Esophageal perforation can be difficult to diagnose promptly. Delay in treatment results in a high mortality rate. There are sharp differences in etiology, presentation, treatment, and results of cervical versus thoracic perforation of the esophagus. Most cervical perforations respond well to simple drainage. Although the treatment of thoracic esophageal perforations is individualized, most patients are candidates for primary repair regardless of whether they are treated early or late.
Esophageal perforation usually is the result of iatrogenic injury caused by instrumentation (e.g., esophagoscopy, bougienage, and achalasia dilation)1–3 (Table 40-1). The most common site for perforation of the normal esophagus is at its most proximal location just above the cricopharyngeus muscle and below the inferior constrictor (Killian's triangle). The injury at this location usually is caused by attempted forceful intubation of the esophagus for endoscopy (rigid or flexible) in a patient who is not sufficiently anesthetized. Other common sites of perforation include those in which the esophagus is normally narrowed (the distal esophagus), pathologically narrowed, or anatomically abnormal. Occasionally, intramural perforation can occur when the mucosa is sheared off the muscularis during endoscopy or bougienage. These conditions are not perforations in the truest sense but present in a similar fashion and must be differentiated from frank perforation. Spontaneous perforation is a misnomer. It is more accurately termed barogenic perforation (Boerhaave's syndrome). Blunt and penetrating trauma contributes a small number of perforations.4 Foreign bodies, infections, and operative injuries are additional causes of perforation.5
Table 40-1. Etiology of Esophageal Perforation |Favorite Table|Download (.pdf)
Table 40-1. Etiology of Esophageal Perforation
Esophagoscopy, dilation, sclerotherapy, pneumatic dilation, laser therapy, biopsy, stent placement, nasogastric tubes, endotracheal tubes, transesophageal echocardiography (TEE), and esophageal ultrasound
Boerhaave's syndrome, childbirth
Blunt, penetrating, high-pressure gas (through the oral cavity)
Cervical spine surgery, pulmonary resection, resection of pleural or mediastinal masses, esophageal surgery, vagotomy, antireflux surgery
Foreign body, caustic ingestion
Esophageal cancer, mediastinal invasion of periesophageal tumors or lung cancer
Pain is prominent in patients presenting with esophageal perforation. Patients with cervical perforations usually present with neck pain, dysphagia, odynophagia, and dysphonia. Subcutaneous emphysema is often palpable in the neck. Pain from an intrathoracic perforation may be localized initially to the subxiphoid region and hence may be misinterpreted as a myocardial infarction, aortic dissection, perforated duodenal ulcer, or pancreatitis. The pain also may be substernal, referred to the back, or poorly localized, but it is usually severe. Dyspnea and anxiety are common findings in patients with esophageal perforation. Tachycardia is very common, and fever quickly develops. The frequency with which shock occurs, rarely seen after a cervical perforation, varies with the type of perforation and length of time after the original insult. With free perforation into the pleural space, as often occurs with Boerhaave's syndrome, rapid progression to shock may occur within 24 hours. Perforation by balloon dilation of ...