Esophageal Perforation And Tears

The clinical manifestations of esophageal perforations depend on several factors including the etiology of the perforation, the location of the perforation (cervical, intrathoracic or intra-abdominal), the severity of contamination, injury of nearby mediastinal structures (trachea in a case of penetrating trauma in cervical esophageal perforations or the pericardium in case of spontaneous thoracic perforations), and the time elapsed from the perforation until treatment.[8][9]

• Cervical esophageal perforations can be presented with neck pain, dysphagia, odynophagia, or dysphonia. Crepitus or tenderness can be elicited on neck palpation.
• Thoracic esophageal perforations are presented with retrosternal chest pain, often preceded by retching and vomiting in patients diagnosed with Boerhaave syndrome. Patients may have crepitus on chest wall palpation caused by subcutaneous emphysema. Mediastinal crackling can be heard on auscultation in patients with mediastinal emphysema. Symptoms and signs of pleural effusion such as dyspnea, tachypnea, dullness on chest percussion, and decreased fremitus may be detected.
• Abdominal esophageal perforations are presented with epigastric pain radiating to the shoulder which might be associated with nausea or vomiting. Transmural tears, extending through the serosa is frequently complicated by peritoneal contamination and patients present with acute peritonitis.
• Fever, tachycardia, tachypnea, hypotension, and cyanosis are signs of late mediastinitis and shock and considered a poor prognostic indicator.

• Plain radiography is used to detect air that has escaped from the perforated esophagus. Subcutaneous emphysema in the case of cervical esophageal rupture, mediastinal air (pneumomediastinum), and widening is indicative of thoracic perforation while free air under the diaphragm is clear evidence of abdominal esophageal perforation. Other findings that may show on plain X-rays include pleural effusion, pericardial effusion, hydrothorax, hydropneumothorax, and air in soft tissues of the prevertebral space.
• Contrast esophagography is used to establish and to confirm the diagnosis of esophageal perforation. Leakage of contrast material is a sure sign to establish the diagnosis of perforation. Dye extravasation can also help determine the location and extent of the rupture. Barium contrast studies are superior to water contrast materials in terms of accuracy and specificity; however, due to the higher risk of barium-induced chemical mediastinitis, water contrast studies are preferred.
• Computed tomography (CT scan) of the chest and abdomen should be performed when esophageal perforation is suspected. It has the advantage of showing intrathoracic or intra-abdominal collections that require percutaneous or surgical drainage. CT findings may include periesophageal fluid collections (pleural effusion, ascites), esophageal thickening, and pneumomediastinum.

Patients with esophageal perforations are of high mortality risk; even with prompt medical care, mortality can reach as high as 36% to 50%. Hence, optimized initial resuscitation is critical to ensure appropriate delivery of care to the affected patients. [10][11]

Initial Management

• ICU admission for all unstable patients or high-risk patients with multiple comorbidities
• Hemodynamic monitoring, volume resuscitation, and stabilization.
• NPO (Nil Per Os) 
• TPN (Total Parenteral Nutrition)
• Intravenous broad-spectrum antibiotics and antifungals
• Intravenous proton pump inhibitors
• Percutaneous drainage of any fluid collection 
• Assessment for operative versus nonoperative management 
• Feeding J-tube

Standard Care of Management

• Endoscopic stent placement: Performed in selected stable patients; esophageal perforations can be covered with synthetic stents delivered via esophageal endoscopy. Failure of this intervention is mostly attributed to either stent migration, malpositioning, or inability to create an air/fluid tight seal between the stent and the margins of the esophageal defect.
• Drainage with/out debridement: Surgical drainage is performed without further operation as most of the esophageal perforations will heal if drained adequately.

Surgical Management

Operative management is required for most patients to minimize morbidity and mortality.

• Patients diagnosed early (less than 24 hours after the perforation) can be treated with debridement of all devitalized contaminated tissue followed by primary repair. In addition, the primary repair should be enhanced with the use of a vascularized pedicle flap using serratus anterior, latissimus dorsi, or the diaphragm.
• Patients who present by extensive leakage of fluid, substantial tissue necrosis, or devitalization or by major fluid collections should undergo emergent surgical stenting, debridement, or drainage to restore the integrity of the esophagus.
• In rare situations, diversion procedures or resection of the esophagus with proximal esophagostomy and feeding gastrostomy/jejunostomy can be a valid option in patients with extensive contamination who are not candidates for primary repair due to friability of the surrounding tissue or pre-existing esophageal disease (inoperable malignancy).
• Postoperative healing can be enhanced by placing a feeding jejunostomy or gastrostomy tube to abstain from oral feeding for more prolonged periods of time and ensure maximum healing conditions for the esophagus, especially when substantial extraluminal leakage exists. However, this operation is optional and relies on the surgeon's preference.
• Oral feedings should be restored when the patient is stable, with a contrast esophagram study confirming the integrity of the esophagus and the absence of any leakage.

• Acute aortic dissection

• Acute coronary syndrome

• Acute pericarditis

• Aspiration pneumonitis and pneumonia

• Bacterial pneumonia

• Emergent management of pancreatitis

• Empyema and abscess pneumonia

• Mallory-Weiss tear

• Myocardial infarction

• Peptic ulcer disease

• Pneumothorax

• Pulmonary embolism

Esophageal perforation poses a significant challenge to the entire therapeutic team. These patients may present with a variety of nonspecific symptoms, such as abdominal, retrosternal chest pain, or vomiting and may also exhibit signs of sepsis and shock. An interprofessional, cooperative team is crucial to delivering optimal and appropriate care. While the general surgeon is almost always involved in managing patients with esophageal ruptures and perforations, other specialists such as a radiologist, intensivist, thoracic surgeon, and expert endoscopist should be involved in providing adequate care for these patients. Surgical residents should also have a high threshold to suspect or diagnose esophageal perforations. A radiologist has a key role in the diagnosis of esophageal ruptures and tears, especially complex or small perforations with minimal leaks.

The mortality of esophageal perforations can be as high as 50%, thus to improve outcomes, prompt consultation with an interprofessional group of specialists is recommended.