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Epidemiology
Iatrogenic instrumentation (e.g., endoscopy, dilatation, tube passage, etc.) has replaced spontaneous rupture as the leading cause of esophageal perforation and accounts for 60 to 75 percent of esophageal injuries.
Pathophysiology
Esophageal perforation results in leakage of esophageal and gastric contents into the mediastinum, producing a chemical burn and superinfection. Left untreated, this leads to a severe inflammatory response and sepsis.
Esophageal perforations are broadly divided into intraluminal and extraluminal types. Intraluminal injuries are caused by instrumentation, foreign bodies, caustic ingestion, esophagitis, carcinoma, infection, or barotrauma. Extraluminal causes include stab or gunshot wounds, blunt trauma, and operative injuries.
Clinical features
Patients sustaining a cervical esophageal perforation typically present with cervical pain, odynophagia, subcutaneous emphysema, and neck tenderness and crepitus. Dysphagia, pain, tachycardia, and fever usually occur shortly after iatrogenic perforation. Intra-abdominal esophageal perforation usually presents with peritonitis. Late manifestations of untreated perforations often include hypoxia, sepsis, and shock.
Diagnostics
An antecedent history of instrumentation or vomiting often points to the etiology and possibility of esophageal perforation. Plain chest radiography may show pneumomediastinum, subcutaneous emphysema, or subdiaphragmatic air. Diagnosis is usually confirmed with esophagography, which demonstrates a leak in 50 to 60 percent of cervical and 80 to 90 percent of thoracic esophageal perforations. Esophagoscopy and computed tomography are other diagnostic modalities used in selected circumstances.
Treatment
The initial management of patients presenting with esophageal perforations includes cessation of oral intake, fluid resuscitation, and broad-spectrum antibiotics. Definitive treatment of perforations is divided into nonoperative and operative management. Nonoperative management may be undertaken in selected patients with limited perforations that drain back into the esophagus and are not associated with distal obstruction, communication with the abdominal cavity, or systemic sepsis. Operative treatment is predicated on adequate debridement, reinforced primary repair, wide drainage, and distal feeding tube placement. In the absence of underlying esophageal disease, there is a trend toward primary reinforced repair, regardless of the perforation’s duration. Underlying esophageal disease is best addressed before or at the time of perforation repair.
Outcomes
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Esophageal perforation was first described in 1724 by the Dutch physician Hermann Boerhaave, who published the presentation, clinical course, and autopsy findings of spontaneous rupture of the esophagus in his patient Lord van Wassenaer, High Admiral of the Dutch Navy. In this seminal work, he described the clinicopathologic correlation between esophageal perforation and a fatal outcome, one that remained inevitable for over 200 years. Despite modern surgical techniques, perforation of the esophagus still represents a true surgical emergency. In the mid-20th century, successful primary repair of esophageal perforation was first reported by Barrett in 1946 and later by Olsen and Claggett in 1947, and esophagectomy for esophageal perforation was described by Satinski and Kron in 1952, all of which led the way to the modern treatment of these injuries.1–4 Although spontaneous esophageal rupture is uncommon today, the dramatic ...