TY  - CHAP
M1  - Book, Section
TI  - Esophageal Perforation
A1  - Kemp, Clinton D.
A1  - Yang, Stephen C.
A2  - Yuh, David D.
A2  - Vricella, Luca A.
A2  - Yang, Stephen C.
A2  - Doty, John R.
PY  - 2014
T2  - Johns Hopkins Textbook of Cardiothoracic Surgery
AB  - EpidemiologyIatrogenic  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.PathophysiologyEsophageal  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  featuresPatients  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.DiagnosticsAn  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.TreatmentThe  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.OutcomesEsophageal  perforation  has  an  associated  mortality  rate  of  20  percent.  
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/19
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1104586430
ER  -