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Ann Thorac Surg 1996;61:1447-1451
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Esophageal Perforation: Emphasis on Management

Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Perforation of the esophagus is a deadly injury that requires expert management for survival.

Methods. We performed a retrospective clinical review of 66 patients treated at Emory University affiliated hospitals for esophageal perforation between 1973 and 1993.

Results. Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower-third injuries occurred in 43 cases (65%), middle third in 14 (21%), and upper third in 9 (14%). Early contained perforations were managed successfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural contamination recognized early were managed by primary closure and drainage in 28 patients. Reinforcement of the primary closure using stomach fundus, pleural, diaphragmatic, or pericardial flap was performed in 16 patients. Those perforations that escaped early recognition required thoughtful management, using generous debridement and drainage and sometimes esophageal resection. The esophageal T tube provided control of leaks in 3 of these patients and was a useful adjunct. Using these management principles, we achieved a 76% survival rate for all patients. Six patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate.

Conclusions. Esophageal perforation remains an important thoracic emergency. Aggressive operative therapy remains the mainstay for treatment; however, conservative management may be preferred for contained perforations and the esophageal T tube may be used for late perforations.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1451.

Esophageal perforation remains a difficult operative problem. The predominance of iatrogenic injuries allows good results for the overall management of esophageal perforation, with earlier detection and prompt attention. The outcomes for spontaneous perforations are worse by comparison, but can be improved with a high degree of suspicion combined with timely intervention and principled intraoperative care. Although the interval between perforation and treatment remains a predictor of survival, its significance is contingent on experienced assessment of the severity of injury [1–3]. Accurate management of esophageal perforations requires mastery of an array of operative procedures for an organ of little plasticity. A review of operative principles used to manage esophageal perforation in a series of patients from a united institution allows recommendations based on successful outcomes to be incorporated into current thoracic surgery. To accomplish this end, we reviewed our 20-year experience in the management of perforation of the esophagus.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Sixty-six patients with esophageal perforation were identified from the Emory University Hospital and Emory affiliated Crawford Long Hospital medical record databases from 1973 to 1993. All clinical data were analyzed and reviewed. All causes of esophageal perforation were included in this review. Underlying esophageal diseases were categorized as none, benign, or malignant. The location of the perforation was defined as upper third (cervical), middle third (thoracic), and lower third (lower thoracic, including gastroesophageal junction and intraabdominal esophagus). Iatrogenic injuries (n = 48) were subdivided into distinct causes: esophagoscopy, 16 patients; pneumatic dilation, 10; esophagoscopy and dilation, 8; intraesophageal intubation, 5; intraoperative, 4; sclerosis of varices, 3; and bougienage, 2.

Nonoperative Management
Nonseptic patients with early defined and contained leaks were managed conservatively. No intake by mouth, parenteral nutrition, and antimicrobial agents were continued for 7 to 10 days. A contrast esophagram was then obtained to document healing of the perforation, and oral intake was then resumed.

Operative Management
Septic patients, those with uncontained free ruptures, perforations of prolonged duration, and iatrogenic intraoperative injuries were managed by a variety of operative procedures. Specific operative strategies were chosen based on location of the injury, presence of underlying esophageal disease, and degree of tissue damage, combined with the overall condition of the patient.

Cervical perforations from endoesophageal procedures were managed by drainage alone, whereas those identified during cervical operations were repaired during the neck procedure. Middle- and lower-third perforations with malignant underlying esophageal disease were treated by resection with immediate or delayed reconstruction, depending on the state of the tissues and the condition of the patient. Stable patients with middle- and lower-third perforations with benign motility disorders and viable tissue underwent primary repair with wide mediastinal and pleural drainage. Severe tissue damage that precluded repair was managed by wide mediastinal and pleural drainage. Esophageal T-tube drainage was combined with this approach in a few cases. Closed-tube thoracostomy drainage was also used for diagnosis and therapy in several patients.

All patients undergoing operative therapy were maintained with no oral intake and received enteral or parenteral nutrition as well as parenteral antimicrobial agents. After uneventful primary repairs, patients underwent contrast esophagram at 7 to 10 days postoperatively, with oral intake resumed if the perforation was healed. Patients who were unable to have primary repair were managed as for controlled esophageal fistulas, with gastrostomy and feeding jejunostomy or central hyperalimentation for long-term nutritional support until fistula closure was achieved.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Sixty-six patients (39 male and 27 female) underwent treatment for esophageal perforation, with an overall survival rate of 76%. The mean age was 60 ± 16 years, with no difference between survivors and nonsurvivors. The average time between perforation and diagnosis was 40.6 ± 61.9 hours. The perforation was located in the upper third in 9 patients, middle third in 14 patients, and lower third in 43 patients. The average length of stay was 25.4 ± 22.6 days.

Nonoperative management was applied without a death in 12 patients (4 upper third, 3 middle third, 5 lower third). The average time between perforation and diagnosis was 27.8 ± 33.1 hours. These patients required an average of 19.3 ± 17.5 hospital days for resolution of the perforation.

Operations were performed in 54 patients, with 70% survival (Table 1). The average time between perforation and diagnosis was 40.5 ± 63.4 hours. Hospitalization was required for an average of 26.9 ± 23.4 days in this group. Primary closure was performed in 28 patients; pleural drainage, mediastinal drainage, or both in 15 patients; and esophageal resection in 7 patients. Three patients with delayed presentation were managed by esophageal T-tube and 1 by exclusion and diversion.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Esophageal perforation currently has a broad clinical spectrum, ranging from contained small leaks to barogenic lower esophageal rupture. This spectrum results from more frequent iatrogenic causes, introducing less severe esophageal injury that is recognized earlier than historic spontaneous perforation. This range of disease has been accompanied by the development of an array of esophageal procedures to manage perforation. Most of the operative literature is committed to the treatment of severe esophageal injury, and the appropriate procedure remains disputed among leaders in the field [2, 4–6]. Nonoperative management of contained esophageal perforation has expanded the algorithm for management [7, 8]. This report details the spectrum of injury over a 20-year period and outlines the principles and strategies used for successful management of esophageal perforation.

A high incidence of preexisting esophageal disease has been reported in recent series [3]. Underlying esophageal disease was present in 44 of 66 patients (67%) in this series, reflecting a similar experience. This high incidence of preexisting associated esophageal disease is a marker for the iatrogenic nature of esophageal perforation. A defined few iatrogenic perforations lend themselves to conservative management, ie, those presenting as contained disruptions draining back into the esophagus with no signs of general sepsis.

Classic teaching cites time from perforation to diagnosis as a predictor of outcome, and various series have identified the first 24 hours as the interval acceptable for successful primary repair [3, 9–11]. The average time to diagnosis in this report was 40 hours, emphasizing the propensity for late diagnosis of esophageal perforation. Although iatrogenic injuries were recognized within the first 24 hours more frequently than other injuries (75% versus 39%; p < 0.015), this did not translate into improved survival. Some have used the time from diagnosis as a determinant of appropriate operative therapy, avoiding primary repair after the first 24 hours [12]. This and other recent reports identified the high frequency of late diagnosis and displayed improved survival rates with primary repair for injuries recognized outside the first 24 hours when compared with results from the literature [2, 13, 14]. The changing patterns of injury and refined intensive care practices play an important role in the better results; however, accurate intraoperative evaluation and precise operative repair form the foundation of this improvement.

Nonoperative management of esophageal perforation was applied without any deaths in a selected group of 12 patients in this series. We strictly observed the requirements for conservative therapy as outlined in earlier reports: contained perforation, drainage of the perforation into the esophagus, and absence of clinical sepsis [7]. These patients require careful assessment during the observation period, and deterioration in clinical status requires crossover to operative management. Antimicrobial agents with activity against oropharyngeal flora are combined with elimination of oral intake for 7 days. Successful conservative management is confirmed at this time by repeat contrast esophagram, which displays healing or decreased size of the contained leak. Oral intake is then resumed.

Although conservative management of perforation can be applied successfully, it is appropriate in only a small subgroup of esophageal perforations [8]. The majority of esophageal perforations are not contained and require operative attention. In the group of patients reported, 83% underwent operations for esophageal perforation, underscoring the limited role of conservative management for this injury.

Our approach to the operative care of these patients differs based on the location of injury. Upper-third perforations that are not contained on contrast esophagram or occur during adjacent operation require operation for repair and drainage to prevent the development of mediastinitis. For noncervical, uncontained esophageal leaks, debridement of necrotic tissue, generous irrigation, and complete mediastinal and pleural drainage are a part of all operations designed for therapy of these esophageal perforations. However, care for the injured esophagus varies based on the location, nature of the esophageal tissue, underlying disease, and overall condition of the patient. The major decision at operation concerns the repair of the esophageal perforation.

Primary repair with or without reinforcement was performed in 52% (28 of 54) of the patients in this series, with an 82% survival rate. The average time to diagnosis was 20 hours from the onset of symptoms. There were no leaks documented on postoperative contrast esophagogram in these patients. The success of primary repair in this group of patients is based on timely diagnosis, careful intraoperative assessment, and meticulous repair. Normal tissue with usual tensile strength and pliability is absolutely required for successful primary repair, and necrotic esophageal tissue that flanks the wound requires debridement. Circumferential injuries of large magnitude and perforated, nondilatable esophageal strictures require esophageal resection and reconstruction.

Successful primary repair begins with debridement of devitalized tissue and identification of the muscular and mucosal layers of the esophagus, as the mucosal tear is usually longer than the muscular tear. Reinforcement of the primary repair has proven useful in 16 of 28 patients undergoing primary closure. We currently favor use of the gastric fundus for lower-third injuries and the pleural flap for those repaired in the middle third.

Perforations of the noncervical esophagus that escape early recognition, with esophageal tissue that is beyond repair, represent the controversial category for management. This series of patients included 12 injuries that were beyond repair. Wide debridement and drainage was performed in 5 patients, resection in 3, and T-tube drainage in 3; a single patient underwent exclusion and diversion. The survival rate in these patients was 85%. Wide debridement and drainage was a useful modality that provided quick and effective therapy.

Our preferred treatment of lower-third esophageal perforations that are beyond early repair, based on our previous experience, is placement of the esophageal T tube to divert all secretions and to allow time for healing of the surrounding injury [6, 15]. In two other detailed reports of T-tube drainage in this decade, 12 of 15 patients survived, with resolution of the controlled fistula [16, 17].

Placement of the esophageal T tube in the lower-third injuries should be precise. The long arm is directed toward the stomach, with the short arm in the esophagus proximal to the site of injury (Fig 1). The T tube should be brought out through a separate stab incision and secured in a lateral position away from the aorta. These tubes remain in place for 2 to 3 weeks to allow development of a defined tract. There have been reports of aortic erosion from malpositioned T tubes, so attention to these details is important [15]. Concomitant laparotomy, decompression gastrostomy (in lieu of nasogastric decompression), and placement of feeding jejunostomy are performed for nutritional support. Central hyperalimentation is an alternative.

View larger version (39K): [in this window] [in a new window]   Fig 1. . T tube placed in the esophagus, secured to the diaphragm away from the aorta.

Resection was applied to 7 patients in this series, and was reserved for irreparable perforations (3 patients) or perforations that occurred with esophageal neoplasms (4 patients). Spontaneous or iatrogenic perforation with malignancy requires esophageal resection, as healing will universally fail in cancerous tissue. Primary reconstruction with gastric pull-up should be used if the patient's condition permits. Resection and drainage with end-cervical esophagostomy and gastrostomy can be used in those patients whose condition is of concern and with plans for secondary reconstruction. The short-term outlook for perforation with malignancy was grim, with only 1 of 4 surviving hospitalization.

Patients presenting in extremis with late-recognized esophageal perforation remain candidates for open procedures. Closed-tube thoracostomy was unsuccessful in controlling mediastinal and pleural sepsis in 6 of 7 patients in this series. Perhaps some of these patients would have survived had we followed a more aggressive approach using open debridement and drainage, exclusion and diversion, or even esophageal resection.

Esophageal perforation as a complication of management of esophageal varices secondary to portal hypertension was a particularly lethal injury. This cause accounted for 9% of perforations in this series, reflecting the continued interest in liver disease at our institution. Incorrect positioning of the gastric balloon of the Sengstaken-Blakemore tube and perforation secondary to variceal sclerosis were the causes. The only survivor in this set of patients had a contained perforation that was managed by conservative measures. The poor general condition of cirrhotic patients and the high mortality rate from refractory variceal bleeding make esophageal perforation a lethal injury in this group of patients.

In summary, perforation of the esophagus remains a critical injury with a high mortality rate. The algorithm in Figure 2 is a distillation of the recommended approach to esophageal perforation. Nonoperative management can be successful in a selected group of patients, but most perforations require operation. Careful attention to appropriate critical care and antimicrobial therapy and correct management of esophageal injury are required for success.

View larger version (17K): [in this window] [in a new window]   Fig 2. . Algorithm for management of esophageal perforation. (NPO = nil per os.)

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-second Annual Meeting of the Southern Thoractic Surgical Association, San Antonio, TX, Nov 9–11, 1995.

Address reprint requests to Dr Mansour, Division of Cardiothoracic Surgery, The Emory Clinic, 1365 Clifton Rd, NE, Atlanta, GA 30322.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 1995;60:245–9.[Abstract/Free Full Text]
2. Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation: the merit of primary repair. J Thorac Cardiovasc Surg 1995;109:140–6.[Abstract/Free Full Text]
3. Jones WG, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534–43.[Abstract]
4. Salo JA, Isolauri JO, Heikkilä LJ, et al. Management of delayed esophageal perforation with mediastinal sepsis: esophagectomy or primary repair? J Thorac Cardiovasc Surg 1993;106:1088–91.[Abstract]
5. Urschel HC, Razzuk MA, Wood RE, Galbraith N, Pockey M, Paulson DL. Improved management of esophageal perforation: exclusion and diversion in continuity. Ann Surg 1974;179:587–91.[Medline]
6. Mansour KA, Wenger RK. T-tube management of late esophageal perforations. Surg Gynecol Obstet 1992;175:571–2.[Medline]
7. Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intrathoracic esophageal disruption. Ann Thorac Surg 1979;27:404–8.[Abstract]
8. Lo AY, Surick B, Ghazi A. Nonoperative management of esophageal perforation secondary to balloon dilatation. Surg Endosc 1993;7:529–32.[Medline]
9. Skinner DB, Little AC, DeMeester TR. Management of esophageal perforation. Am J Surg 1980;139:760–4.[Medline]
10. Goldstein LA, Thompson WR. Esophageal perforations: a 15 year experience. Am J Surg 1982;143:495–503.[Medline]
11. Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;50:45–51.[Abstract]
12. Richardson JD, Martin LF, Borzotta AP, Polk HC. Unifying concepts in the treatment of esophageal leaks. Am J Surg 1985;149:157–62.[Medline]
13. Nesbitt JC, Sawyers JL. Surgical management of esophageal perforation. Am J Surg 1987;53:183–91.
14. Ohri SK, Liakakos TA, Pathi V, Townsend ER, Fountain SW. Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave's syndrome. Ann Thorac Surg 1993;55:603–6.[Abstract]
15. Abbott OA, Mansour KA, Logan WD Jr, Hatcher CR Jr, Symbas PN. Atraumatic so-called ``spontaneous'' rupture of the esophagus. A review of 47 personal cases with comments on a new method of surgical therapy. J Thorac Cardiovasc Surg 1970;59:67–83.[Medline]
16. Naylor AR, Walker WS, Dark J, Cameron EWJ. T tube intubation in the management of seriously ill patients with oesophagopleural fistulae. Br J Surg 1990;77:40–2.[Medline]
17. Larsson S, Pettersson G, Lepore V. Esophagocutaneous drainage to treat late and complicated esophageal perforation. Eur J Cardiothorac Surg 1991;5:579–82.[Abstract]
18. Johnson J, Schwegman CW, Kirby CK. Esophageal exclusion for persistent fistula following spontaneous rupture of the esophagus. J Thorac Surg 1956;32:827–32.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bradley L. Bufkin Joseph I. Miller, Jr Kamal A. Mansour Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bufkin, B. L. Articles by Mansour, K. A. Search for Related Content PubMed PubMed Citation Articles by Bufkin, B. L. Articles by Mansour, K. A. Related Collections Related Article