esophageal perforation - suny downstate medical center · “a management algorithm for esophageal...

Esophageal Perforation

Lidie Lajoie, MD MSc

SUNY Downstate Surgery Grand Rounds

June 2, 2011

www.downstatesurgery.org

HPI

•xxxx presents to ER xx hrs after ingesting boneless chicken breast at Popeye's restaurant resulting in foreign body sensation in chest and inability to swallow solids, liquids, or saliva. Multiple episodes of food impaction after swallowing large meaty food boluses in past resolved spontaneously or with fluid intake.

PMH

• Childhood asthma

• No prior surgery or endoscopy

• No medications

• NKDA


PE

• Vitals: 97.5 F, 144/87, 69, 96% RA

• O/P clear, no stridor

• Neck no tenderness or crepitus

• Lungs CTAB, chest no crepitus

• Abd soft, NT/ND

Labs

• CBC: 159 363

46

• CHEM7141 104 14

109

5 27 0.9

• Coags

1 / 14 / 28


• 8h: laryngoscopy by ENT – no FB in O/P

• 11h: CT neck – WNL• 13h: CXR – no radio-opaque FB

or pneumomediastinum• 16h: EGD by GI – impacted food

bolus 30cm from gums, unsuccessful attempted removal with tripods, rothnet, and rat tooth forceps

• 18h: CT chest: dilated proximal esophagus, noncalcified FB distal esophagus at T7


• 20h: evaluated by CT surgery• 22h: taken to OR

– 35cm rigid esophagoscope: unable to visualize

– 50cm rigid esophagoscope: meat at GE junction, unable to reach with laparoscopic instruments

– Flexible endoscope under direct visualization: meat pushed into stomach. Retroflexion reveals nLGE junction and on withdrawal, small mucosal tear posterior esophagus 2cm length visualized just proximal to GE junction


Postoperative course

• NPO, Abx

• 4h: CXR –mediastinal & SQ emphysema

• 8h: Tm 99, chest wall crepitus, WBC 16

• 14h: gastrograffinswallow NEG


Postop course cont.

• 24h: CT chest

R PTX, pneumomediastinum, high attenuation in distal esophagus

• 32h: CXR R pleural effusion

• 36h: chest pain and episode desaturation

• 40h: EGD, R VATS, washout


• Operative findings: posterior abrasion at 25cm, no perforation visualized

• VATS revealed clear pinkish pleural fluid. Washout performed and chest tube placed

• POD 1 esophogram: contained perforation distal esophagus

• Chest tube removed POD 5

• Discharged home HD 8


Esophageal Perforation

• Historical Perspective

• Etiology

• Algorithm for Diagnosis and Treatment

• Outcomes – Mortality

• Endoscopic Esophageal Stent Placement


Historical Perspective

• 1724: Boerhaave described symptoms, signs, and autopsy findings of esophageal perforation

• 1946: Barrett performed first surgical repair

• 1970s: Cameron described nonoperativeapproach


Presenter

Presentation Notes

First described by Boerhaave nearly 300 years ago, only 60 years since the first surgical repair.

Iatrogenic Perforation

48%

8%

33%

10%

1%

Causes of Esophageal Perforation

Iatrogenic

Spontaneous

Trauma

Foreign Body

Chemical

Endoscopy

Rigid endoscopy 0.11%

Flexible endoscopy 0.03%

Bougie dilator 0.4%

Pneumatic (achlasia) 1.7&

Thermal (UGIB) 1-2%

Sclerotherapy (varices) 1-6%

Photodynamic Tx (Ca) 4.6%

Stent (plastic >> metal) 5-25%

EUS 0.1%

Surgery

vagotomy

pneumonectomy

Heller myotomy

mediastinoscopy

ACDF

ASGE “Complications of Upper GI Endoscopy” GI Endosc 55:1(2002) 784.


Presenter

Presentation Notes

Iatrogenic perforation is by far most common, primarily as a complication of endoscopy. Spontaneous rupture includes barogenic perforation, infection, and tumors. Trauma is primarily penetrating injuries from SW or GSW, rarely blunt (0.001% from steering wheel). Chemical causes include caustic ingestion and long term contact with corrosive medications including potassium tablets, tetracycline, and NSAIDS.

Esophageal Anatomy

Brinster et al. “Evolving options in the Management of Esophageal Perforation” Ann Thorac Surg 77(2004): 1475.

LES ☐ Thoracic Cervical


Presenter

Presentation Notes

Perforations typically occur at one of 3 areas of physiologic narrowing: the cricopharyngeus, the level of the carina, and the LES. The differing etiologies are associated with varying incidence of perforation at these locations.

SIGNS AND SYMPTOMS OF ESOPHAGEAL PERFORATION

• Depends on location, degree of containment, and elapsed time

• CERVICAL– Neck tenderness, odynophagia, SQ emphysema (60%)

• INTRATHORACIC– Dysphagia, pain (71%), tachycardia, fever (51%),

dyspnea (24%), crepitus (22-30%),

• INTRA-ABDOMINAL– Peritonitis, free air


Water-Soluble or Barium Contrast Esophagography, Chest X-Ray, Computed Tomography

• CXR– 75-90% sensitivity– May be nL in first hour– Pneumomediastinum– Pleural effusions

• Midesoph Rt• Distal esoph Lt

• CT– neg esophogram & high

clinical suspicion, critically ill, atypical symptoms

– Extraluminal or mediastinalair, esophageal thickening, pleural effusion, abscess

• Contrast esophagography– 10% false negative rate

• Gastrograffin– Rapidly absorbed– Necrotizing pneumonitis– Sensitivity: cervical 50%,

thoracic 80%

• Barium– Retained after study– fibrosing mediastinitis– Sensitivity: cervical 60%,

thoracic 90%


Contained Perforation “Nonoperative Management”

• Cameron/AltorjayCriteria:– intraluminal dissection

– transmural perforation that drains back into the esophagus

– no associated distal obstruction

– not intra-abdominal

– no evidence of sepsis

• NPO

• IV broad-spectrum Abx

• NGT

• +/- TPN

• +/- Chest tube

• close observation for 72hrs


Determinants for Failure of Conservative Management (20% in 24hrs)

• Retrospective review of 119 pts

• Successful nonoperative Txin pts with scores 2 or less

• Better outcomes with operative Tx for score 3 or more

Abbas et al. “Contemporaneous management of esophageal perforation.” Surgery 146(2009):749.


Uncontained Perforation

Pathophysiology• negative intrathoracic

pressure sucks esophageal & gastric contents into mediastinum, inducing chemical burn. Saliva, oral bacteria and digestive enzymes initiate mixed necrotizing superinfection

Treatment Principles

• Evaluate site & severity via EGD

• Resect vs repair

• Establishment of enteric access distally (PEG, G-tube, or J-tube)

• Complete debridement with wide drainage

• 2 layer closure followed by buttressing to adjacent healthy tissue


Management of Cervical Perforation

Drainage alone SCM flap


Surgical approach to thoracic or abdominal

perforations

• Middle third of esophagus Right thoracotomy sixth ICS

• Lower third of esophagus Left thoracotomy seventh ICS

• Abdominal esophagus upper midline laparotomy


Esophagectomy

• Malignancy• Long-segment Barrett’s

esophagus• Severe stricture w/ prior

dilations• Long-standing dysphagia• Severe reflux with

regurgitation and aspiration

• Megaesophagus• Caustic ingestion

• Early Dx, confined to mediastinum, minimal contamination transhiatalesophagectomy with immediate reconstruction

• Delayed Dx, extensive mediastinal or pleural contamination Transthoracic approach with staged reconstruction


Primary Repair

• Healthy esophagus• Early diagnosis (24-48hrs)• Debride necrotic tissue• Vertical

esophagomyotomy• Secure closure of mucosa• Irrigation and drainage of

contaminated area• Buttressing with adjacent

healthy tissue


Pleural Flap Intercostal Muscle Flap


Diaphragmatic pedicle flapOutcomes for Primary Repair

• Mortality 3-13%

• Without treatment of distal obstruction (stricture, achalasia) mortality nears 100%

• Leak rate 80% in pt presenting >24hrs after perforation


Controlled Fistula

• Critically ill or unstable

• Extensive tissue inflammation

• Debridement and washout followed by closure over T-tube

• T-tube Removal after 6wks


Exclusion and Diversion

• Wide drainage of contamination

• Proximal and distal diversion with exclusion of perforated segment

• Cervical esophagostomy• Drainage gastrostomy• Feeding jejeunostomy• Esophageal ligation with

absorbable suture converts to single-stage procedure


Mortality after Esophageal Perforation

0%

5%

10%

15%

20%

25%

30%

35%

40%

Etiology

Location

Delay


Endoscopic Esophageal Stent Placement

Author etiology # Pts Stent Seal Compl Mortality

Fischer et al 2006 Benign 15 cSEMS 100% 7% ---

Freeman et al 2007 Benign 17 silicone 94% 18% 0

Kiev et al 2007 Various 14 polyfex 100% 21% 0

Kim et al 2008 Delayed 16 Silicone 100% 35% 6%

Leers et al 2009 Iatrogenic 31 cSEMS 92% 3% 6%

Radecke et al 2005 Perf+stenosis 39 SEPS 73% 30% 0

Salminen et al 2009 Thoracic 32 cSEMS 78% 28% 16%

Van Heel et al 2010 Benign 33 SEPS 97% 33% 15%

cSEMS = covered self-expanding metallic stent; SEPS = self-expanding plastic stent


References• Abbas et al. “Contemporaneous management of esophageal perforation.” Surgery 146(2009):749.• ASGE “Complications of Upper GI Endoscopy” GI Endosc 55:1(2002) 784.• Brinster et al. “Evolving options in the Management of Esophageal Perforation” Ann Thorac Surg 77(2004): 1475.• Cameron JL. Current Surgical Therapy, 9th Ed.• Fischer A et al. “Nonoperative treatment of 15 benign esophageal perforations with self expanding covered metal

stents.” Ann Thorac Surg 81(2006 467.• Fischer JE. Mastery of Surgery, 5th Ed.• Freeman RK et al. “Esophageal stent placement for treatment of iatrogenic intrathoracic esophageal perforation.”

Ann Thorac Surg 83(2007)2003.• Kiev et al. “A management algorithm for esophageal perforation” Am J Surg 194(2007)103.• Kim AW et al. “Utility of silicone esophageal bypass stents in management of delayed complex esophageal

distruption.” Ann Thorac Surg 83(2009)1962.• Leers JM et al. “Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable

metallic stent.” Surg Endosc 23(2009)2258.• Fadecke K et al. “Impact of a self expanding plastic esophageal stent on various esophageal stenoses, fistulas, and

leakages: a single-center experience in 39 patients.” Gastrointest Endosc 61(2005) 812.• Salminen P et al. “Use of self-expandable metal stents for the treatment of esophageal perforation and

anastomotic leaks” Surg Endosc 23(2009) 1526.• Sepesi et al. “Esophageal Perforations: surgical, endoscopic and medical management strategies.” Curr Opin

Gastroenterol 26 (2010), 379.• Van Heel NC et al. “Short term esophageal stenting in the management of benign perforations.” J Am

Gastroenterol 105(2010)1515.• Wu et al. “Esophageal Perforations: New Perspectives and Treatment Paradigms.” J Trauma 63:5(2007), 1173.• Zinner MJ, Ashley SW, eds. Maingot’s Abdominal Operations, 11th Ed.


esophageal perforation - suny downstate medical center · “a management algorithm for esophageal...

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