Trauma to the esophagus 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. 175 Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 176 Cleveland Clinic Quarterly Vol. 42, No. 1 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 neck; 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 fascia is lacerated, venously, and broad spectrum anti- thus contaminating the retroesopha- biotics are administered until the geal or prevertebral space. 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- Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1975 Trauma to the esophagus 177 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 thyroid 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 trachea and carotid sheath. 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. Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 178 Cleveland Clinic Quarterly Vol. 42, No. 1 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. Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1975 Trauma to the esophagus 179 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