECG (electrocardiogram) can be advised to exclude myocardial infarction or other cardiac abnormalities.

How Are Esophageal Perforations Managed?

• The choice of treatment is directed by the etiology, site of perforation, the general physical condition of the patient, and the extent of contamination, which is revealed by radiologic studies.

• Surgery is the mainstay of treatment; however, the non-operative mode of treatment is gaining popularity in recent times.

• Patients with hemodynamic instability or suffering airway compromise should be managed in an intensive care unit (ICU) having complete resuscitative facilities, including emergency airway equipment and artificial respiratory support.

• Esophageal perforations can be managed by the following.

1. Surgical Approach:

• Surgery is indicated in cases of:

1. Early postemetic perforation.

2. Hemodynamic instability.

3. Intra-abdominal perforation.

4. Extravasations of contrast into adjacent body cavities.

5. Presence of underlying malignancy.

6. Obstruction or stricture in the region of the perforation.

7. Surgically fit the patient.

• Resection is indicated in the perforation of a diseased esophagus. Primary closure can be attempted in the perforation of a healthy esophagus.

• Most of the time, it is advised to perform a two-layer closure (mucosa and muscularis) in case of a primary suture repair.

• If it is not feasible, a single-layer closure should be done. Sometimes, it is not possible to do a direct closure because of the friability of the tissue. Such cases demand flap surgeries to cover the defects.

• Pleural flaps, omental flaps, intercostal muscle flaps, and pericardial flaps are commonly advised.

• Reinforcement with vascularized tissue decreases fistula formation and mortality compared to repair without reinforcement.

• Esophageal resection or exclusion and diversion is indicated in cases when a primary repair is not possible due to local tissue friability or in case of severe mediastinitis.

• Exclusion and diversion procedures include cervical esophagostomy, gastric decompression with a gastrostomy, esophagogastric junction stapling, and jejunostomy.

• Patients with megaesophagus, carcinoma, caustic ingestion, stenosis, or severe un-dilatable reflux are indicated for esophageal resection with or without immediate reconstruction.

• Postoperative care includes hemodynamic monitoring, cardiac and respiratory support, broad-spectrum antibiotic therapy for seven to ten days, and nasogastric decompression of the stomach until resolution of the postoperative ileus occurs.

• A Contrast study should be advised on the 5th postoperative day to evaluate the integrity of the repair. Long-term surveillance is advised to check for stricture, reflux, or carcinoma formation.

1. Non-surgical Approach:

• Nonoperative treatment involves large-bore intravenous access, supplemental oxygen, and cardiopulmonary monitoring in a critical care setting.

• The patient should be kept nil per oral, and gastric contents can be cleared with the help of a nasogastric tube; hence, further contamination can also be eliminated.

• Broad-spectrum intravenous antibiotics should be administered for a minimum of seven to ten days.

• Narcotic analgesia is administered to control pain and discomfort.

• The intercostal chest tube should be placed to decompress the chest whenever required.

• Total parenteral nutrition is advised in prolonged cases.

• Endoscopic placements of removable covered esophageal stents like poly flex esophageal stents have been advocated as they are more flexible in treating primary and secondary esophageal leaks with a reduced hospital stay, fewer adjunctive procedures, and early resumption of oral diet.

• Metallic clips are being used for successful endoscopic closure of esophageal perforation in case of iatrogenic errors, foreign body ingestion, and Boerhaave’s syndrome. This procedure benefits patients with clearer and smaller perforations and minimal sepsis.

• Contrast studies should be advised at regular intervals to determine the progress of the treatment.

Conclusion

Esophageal perforation is a highly morbid condition with increased mortality rates, which is mainly directed by the time of presentation and etiology of perforation. The esophageal perforations have better outcomes when treated within 24 hours of perforation than the ones treated after 48 hours. The characteristic variable clinical manifestations and unspecific radiographic findings often result in appropriate diagnostic delays, thus affecting the prognosis of the condition. Early diagnosis and timely therapeutic intervention are critical for the successful management of the case.