Trauma to the

All esophageal perforations, regardless of loca- tion or size, are potentially lethal. As with the rupture of any hollow viscus, an esophageal tear Floyd D. Loop, M.D. demands recognition without delay, for early Department of Thoracic and Cardio- diagnosis influences the patient's hospital course vascular Surgery more than any other single factor. Mediastinitis and its devastating sequelae progress rapidly, and any prolonged loss of time may eventually render the patient unresponsive to even the most aggres- sive treatment. Before the era of antibiotics and incisional drainage, most patients died after cervical esophageal perforation and disruption of the thoracic esophagus was uniformly fatal. From the experiences reported by Jemerin,1 Pearse,2 Barrett,3 Samson,4 and others, the concept of operative treatment was introduced. In recent years, surgical intervention has become well established, and the prognosis for esophageal in- jury has greatly improved. It is the purpose in this paper to present the mechanisms of eso- phageal perforation, the methods that aid in preventing such injury, and the surgical prin- ciples involved in early and late stages of manage- ment.

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Upper esophageal perforation drainage. In contrast, cervical medias- Virtually all perforations of the cer- tinotomy is a safe and simple ap- vical esophagus are caused by instru- proach that halts the threat of descend- mentation or penetrating wounds. The ing mediastinitis, drains the abscess, upper end of the esophagus is the nar- and shortens the hospital stay (Fig. 1). rowest part, and the esophageal wall is Often the laceration cannot be seen compressed against the sixth or due to the tremendous inflammatory seventh cervical vertebra as the esopha- reaction, but primary suture is not goscope passes across the cricopharyn- mandatory and the hole will close geus muscle.5 The endotracheal tube spontaneously if no distal esophageal cuff should always be deflated, since it obstruction exists. Soft drains are contributes to a further decreased placed both superiorly and inferiorly lumen diameter. The crushing effect into the upper mediastinum and should remain in place 4 or 5 days, is increased by hyperextending the pa- 7 tient's ; perforation during diag- until a suitable tract is established. nostic instrumentation is most likely to During this time, the patient is fed occur at this level. The surrounding through a nasogastric tube or intra- buccopharyngeal is lacerated, venously, and broad spectrum anti- thus contaminating the retroesopha- biotics are administered until the geal or . Although drainage decreases. Thereafter, a solid lateral spread is contained by muscle diet is preferred, since liquids only and fascia, the retroesophageal space add to the fistula output. In most cases, extends to the carina, providing an the leak closes within 10 days. open route for descending mediastinal Lower esophageal perforation infection. The endoscopist may realize what Endoscopic errors occur beyond the has happened when he becomes "lost" cricopharyngeal region less frequently. during the procedure. A suspected The incidence of perforation increases, perforation should be confirmed by however, in the presence of distal immediate contrast swallow. If the esophageal obstruction. Bouginage laceration is unnoticed, the patient used for the treatment of achalasia, will soon provide his own clues: cervi- stricture, or neoplasm is associated cal pain and tenderness, dysphagia, with the greatest risk. Major opera- and fever occur within a few hours. tions, such as removal of large thoracic Subcutaneous air soon becomes palp- aneurysms or radical pulmonary resec- able in the neck and also can be seen tion may also cause injury to the on the roentgenogram. Within 6 to 8 nearby esophagus.8 Perforation dur- hours, the infection becomes promi- ing abdominal vagotomy is another nent laterally and descends into the cause, and the possibility of esophageal mediastinum.6 injury should be considered when un- Unless the perforation is minute, explained pleural infection arises in e.g., from a pin or fish bone, expectant conjunction with these procedures.9 treatment with antibiotics involves a In the past decade, the so-called risk which may result in abscess forma- spontaneous rupture has been redis- tion, ultimately requiring cervical covered and now rivals instrumenta-

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Fig. 1. Instrumental rupture of the cervical esophagus shown contaminating the prevertebral space. The drainage incision parallels the anterior border of the sternomastoid muscle and can be performed on either side. The middle vein and inferior thyroid artery are ligated to gain wide exposure of the prevertebral space. The inflammatory reaction guides the surgeon into the proper plane between and .

tion as the leading cause of intra- the left side is least supported by sur- thoracic esophageal injury. The term rounding viscera.11 spontaneous implies a tear not caused For increased intraluminal pressure by external trauma, foreign bodies or to cause a blowout, a temporary ob- instruments, but inflicted by the pa- struction must exist at the other end tient upon himself. Postemetic per- of the esophagus. This can be pro- foration has been suggested as more duced through spasm of the crico- descriptive, but many reports em- pharyngeal pinchcock during alco- phasize heavy straining rather than holic intoxication, or in central nerv- vomiting.10 The eponym, Boerhaave's ous system disease.12 Muscular inco- syndrome (after the Dutch physician ordination associated with prolonged who first described the entity in 1754), retching and benign or malignant is probably more applicable than the stricture can also provide the neces- descriptive terms. A full thickness sary obstructive element. The esopha- linear laceration is usually produced geal damage is often misdiagnosed, in the lower third of the esophagus on and the resulting delay accounts for the left posterolateral wall. The a graver prognosis than with cervical muscle is thinner in this region and perforations.

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Fig. 2. Thoracic esophageal perforations create a fulminating chemical and bacterial effect that soon ruptures the mediastinal pleura. The negative intrapleural pressure then draws more saliva, air, and gastric fluid through the defect, causing a hydropneumothorax and compressive atelectasis.

Within several hours perforation of one third of the patients. Hematemesis the thoracic esophagus produces a ful- may have been noted initially, but its minating mediastinitis that directly significance is much less than in Mal- contaminates one or both pleural cavi- lory-Weiss syndrome, in which the tear ties. The chemical insult quickly is confined in depth to the mucosa changes to a necrotizing aerobic and and circular muscle near the gastric anaerobic process that ruptures the junction. The diagnosis of a ruptured mediastinal pleura. When the pleura esophagus must be considered when- is contaminated, it reacts by produc- ever vomiting and upper abdominal ing a large effusion which compresses pain are prominent in the history. the lung, shifts the mediastinum and, These early symptoms later give way eventually, compromises the cardio- to thoracic pain which will worsen respiratory mechanism (Fig. 2). despite supportive treatment and, Typically, the so-called spontaneous finally, a shock-like picture develops. rupture occurs in men older than age The most valuable diagnostic pro- 50, and the history often includes ex- cedure is the upright chest roent- cessive intake of food or alcohol. genogram. Most patients have pleural Mackler13 described a triad of vomit- effusion or hydropneumothorax and a ing, chest pain, and subcutaneous em- small percentage show fluid bilater- physema that is pathognomonic for ally. Air is common in the fascial thoracic esophageal rupture, but the planes of the mediastinum and can be clinical findings are atypical in at least seen in the soft tissues of the neck (Fig.

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3). A contrast swallow of barium or an iodinated dye confirms the presence of a leak. In moribund patients, the medium can be injected through a naso-esophageal tube. When the esoph- agogram is normal, a diagnostic esoph- agoscopy can be performed.14 If the diagnosis is still in doubt, the barium swallow should be repeated after an hour or two. Free subdiaphragmatic air is rarely % found and is an important differential point in ruling out a perforated peptic ulcer. The serum amylase level and roentgenographic picture of medias- tinal or subcutaneous emphysema dis- tinguish esophageal injury from pan- creatitis, and an electrocardiogram Fig. 3. Subcutaneous and mediastinal air helps exclude myocardial infarction. demonstrated on posteroanterior chest roent- The pattern of signs and symptoms genogram. The patient sustained an iatrogenic esophageal perforation during diagnostic gas- eliminate most other acute emergencies troscopy. The film was taken within 1 hour of such as dissecting aneurysm, pulmo- injury. Note that neither pleural space is yet nary emboli, mesenteric thrombosis, involved. and inflammatory gastrointestinal dis- eases. from the left side; middle third or Treatment begins with insertion of higher thoracic esophageal injuries a large intravenous cannula. The are approached through a right thora- pleural contamination causes a massive cotomy. The mucosal laceration may fluid shift that requires large volume extend further than the muscular tear, replacement and blood transfusions as and the surgeon should clearly visual- indicated. A broad spectrum antibiotic ize the limits of the defect before or combinations thereof are also ad- proceeding with a two-layer closure ministered intravenously. A nasogas- (Fig. 4). Multifenestrated chest tubes tric tube is passed down the esophagus can be accurately sutured in dependent and its position in the is con- positions, preferably away from the firmed when the chest is opened. A thoracic aorta. massive hydrothorax can be decom- When the perforation is treated pressed by tube thoracotomy while within 6 to 8 hours and no associated preparations are made for the formal esophageal disease exists, the patient procedure, but the definitive opera- can begin eating by the end of the 1st tion must be prompt. Toxicity and week. Unfortunately this situation is shock are not contraindications to the exception rather than the rule. operative treatment, and improvement More often, the patient already has cannot be expected until the defect is gangrenous mediastinitis or underly- closed.15 ing obstructive disease, such as car- Lower perforations are exposed cinoma or esophagitis with stricture.

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The fundic patch operation of Thai18 is a proven method for cover- ing large lacerations with necrotic edges or a perforation located above a benign stricture. The fully mobilized gastric fundus is applied over the divided stricture or long rent, thereby covering the defect and widening the esophageal lumen. Reflux is con- trolled by wrapping the remaining Fig. 4. View of lower esophageal rent seen fundus around the patch (Fig. 5B). through a left thoracotomy. The necrotic Esophageal exclusion is the last re- mediastinal pleura is widely opened and sort of the alternative procedures and debrided. Mucosa and muscles are closed in two separate layers using interrupted 4-0 non- is reserved for the most desperate cir- absorbable sutures. cumstances. This method described by Johnson et al19 entails division of the In these cases, the major complication lower esophagus and creation of a to avoid is breakdown of the repair. cervical esophagostomy. The pleural Suture of the perforation above a con- cavity is evacuated by water seal drain- striction, whether it be benign or ma- age and a gastrostomy is constructed lignant, is inadequate treatment, since for feeding. Exclusion may be life- a persistent fistula will inevitably re- saving but requires a secondary recon- sult. Primary esophageal resection for struction (Fig. 5C). benign disease is generally not a good Pulmonary complications are a pri- alternative plan since reflux can later mary concern in the postoperative lead to severe esophagitis. Neverthe- period. Even the patient undergoing less, esophagogastrectomy is a straight- early repair often requires ventilatory forward procedure and results even in assistance for the first 24 to 48 hours the presence of established mediastini- postoperatively. The elderly, mal- tis have been good16 (Fig. 5A). Reflux nourished, alcoholic, and those pa- of gastric contents through the esopha- tients seen after 24 hours usually need gogastric anastomosis can be dimin- tracheostomy. Serial upright chest ished and even eliminated by invagi- roentgenograms are important in as- nating several centimeters of distal sessing the parenchymal and pleural esophagus into the gastric fundus.17 A changes during hospital convalescence. one-stage resection is indicated when a Nutritional support is a problem in perforation is encountered with car- patients who experience dehiscence of cinoma, providing the neoplasm has the repair. Intravenous hyperalimenta- not widely disseminated. One opera- tion may be employed during the first tion is more beneficial than staged week of management; thereafter, if the procedures and avoids prolonged hos- patient is unable to swallow because pitalization. Staging rarely accom- of a persistent leak, a feeding jejunos- plishes anything because the car- tomy is preferred to gastrostomy to cinoma is usually so advanced that its reduce the reflux through the rent. removal is impossible by the time the Late suture line breakdown, after the mediastinitis has cleared. chest tubes have been removed, pro-

Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1975 Trauma to the esophagus 181 duces symptoms of sepsis and the chest EXCLUSION roentgenogram demonstrates air-fluid levels. This situation does not obligate the surgeon to reoperate for closure, if the collection is well drained. These leaks often close when nutrition is

E»ophagogastrectomy

Fig. 5C

Fig. 5. The established surgical methods for treating large, necrotic tears or perforations that occur above an obstruction. A, Esopha- geal resection with a standard esophagogastric anastomosis, usually reserved for carcinoma. B, Mobilized gastric fundus covers the esopha- Fig. 5A geal opening and a fundoplication is used to retard reflux. C, Esophageal exclusion. The esophagus is isolated by cervical esophagos- THAL PROCEDURE AND tomy above and division below. FUNDOPLICATION preserved and no distal obstruction exists.20 A solid diet can be started even in the presence of a moderate fistula. The patient will usually toler- ate these feedings and hold a steady weight when more than half the food enters the stomach. Bronchoesopha- geal fistulas may also form after long-standing mediastinitis and pyo- pneumothorax. Under these circum- stances, the esophagus should be kept at rest and the pleural cavity well drained. If satisfactory caloric intake can be maintained, the smaller fistulae will often heal spontaneously (Fig. 6). The goals of surgical management are (1) secure closure of the rent

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Corrosive injury of the esophagus Corrosive liquids are most often in- gested by children between the ages of 1 and 2 years. Swallowing caustics with suicidal intent involves a relatively small number of adults. The extremely high acid or alkali concentration in drain cleaners and many cleansing agents inflicts an esophageal burn on immediate contact, and the healing process ends in stricture. The esopha- geal mucosa is more resistant to a sub- stance with low pH, and acid ingestion produces its primary effect on the gastric antrum, which may lead to fibrosis, scarring, and pyloric obstruc- tion. Corrosive chemicals rarely cause esophageal perforation, but this type of injury has an especially poor prog- nosis due to intense inflammatory destruction and suppurative medias- tinitis.21 Fig. 6. The ravages of persistent mediastinal Esophagoscopy must be performed infection include bronchoesophageal fistulas. at the outset to assess the extent of the This communication formed 4 weeks after burn and to decide whether hospi- initial treatment. A feeding jejunostomy com- talization is necessary. The chance of bined with further mediastinal drainage re- sulted in spontaneous closure. iatrogenic injury lessens when the esophagoscope is not advanced beyond coupled with wide mediastinal and the first esophageal burn. To diminish pleural drainage, (2) full lung expan- the fibroblastic response, steroid ther- sion, and (3) provision of a high caloric apy (prednisone) should be admin- intake that yields a positive nitrogen istered within 48 hours of the inges- balance. When the patient can gain tion and continued for approximately 22 weight through oral intake, he will 6 to 8 weeks. Antibiotic therapy usually overcome all late wound com- shortens the necrotic phase of the burn plications. None of these objectives are and thus indirectly promotes healing. easy to attain, especially in the deterio- In children and adults diagnostic rating patient who already has wide- esophagoscopy and the initial dilata- spread necrotic mediastinitis and em- tion procedures should be performed pyema. These challenging problems under general anesthesia. It is dan- must be met with unerring surgical gerous to inspect repeatedly the areas judgment, sound metabolic manage- of reepithelization, since the esoph- ment, and the aggressive persistence ageal wall is weakest and most vulner- always required in long-term support. able to rupture during the first month

Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1975 Trauma to the esophagus 183 after steroid treatment. If the patient toms often are irritability or refusal to is suspected of having a severe corro- eat. sive injury, a gastrostomy should be Pennies, buttons, and safety pins performed early and a string swal- are the most frequent offenders in lowed to guide later dilatation. The childhood (Fig. 7 A and B), and bones fusiform Tucker bougies pulled and meat are most often responsible through a gastrostomy are safer and in the adult. Upper dentures inhibit more effective than antegrade dilata- the tactile sensation and disguise the tion when multiple strictures are pre- true size of the object. In either age sent. group, the surgeon must remove the The esophageal segment below a object and also rule out any associated long constriction may not be well disease process that would reduce the visualized in an ordinary contrast size of the lumen. Although some study. An isolated area of scar can foreign materials may pass with con- usually be dilated from above using servative treatment, this approach olive-tipped bougies over previously generally is not accepted. In adults, swallowed string. Success using local the "steakhouse syndrome" of meat triamsinalone infiltration to resolve impaction is often associated with an short strictures has been reported.23 esophageal web or an esophagitis with 25 When dilatation fails or extensive stricture formation. One of the first injury leads to obliteration of the symptoms of esophageal carcinoma is esophagus, reconstructive surgery is obstruction from a bolus of food. required. This surgical procedure Roentgenograms are taken in the may be performed any time after the two standard planes with cervical age of 1 year, and is usually colon in- hyperextension in the lateral view to terposition or the reversed gastric tube raise the and esophageal inlet operation. above the clavicle. In difficult cases, cineradiography is of value. Foreign Foreign bodies bodies in the esophagus lie in the More than half of all foreign bodies coronal plane; those in the larynx or taken in through the oral cavity lodge trachea lie in the sagittal plane. After in the esophagus. In children under careful study of the films, esophagos- age 4, the swallowed material can copy is performed under general anes- become impacted at or just below the thesia. The endoscopist should never cricopharyngeus muscle and, if un- override or push the foreign body diagnosed, may eventually migrate ahead of the esophagoscope but, in- through the lateral or ventral wall, stead, grasp the object with forceps, even into the trachea.24 The physician advance the esophagoscope to contact must suspect an impacted object in all and then gently withdraw forceps, children with respiratory complaints, foreign body, and esophagoscope in gagging, or difficulty swallowing. Re- one motion. Success has been reported spiratory complaints such as dyspnea in passing a Foley catheter beneath or wheezing are due to compression, the foreign body, inflating the bag, aspiration, or fistulous communication and removing the object with gentle with the trachea. In infants, the symp- traction.26 Obviously, this technique

Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 184 Cleveland Clinic Quarterly Vol. 42, No. 1 should not be used for sharp objects or when there has been a long delay before the extraction procedure. After the inflammation subsides, sometimes the impacted material still cannot be extracted endoscopically. In these cases and when esophageal erosion has occurred, direct surgical intervention is indicated rather than risk further damage by difficult instru- mental manipulation. The same prin- ciples of exposure, esophageal suture, and mediastinal drainage apply.

External trauma

Penetrating injury from knife or gunshot wounds almost always in- volves the cervical esophagus.27 One should suspect esophageal damage in Fig. 7B any neck wound, no matter how small. Fig. 7. A, An open safety pin with the sharp Subcutaneous emphysema associated point proxiraally imbedded into the esopha- with cervical penetration could mean geal wall. The point was manipulated into the esophageal perforation and laceration esophagoscope before withdrawing the pin. B, A suspected perforation is confirmed by of the larynx, trachea, or apical barium swallow. The lung has been re- pleura. If the wound has pierced the expanded by chest tube water seal drainage but a right thoracotomy was required for repair.

, exploration is in- dicated. When time permits, endos- copy and contrast studies can confirm or exclude occult injury to the trachea or esophagus. Esophageal lacerations from knife wounds are small and easily missed, even with contrast studies.28 An esophageal laceration pro- duced by blunt trauma is uncommon but mimics the symptoms and signs of spontaneous rupture.28 External penetrating wounds rarely involve the thoracic esophagus alone, but the pos- sibility of esophageal injury must be kept in mind whenever the picture is 7A confusing or when exploration is per- Fig. 7A formed for other injury. A thoracot-

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omy is necessary for closure of the 15. Groves LK: Instrumental perforation of defect and drainage. the esophagus: What is conservative man- agement? J Thorac Cardiovasc Surg 52: References 1-10, 1966. 16. Hendren WH, Henderson BM: Immediate 1. Jemerin EE: Results of treatment of per- esophagectomy for instrumental perfora- foration of the esophagus. Ann Surg 128: tion of the thoracic esophagus. Ann Surg 971-975, 1948. 168: 997-1003, 1968. 2. Pearse HE Jr: The operation for per- 17. Pearson FG, Henderson RD, Parrish RM: forations of the cervical esophagus. Surg An operative technique for the control of Gynecol Obstet 56: 192-196, 1933. reflux following esophagogastrostomy. J 3. Barrett NR: Report of a case of sponta- Thorac Cardiovasc Surg 58: 668-677, 1969. neous perforation of the oesophagus suc- 18. Thai AP: A unified approach to surgical cessfully treated by operation. Br J Surg problems of the esophagogastric junction. 35: 216-219, 1947. Ann Surg 168: 542-550, 1968. 4. Samson PC: Postemetic rupture of the 19. Johnson J, Schwegman CW, Kirby CK: esophagus. Surg Gynecol Obstet 93: 221- Esophageal exclusion for persistent fistula 229, 1951. following spontaneous rupture of the 5. Wychulis AR, Fontana RS, Payne WS: esophagus. J Thorac Surg 32: 827-832, Instrumental perforations of the esopha- 1956. gus. Dis Chest 55: 184-189, 1969. 20. Tuttle WM, Barrett RJ: Late esophageal 6. Paulson DL, Shaw RR, Kee JL: Recogni- perforations. Arch Surg 86: 695-700, 1963. tion and treatment of esophageal per- forations. Ann Surg 152: 13-21, 1960. 21. Dafoe CS, Ross CA: Acute corrosive oesophagitis. Thorax 24: 291-294, 1969. 7. Seybold WD, Johnson MA III, Leary WV: Perforation of the esophagus; an 22. Webb WR, Koutras P, Ecker RR, et al: analysis of 50 cases and an account of ex- An evaluation of steroids and antibiotics perimental studies. Surg Clin North Am in caustic burns of the esophagus. Ann 30: 1155-1183, 1950. Thorac Surg 9: 95-102, 1970. 8. Takaro T, Walkup HE, Okano T: Esoph- 23. Holder TM, Ashcraft KW, Leape L: The agopleural fistula as a complication of treatment of patients with esophageal thoracic surgery; a collective review. J strictures by local steroid injections. J Thorac Cardiovasc Surg 40: 179-193, 1960. Pediatr Surg 4: 646-653, 1969. 9. Postlethwait RW, Kim SK, Dillon ML: 24. McLaughlin RT, Morris JD, Haight C: Esophageal complications of vagotomy. The morbid nature of the migrating Surg Gynecol Obstet 128: 481-488, 1969. foreign body in the esophagus. J Thorac 10. Anderson RL: Spontaneous rupture of Cardiovasc Surg 55: 188-192, 1968. the esophagus. Am J Surg 93: 282-290, 25. Hargrove MD Jr, Boyce HW Jr: Meat im- 1957. paction of the esophagus. Arch Intern 11. Mosher HP: Lower end of the esophagus Med 125: 277-281, 1970. at birth and in the adult. J Laryngol Otol 26. Bigler FC: The use of a Foley catheter for 45: 161-180, 1930. removal of blunt foreign bodies from the 12- Maclver IN, Smith BJ, Tomlinson BE, et esophagus. J Thorac Cardiovasc Surg 51: al: Rupture of the oesophagus associated 759-760, 1966. with lesions of the central nervous system. 27. Fogelman MJ, Stewart RD: Penetrating Br J Surg 43: 505-512, 1956. wounds of the neck. Am J Surg 91: 581- 13. Mackler SA: Spontaneous rupture of the 596, 1956. esophagus; an experimental and clinical 28. Noon GP, Beall AC Jr, DeBakey ME: Sur- study. Surg Gynecol Obstet 95: 345-356, gical management of penetrating esopha- 1952. geal injuries. J Trauma 8: 458-464, 1968. 14. Carter R, Hinshaw DB: Use of the 29. Worman LW, Hurley JD, Pemberton AH, esophagoscope in the diagnosis of rupture et al: Rupture of the esophagus from ex- of the esophagus. Surg Gynecol Obstet ternal blunt trauma. Arch Surg 85: 333- 120: 1304-1306, 1965. 338, 1962.

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