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  • • 4 sources

    • 1. Direct contamination

      2. Hematogenous/lymphatic spread (granulomatous)

      3. Extension of infection from neck/retroperitoneum

      4. Extension from lung/pleura

    • Empyema loculates to form paramediastinal abscess; true mediastinal involvement uncommon

    • Mediastinitis often involves pleura

    • Esophageal perforation is most common form of direct contamination (90% of cases)

    • Secondary causes include:

    • -Oral surgery

      -Trauma to pharynx

      -Tracheostomy

      -Mediastinoscopy

      -Thyroidectomy

    • Pneumothorax after upper endoscopy indicates esophageal perforation

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Epidemiology

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  • • Acute: Esophageal, cardiac or other mediastinal operations

    • Rarely, direct infection by suppurative conditions involving ribs or vertebrae

    • Most cases caused by pyogenic organisms

    • Continuous involvement from cervical infection common (along fascial planes)

    • Retroperitoneum less commonly involved

    • Esophageal perforation caused by:

    • -Boerhaave syndrome

      -Iatrogenic trauma (dilation, esophagogastroduodenoscopy, etc)

      -External trauma

      -Cuffed endotracheal tubes

      -Ingestion of corrosives

      -Carcinoma

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Symptoms and Signs

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  • • History of vomiting

    • Severe boring pain in substernal, left or right chest, or epigastric regions, radiation to back

    • Chills, fever, shock, tachycardia

    • Dyspnea, pain in shoulder if involves pleura

    • Swallowing worsens pain; dysphagia

    • 60% have pneumomediastinum/subcutaneous emphysema

    • Pericardial crunching with systole (Hamman sign) is late finding

    • 50% have pleural effusion or hydropneumothorax

    • Neck tenderness, crepitance found in cervical perforation

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Imaging Findings

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  • • Hypaque esophagogram (use water soluble media)

    CT chest: With PO and IV contrast, may help determine level of perforation, degree of soilage, underlying pathology

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Rule Out

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  • • Myocardial infarction

    • -Often confused with esophageal perforation

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  • • History and physical exam

    • Hypaque esophagogram (use water soluble media)

    • Chest CT with PO or IV contrast

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  • • Underlying cause determines treatment

    Initial management: Immediate drainage of pleural contamination with chest tube

    • Broad-spectrum antibiotics initiated with fluid hydration

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Surgery

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  • Right thoracotomy: Best access to most of intrathoracic esophagus (including distal portion)

    Left thoracotomy: Useful for perforation secondary to distal esophageal stricture

    Iatrogenic perforation (< 24 hrs): 2-layer closure (mucosal layer with interrupted absorbable sutures and muscle closure), buttress with pleura or muscle flap, wide irrigation and drainage

    Perforations > 48 hrs: Wide drainage, resect esophagus

    Perforation secondary to cancer, severe reflux stricture, achalasia: Resect esophagus with gastric pull-up if stable and < 24 hrs; if unstable, divert or resect without reconstruction

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Indications

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  • • All intrathoracic leaks should be explored

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Medications

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  • • Broad-spectrum antibiotics (including aminoglycosides)

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Prognosis

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  • • 30-60% mortality with esophageal perforation

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References

Freeman RK et al: Esophageal stent placement for the treatment of iatrogenic, intrathoracic esophageal perforation. Ann Thorac Surg 2007;83:2003.  [PubMed: 17532387]
Kiev J et al: A management algorithm for esophageal perforation. Am J Surg 2007;194:103.  [PubMed: 17560919]
Vogel SB et al: Esophageal perforation in adults: aggressive, ...

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