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Surgical Management of Esophageal Perforation

Open ArchivePublished:February 05, 2016DOI:https://doi.org/10.1053/j.optechstcvs.2016.02.002
      Esophageal perforations remain a challenging problem with significant morbidity and mortality. Accurate diagnosis to isolate the location and etiology of the injury, as well as associated upper gastrointestinal pathologies is vital to determine appropriate, prompt treatment plan. Management options include nonoperative resuscitation and medical management, endoscopic stenting and thoracoscopic decortication, primary repair with tissue flap buttress or esophageal diversion ± resection. Posterolateral thoracotomy and primary repair of the injury with reinforcement with a pedicled tissue flap is historically considered the standard treatment by which other treatments are measured. The thoracic surgeon should be skilled in all potential treatment algorithms to provide the best outcome for the patient in these difficult clinical scenarios.

      Keywords

      Introduction

      Esophageal perforation continues to provide thoracic surgeons’ with a diagnostic and therapeutic dilemma associated with significant morbidity and mortality. Clinical outcome is determined by several factors, including the etiology of the injury, location of perforation, and delay in diagnosis and treatment. A recent meta-analysis reports a mortality rate of up to 18%.

      Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 77:1475-1483, 2004.

      However, a delay in diagnosis and treatment greater than 24 hours have been shown to double the resultant mortality.
      • White R.K.
      • Morris D.M.
      Diagnosis and management of esophageal perforations.
      Despite the high morbidity and mortality rates, the advantage of surgical repair in the appropriate clinical scenario cannot be understated.
      The etiology of esophageal perforation can be divided into iatrogenic, spontaneous, and traumatic. Iatrogenic causes are the most common, accounting for up to 60% of the cases.

      Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 77:1475-1483, 2004.

      These include rigid and flexible esophagoscopy, esophageal dilation, and other interventional endoscopic techniques. Spontaneous perforations are often related to Boerhaave syndrome, in which severe wretching and vomiting leads to an esophageal tear because of significant barotrauma. Traumatic perforations are less common and usually due to penetrating injuries.
      The location of the perforation is an important determinant of treatment plan, as well as resultant outcome. Although the perforation can occur at any location in the esophagus, there is a predilection to key anatomic areas that correspond to natural points of luminal narrowing. The most proximal location is in the cervical esophagus at the cricopharyngeus. Endoscopic iatrogenic injuries often occur at this location. Next, a narrowing is present in the mid-esophagus, at the area of the aortic arch, and carina. This location plays a part in the obstruction of ingested foreign bodies and resultant perforation. Finally, the gastroesophageal junction is a common area of perforation, especially those of barotrauma etiology.
      Patients with cervical perforations often present with neck pain, dysphagia, and subcutaneous emphysema. In contrast, patients with intrathoracic perforations usually present with more severe findings. These include symptoms of septic shock, such as fever, leukocytosis, hypotension, and tachycardia. Additionally, the pleural contamination can induce chest pain and respiratory failure.
      Several diagnostic tests are vital to the appropriate diagnosis of an esophageal perforation. Chest radiographs and computed tomography of the chest can show pleural effusions, pneumothorax, pneumomediastinum, and subcutaneous emphysema. Contrast esophagram as shown in Figure 1, preferably with gastrograffin followed by thin barium for smaller defects, is the gold standard diagnostic modality.
      • Gollub M.J.
      • Bains M.S.
      Barium sulfate: A new (old) contrast agent for the diagnosis of postoperative esophageal leaks.
      Flexible endoscopy is often used by the surgeon perioperatively to steer surgical repair or detect additional esophageal pathologies or both.
      Figure thumbnail gr1
      Figure 1(A) Esophagram showing extravasation of contrast indicating esophageal perforation. Water-soluble contrast agents should be used initially, followed by thin barium, if necessary. Specific features to note on the imaging include anatomical features or abnormalities of the esophagus, location of perforation, and direction and extent of contrast extravasation. (B) Esophageal stent in place excluding perforation.
      Surgical approach and technique for esophageal perforation is varied and based on location of the perforation, timing of diagnosis, and the patient’s clinical state. Cervical perforations are often treated with surgical drainage alone or primary repair, and drainage. In general, they have a lower morbidity and mortality than intrathoracic perforations.

      Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 77:1475-1483, 2004.

      If diagnosed within 24 hours and the patient is not floridly septic, than intrathoracic perforations require surgical exploration, debridement, buttressed repair, and wide drainage. Surgical repair is the historical standard and author’s preference for treatment of an esophageal perforation, especially in patients who have presented early or are appropriate candidates for surgical intervention. If diagnosed after 24 hours, primary repair may not be feasible due devitalized, necrotic tissue. In this situation, or in the case of an unstable patient, esophageal diversion may be the best approach. Additionally, in those patients who have small, usually iatrogenic, clinically insignificant perforations or in the elderly or medically comorbid, a minimally-invasive endoscopic approach may provide the most benefit. The following sections would describe a buttressed primary repair of a distal esophageal perforation via a left posterolateral thoracotomy, as well as minimally-invasive endoscopic therapeutic options and a brief description of esophageal diversion.

      Operative Technique

      Thoracic Exploration and Repair

      Before surgical exploration and repair, a flexible esophagogastroduodenoscopy should be performed to visualize the injury location and extent, as well as possible associated upper gastrointestinal pathologies. The esophagogastroduodenoscopy also helps identify potential distal obstructions, such as achalasia or malignancy that could lead one to avoid primary repair, but rather resection vs esophageal diversion. The authors frequently also place a percutaneous endoscopic gastrostomy (PEG) for postoperative drainage as well eventual enteral access (Fig. 2A). We have not noticed further damage to the perforation site with this procedure. Additionally, the PEG tube placement has not been a hindrance to a possible subsequent esophagectomy and gastric pull-up, only requiring a simple repair in that scenario. Alternatively, a small upper midline laparotomy can be performed before or after the perforation repair for enteral access (Figs. 2B and 3).
      Figure thumbnail gr2a
      Figure 2(A) A flexible esophagogastroscopy can be performed to further examine the esophagus and stomach. The location and details of the perforation can be delineated as well. A percutaneous endoscopic gastrostomy tube can then be placed safely in standard fashion. This provides postoperative gastric decompression and access for eventual enteral feeding. PEG = percutaneous endoscopic gastrostomy.
      Figure thumbnail gr2b
      Figure 2(Continued) (B) Alternatively, with the patient in the supine position, a 6-8 cm upper midline laparotomy can be performed. A standard dual-lumen gastrojejunostomy tube can be then placed with 1 lumen opening into the stomach for gastric decompression and the other emptying into the jejunum for enteral feeding access. Separate gastrostomy and jejunostomy tubes can also be placed if a gastrojejunostomy tube is unavailable.
      Figure thumbnail gr3
      Figure 3The patient is placed in the lateral decubitus position. A roll is placed below the axilla to protect the brachial plexus. The bottom leg is bent at the knee and the top leg is placed straight. The arms are placed on arm boards. The table is flexed at the hip. Reverse trendelenberg positioning is used to ensure the table is parallel to the floor. Injuries to the distal esophagus are approached via the left chest, whereas injuries to the upper to middle esophagus are approached through the right chest.
      Esophageal perforations are most commonly located in the distal third of the esophagus. Injuries at this location are best approached via a left seventh or eighth intercostal space posterolateral thoracotomy (Figure 4, Figure 5). In rare circumstances, a lower esophageal perforation can extend across the gastroesophageal junction. Unfortunately, this is usually not discovered until during the thoracotomy and exploration. If the full extent of the perforation cannot be visualized and extends across the gastroesophageal junction, the left diaphragm may need to be partially opened to access the abdominal cavity and repair the perforation accordingly. The diaphragm can subsequently be closed with interrupted 0 or 2-0 interrupted, horizontal mattress, Ethibond suture. Perforations of the middle third of the esophagus are managed via a fourth or fifth intercostal space posterolateral thoracotomy. The technique of repair is the same for both approaches: longitudinal myotomy, mucosal repair, closure of myotomy, and buttress reinforcement with intercostal muscle, pericardial fat, pleural patch, or diaphragm flap. Importantly, the decision to use an intercostal muscle flap must be made before the thoracotomy as it is harvested on entry (Fig. 8).
      Figure thumbnail gr4
      Figure 4A standard serratus-sparing posterolateral thoracotomy and exposure is used. Distal esophageal injuries are approached via a left posterolateral thoracotomy, usually in the seventh or eighth intercostal space. Upper to middle esophageal injuries are approached via a right posterolateral thoracotomy, usually in the fourth or fifth intercostal space. Resection of a 1 cm segment of the posterior aspect of the inferior rib allows improved exposure when opening the intercostal space with Finochietto retractors. Importantly, the decision to use an intercostal muscle buttress should be made before performing the thoracotomy, so that the muscle can be dissected accordingly.
      Figure thumbnail gr5
      Figure 5After entry via the posterolateral thoracotomy, the pleural cavity is evacuated of gastric content and food debris. Cultures can be taken at this time. The inferior pulmonary ligament is divided with electrocautery and the isolated lung is retracted superiorly with a folded, moistened sponge. The mediastinal pleura overlying the site of the tear is often bulging and necrotic. The pleura is opened widely and necrotic pleura is aggressively debrided. Although palpating the previously placed nasogastric tube, the esophagus is mobilized bluntly away from the site of the tear encircled. The esophagus is then encircled with a Penrose drain.
      Figure thumbnail gr6
      Figure 6The mucosal tear is usually more extensive than the overlying muscularis injury. Therefore, a longitudinal myotomy is performed with electrocautery until the entire length of the mucosal defect is visualized. Edematous and necrotic mucosal edges are sharply debrided to ensure healthy tissue for repair.
      Figure thumbnail gr7
      Figure 7Before repair, a 42 Fr to 48 Fr bougie is placed in the esophagus. The mucosal defect is reapproximated with interrupted 3-0 Vicryl sutures. The myotomy is closed with interrupted 3-0 Silk sutures. The bougie is removed and replaced with a nasogastric tube inserted proximal to the site of the repair.
      Figure thumbnail gr8a
      Figure 8(A) If using an intercostal muscle flap to buttress the repair, this step should be completed at the time of thoracotomy and pleural cavity entry. The intercostal muscle is carefully cauterized free from the superior rib. Using blunt dissection and a periosteal elevator, the muscle and associated neurovascular bundle is mobilized from the inferior rib. The free muscle is divided anteriorly between suture ligatures. The intercostal muscle flap should be mobilized posteriorly as much as possible to gain adequate length. After the esophageal repair is complete, the flap is placed on the repair and sutured circumferentially with interrupted 3-0 Vicryl suture.
      Figure thumbnail gr8b
      Figure 8(Continued) (B) The pedicled diaphragmatic flap is another option for buttressing the esophageal repair. A U or V shaped flap is created starting near the esophageal hiatus and mobilizing laterally until adequate length is estimated. The width of the base should be 1 quarter of the length. The flap is rotated onto the esophageal repair and sutured circumferentially with interrupted 2-0 Vicryl. The defect in the diaphragm is repaired with interrupted, horizontal mattress 2-0 Ethibond.
      An important point in esophageal perforation repair is that the mucosal injury in usually more extensive than the defect in the muscularis. A longitudinal myotomy should be performed to identify the full extent of the mucosal injury (Fig. 6). A 2-layer repair is used with interrupted 3-0 vicryl to repair the mucosal defect and interrupted 3-0 silk to repair the myotomy (Fig. 7). Finally, a “third layer” is added with the tissue flap. The authors prefer an intercostal muscle flap or diaphragm flap as a pedicled, viable tissue to buttress (Fig. 8), however, pericardial fat and pleural patch have also been described.
      A nasogastric tube is placed proximal to the site of the repair. The pleural cavity and mediastinum are thoroughly irrigated. A 28-Fr straight chest tube is placed posteriorly and apically; a 28-Fr right angle chest tube is placed over the diaphragm. Standard posterolateral thoracotomy closure is performed (Fig. 9).
      Figure thumbnail gr9
      Figure 9Wide large bore chest tube drainage is required using a right angle tube placed along the diaphragm, as well as a straight tube placed posteroapically. Occasionally, the contralateral pleural cavity requires drainage either by a transmediastinally maneuvered chest tube from the ipsilateral side or by placement of a contralateral chest tube. Standard posterolateral thoracotomy closure using #2 Vicryl pericostal sutures to close the intercostal space, followed by a layered closure of the skin and soft tissue.
      Postoperatively, aggressive resuscitation and broad spectrum antibiotic or antifungal treatment is important. The nasogastric tube can usually be removed on postoperative days 3-5 and the patient can be started on slow tube feeds via the PEG. An esophagram is checked on postoperative day 7 and the diet is slowly advanced accordingly (Fig. 10).
      Figure thumbnail gr10
      Figure 10Esophageal stenting is an option for treatment in esophageal perforation, especially for patients that may not tolerate an extensive operation. A standard flexible esophagoscopy is performed to delineate the nature and location of the tear. Under fluoroscopic guidance, skin markers are placed corresponding to the proximal and distal aspect of the tear. A guidewire is placed into the stomach and the endoscope is removed, leaving the guidewire in place. An appropriately sized covered esophageal stent and deployment apparatus is placed under fluoroscopic guidance along the guidewire. The stent is deployed according to manufacturer׳s instructions. Care is taken that the stent is deployed between the previously placed markers, so that the leak is excluded. A repeat swallow study can be performed within 48 hours and subsequent resumption of diet if successful leak exclusion is obtained.

      Esophageal Stenting and Thoracoscopic Decortication

      The placement of endoscopic esophageal stent under fluoroscopy for the treatment of esophageal perforation has recently been reported (Fig. 1B). A variety of removable, covered esophageal stents with different deployment apparatuses are currently available. The authors selectively employ this technique, especially in patients with small clinically insignificant perforations, the elderly and the medically comorbid. In their review of the literature, Dasari et al
      • Dasari B.V.
      • Neely D.
      • Kennedy A.
      • et al.
      The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations.
      reported an 81% success rate with esophageal stenting in benign perforations or anastomotic leaks. Stent migration requiring repeat interventions remains the most common postprocedural complication.
      • Van Boeckel P.G.
      • Sijbring A.
      • Vieggaar F.P.
      • et al.
      Systematic review: Temporary stent placement for benign rupture of anastomotic leak of the oesophagus.
      The stent should be removed within 6-8 weeks to avoid overgrowth of tissue along the interstices. Of note, the authors usually place a PEG before stent placement as well.
      Importantly, if esophageal stent placement is used as treatment for esophageal perforation, the pleural cavity and mediastinum should be adequately irrigated and widely drained. This can be done via a thoracoscopic approach (Fig. 11). Port placement can be according to the surgeon’s specific practice.
      Figure thumbnail gr11
      Figure 11If using an esophageal stent for exclusion or repair of the esophageal perforation, the contamination in the pleural space still needs to be addressed. A minimally-invasive thoracoscopic approach can be employed to evacuate the debris, irrigate the pleural space and decorticate pleural rind that may lead to chronic trapped lung. A 5-10 mm trocar for the thoracoscope is placed in the eighth or ninth intercostal space in the posterior axillary line. Overall, 2 additional 1-2 cm working incisions are made in the fourth and fifth intercostal spaces anteriorly and posteriorly to allow the insertion of instruments.

      Esophageal Diversion

      Patients that present late after an esophageal injury in extremis because of advanced sepsis often require prompt esophageal diversion ± esophageal resection. The full details of this procedure are beyond the scope of this article. The general premise includes: left neck exploration and cervical esophagostomy creation, midline laparotomy with division of gastroesophageal junction and gastrostomy and jejunostomy tube placement, and wide drainage of bilateral pleural spaces (Fig. 12).
      • Raymond D.P.
      • Watson T.J.
      Esophageal diversion.
      If clinically appropriate, a right thoracotomy and esophageal resection with closure of the diaphragmatic hiatus can also be performed.
      Figure thumbnail gr12a
      Figure 12For patients that present late after the perforation in extremis, esophageal exclusion with cervical esophagostomy may be the most judicious choice. Briefly, a left neck incision is made along the anterior border of the sternocleidomastoid muscle. The esophagus is identified and mobilized. The esophagus is divided distally in the neck with an endoscopic stapler. A suitable position in the left inferior neck is identified, usually just inferior to the clavicle, and 2 cm skin incision is created for the esophagostomy. The stump of the divided cervical esophagus is drawn through the cutaneous defect. The staple line is removed. The esophagostomy is created with 3-0 Vicryl interrupted sutures placed through the skin and full-thickness esophagus. Next, an upper midline laparotomy is performed. The stomach is identified and gastroesophageal junction is isolated. The distal esophagus is fully mobilized and encircled. The distal esophagus is divided with an endoscopic stapler. A gastrojejunostomy tube or separate gastrostomy and jejunostomy tubes are placed as shown in . If the patient can tolerate it, a right thoracotomy should be performed before or after the earlier steps to irrigate the mediastinum and possibly resect the esophagus while closing the hiatus. If the patient׳s clinical state precludes resection, large bore bilateral chest tubes should be placed.
      Figure thumbnail gr12b
      Figure 12For patients that present late after the perforation in extremis, esophageal exclusion with cervical esophagostomy may be the most judicious choice. Briefly, a left neck incision is made along the anterior border of the sternocleidomastoid muscle. The esophagus is identified and mobilized. The esophagus is divided distally in the neck with an endoscopic stapler. A suitable position in the left inferior neck is identified, usually just inferior to the clavicle, and 2 cm skin incision is created for the esophagostomy. The stump of the divided cervical esophagus is drawn through the cutaneous defect. The staple line is removed. The esophagostomy is created with 3-0 Vicryl interrupted sutures placed through the skin and full-thickness esophagus. Next, an upper midline laparotomy is performed. The stomach is identified and gastroesophageal junction is isolated. The distal esophagus is fully mobilized and encircled. The distal esophagus is divided with an endoscopic stapler. A gastrojejunostomy tube or separate gastrostomy and jejunostomy tubes are placed as shown in . If the patient can tolerate it, a right thoracotomy should be performed before or after the earlier steps to irrigate the mediastinum and possibly resect the esophagus while closing the hiatus. If the patient׳s clinical state precludes resection, large bore bilateral chest tubes should be placed.

      Conclusions

      The management of esophageal perforation remains a vital, albeit challenging, skill that all thoracic surgeons should master. The patient presentation and location and etiology of the injury are varied. These factors determine the treatment algorithm, which includes nonoperative treatment, minimally-invasive and endoscopic techniques, primary repair with tissue buttress and esophageal diversion. Accurate diagnosis, aggressive resuscitation, and prompt, yet skilled, repair are necessary proficiencies that the thoracic surgeon must employ to provide successful results in this difficult clinical scenario.

      References

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