௡ Review Article The Journal of TRAUMA Injury, Infection, and Critical Care Esophageal Perforations: New Perspectives and Treatment Paradigms James T. Wu, MD, Kenneth L. Mattox, MD, and Matthew J. Wall Jr, MD Despite significant advances in mod- ever, less invasive approaches to esophageal attempt to summarize the pathogenesis ern surgery and intensive care medicine, perforation continue to evolve. As the inci- and diagnostic evaluation of esophageal esophageal perforation continues to present dence of esophageal perforation increases injuries, and highlight the evolving thera- a diagnostic and therapeutic challenge. Con- with the advancement of invasive endo- peutic options for the management of troversies over the diagnosis and manage- scopic procedures, early recognition of esophageal perforation. ment of esophageal perforation remain, and clinical features and implementation of Key Words: Esophageal trauma, debate still exists over the optimal therapeu- effective treatment are essential for a fa- Esophageal perforation, Minimally inva- tic approach. Surgical therapy has been the vorable clinical outcome with minimal sive thoracoscopic surgery, Esophageal traditional and preferred treatment; how- morbidity and mortality. This review will stenting, Esophageal endoclipping. J Trauma. 2007;63:1173–1184. PATHOPHYSIOLOGY injuries to the esophagus occurred in 4% of patients, and the External Trauma overall mortality rate was 19%.5 enetrating esophageal trauma occurs mainly in the cer- Esophageal perforation from external blunt trauma is an vical esophagus, and morbidity is usually associated exceedingly rare event. The most common cause is related to 6–9 Pwith vascular, tracheal, and spinal cord injuries.1,2 high-speed motor vehicle crashes. Beal et al. examined 96 Hirshberg et al. evaluated 34 patients with transcervical gun- reported cases of blunt esophageal trauma, and found that the shot wounds, and found 2 patients (6%) with esophageal site of perforation occurred in the cervical and upper thoracic 10 injuries.1 Similarly, Demetriades et al. examined 97 patients esophagus in 82% of patients. The clinical outcome of these with transcervical gunshot wounds, and reported injury to the patients is influenced by the delay in diagnosis, complications aerodigestive tract in 6% of patients.2 Sheely et al. docu- from the esophageal perforation, and associated injuries. Be- mented a 22-year experience in over 700 patients with pen- cause the signs and symptoms of early esophageal perforation etrating neck trauma, and found 39 patients (5.5%) with are subtle, accurate and prompt diagnosis can be challenging cervical esophageal injury.3 Of these patients, there were 55 in patients presenting with multiple blunt injuries. Therefore, associated injuries, with trachea being the most often injured a high index of suspicion is required when treating patients structure (Table 1). In contrast, the thoracic esophagus is less sustaining high-energy trauma to the neck or torso. vulnerable to external trauma because of its central anatomic location and small compact size. Cornwell et al. reported that Spontaneous Esophageal Rupture (Boerhaave’s intrathoracic esophageal injuries occurred in 0.7% of 1,961 Syndrome) 4 patients with gunshot wounds to the chest. A retrospective In 1724, Dr. Hermann Boerhaave described a case of multi-institutional study during a 10.5-year period involving spontaneous esophageal rupture in the autopsy of Baron von 405 patients with known penetrating esophageal injuries Wassenaer, Grand Admiral of the Dutch Fleet. Boerhaave’s showed that the predominant mechanism of injury was gun- patient was a previously robust admiral, who developed a shot or shotgun wounds in 78.8% of patients and stab wounds sudden excruciating chest pain while straining to vomit after 5 in 18.5% of patients. Cervical esophageal injuries were most indulging himself with food and wine. The details of Boer- common (57%), and thoracic and abdominal esophageal in- haave’s findings have been recorded in the report of Derbes juries occurred in 30% and 17%, respectively. Combined published in 1955.11 The incidence of Boerhaave’s syndrome is relatively rare, although likely an underreported phenom- Submitted for publication December 27, 2006. enon, with 300 cases reported in the literature worldwide.12 Accepted for publication March 13, 2007. Boerhaave’s syndrome is thought to arise from a rapid in- Copyright © 2007 by Lippincott Williams & Wilkins crease in intraluminal esophageal pressure through a patent From the Division of Cardiothoracic Surgery, Baylor College of Med- icine, Houston, Texas; and Trauma/Emergency Surgery Service, Ben Taub lower esophageal sphincter during vomiting. This sudden General Hospital (J.T.W., K.L.M., M.J.W.), Houston, Texas. increase of intraluminal pressure is the result of failure of Address for reprints: James T. Wu, MD, 350 Parnassus Ave., Ste. 150, relaxation of the cricopharyngeal muscle. As such, transmural San Francisco, CA 94143-150; email: [email protected]. rupture of the esophageal wall occurs, commonly in the left DOI: 10.1097/TA.0b013e31805c0dd4 posterolateral wall of the lower third esophagus located 2 cm Volume 63 • Number 5 1173 The Journal of TRAUMA௡ Injury, Infection, and Critical Care instrumentation as the most common cause of esophageal Table 1 Associated Injuries in Penetrating Cervical perforation, accounting for 59% of patients in recent series.18 Esophageal Trauma Esophageal perforation during upper endoscopy is estimated Associated Injuries Number to occur at a frequency of 0.03%, compared with 0.11% 19,20 Trachea 20 during rigid endoscopy. The more common sites of iat- Spinal cord 6 rogenic esophageal perforation are at the normal anatomic Thyroid 7 narrowings of the esophagus. Perforation most often occurs Thyroid cartilage 5 Jugular vein 4 in the hypopharynx or cervical esophagus secondary to ex- Recurrent laryngeal nerve 4 ertion of force in attempting to pass the endoscope through 21 Common carotid artery 3 the cricopharynx. The risk of esophageal injury also increases Cricoid cartilage 3 when therapeutic manipulations are undertaking during endo- Lung 2 scopic intervention. Perforation of the distal esophagus is most Larynx 1 Total 55 frequently related to esophageal dilation performed for esopha- geal strictures or achalasia. The incidence of distal esophageal Reproduced with permission from Sheely CH, Mattox KL, Beall rupture after pneumatic dilation for achalasia ranges from 2% to AC, et al. Penetrating wounds of the cervical esophagus. Am J Surg. 22 1975;130:707–711. 6%. Such a complication is often associated with previous pneumatic dilation or the use of high inflation pressures.23 Endoscopic sclerotherapy for esophageal varices leads to to 3 cm proximal to the gastroesophageal junction. This area esophageal perforation in 1% to 3% of patients.24 Salo et al. is structurally and inherently weakened as the longitudinal reported esophageal perforation and mediastinal gas gan- muscle fibers taper out before passing onto the stomach wall. grene after sclerotherapy of bleeding from a Mallory-Weiss laceration.25 The local necroinflammatory reaction after scle- Foreign Body rosant injection contributes to the transmural necrosis of Barber et al. described a variety of objects and materials esophageal wall.26,27 Avoidance of perforation may be that were inappropriately ingested, especially by children and achieved by attempting to control the depth, volume, and individuals with psychiatric disorders.13 The common offend- concentration of injection to prevent extensive and prolonged ers are chicken or fish bones, partial dentures, plastic eating ischemia to the surrounding tissue.28 utensils, and metal safety pins. Objects less than 2 cm in size Perforation of the esophagus can result from a variety of may traverse the normal adult esophagus without problems.14 other forms of endoscopic instrumentation. Iatrogenic esopha- Once in the stomach, most objects can pass through the rest geal perforation during transesophageal echocardiography has of the gastrointestinal tract. About 80% to 90% of ingested been well documented with an incidence of 0.18%.29–31 Rarely, foreign bodies pass the gastrointestinal tract spontaneously.15 rupture of distal esophagus may occur with improper placement Of those that mandate intervention, less than 1% need open and inflation of the gastric balloon of a Sengstaken-Blakmore surgery, whereas the remainder can be removed by endo- tube to control bleeding esophageal varices.27,32 Other forms of scopic manipulation.15 Lam et al. retrospectively reviewed esophageal intubation associated with perforation include naso- 5,848 patients with foreign body ingestion, and found 8 gastric tube placement,33 endotracheal tubes,34,35 endoscopic patients (0.001%) with esophageal perforation secondary to retrograde cholangiopancreatography,36 and endoscopic ultra- bone impaction in the cervical esophagus; 3 patients pre- sound-guided interventions.37,38 sented with clinical evidence of esophageal injury at the time Esophageal injuries during surgical procedures in of presentation, and 5 patients were diagnosed with iatrogenic close proximity to or directly involving the esophagus perforation during esophagoscopy.16 occur infrequently. Operative procedures associated with In some instances, sharp or jagged foreign bodies lacer- esophageal injuries include fundoplication, vagotomy, hi- ate the wall partially or completely. Most commonly, such atal hernia repair, lung transplantation,