48: Management of Esophageal Perforation

Introduction

Esophageal perforation is a challenging clinical condition that requires prompt diagnosis and management. Delay in identification and/or treatment results in high rates of morbidity and mortality. There are sharp differences in etiology, presentation, treatment, and outcome of cervical versus thoracic perforation of the esophagus. Most cervical perforations respond well to simple drainage alone. Although the treatment of thoracic esophageal perforations is individualized, most patients are candidates for primary repair regardless of the time to presentation or intervention. Improvements in endoscopic stent technology and increased experience with placement support this modality as a viable treatment option in cases of benign, malignant, and iatrogenic esophageal perforation.

Etiology

Esophageal perforation usually is the result of iatrogenic injury caused by instrumentation (e.g., esophagoscopy, bougienage, and achalasia dilation)^1-3 (Table 48-1). The most common site for perforation of the normal esophagus is at its most proximal location, immediately above the cricopharyngeus muscle and below the inferior pharyngeal constrictor (Killian's triangle). Injury at this location is most often 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 syndrome). Blunt and penetrating trauma contributes only a small number of perforations.⁴ Foreign bodies, infections, and operative injuries are additional, although rare, causes worth noting.⁵

Diagnosis

Pain is the most common complaint in patients presenting with esophageal perforation. In addition, cervical perforations can present with 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, and is usually severe. Dyspnea and anxiety are common associated findings. Tachycardia is also common, and fever develops early ...