Perforation
Perforation of the oesophagus is a serious
condition that requires prompt diagnosis and treatment.
Barotrauma —
Boerhaave’s syndrome
So-called ‘spontaneous’ perforation of the
oesophagus is usually due to severe barotrauma when a person vomits against a
closed glottis. The pressure in the oesophagus rapidly increases and the
oesophagus bursts at its weakest point in the lower third, sending a stream of
material into the mediastinum and often the pleural cavity as well. The
condition
was first reported by Boerhaave who reported the case of a grand admiral of the
Dutch fleet who was a glutton and practised the habit of autoemesis.
Boerhaave’s syndrome is the most serious type of perforation because of the
volume of infected material that is released under pressure.
Suspect
perforation if pain follows vomiting
The
clinical history is of severe pain in the chest or upper abdomen following a
meal or a bout of drinking. Many cases are misdiagnosed as myocardial infarction
or as a perforated peptic ulcer or pancreatitis if the pain is confined to the
zipper abdomen. There may be a surprising amount of rigidity on examination of
the upper abdomen even in the absence f any peritoneal contamination.
Pathological
perforation
Perforation of ulcers, such as a Barrett’s ulcer (see below) or
tumours of the oesophagus are unusual, but do occur. They may also erode into
the aorta or ventricle with rapidly fatal results.
Penetrating
injury
Perforation by knives and bullets is uncommon, even in war, since the
oesophagus is a relatively small target surrounded by other vital organs.
Foreign
bodies
The oesophagus may be perforated during removal of a foreign body, but
occasionally an object that has been left in the oesophagus for several days
will erode through the wall.
Instrumental
perforation
Instrumentation is by far the commonest cause of oesophageal
perforation. Modern instrumentation is remarkably safe, but perforation remains
a risk that should never be forgotten. The virtual demise of the rigid
oesophagoscope has
Prevention
of perforation is better than cure
Perforation
during diagnostic flexible endoscopy of the upper CI tract is unusual, but
occurs at a frequency of one in 4000 examinations. Therapeutic endoscopy
increases the risk, but the overall risk should remain low. Dilatation of the
oesophagus increases the risk significantly, but biopsy does not. The
oesophagus may be perforated by a guidewire or dilator above or below a
stricture. Splitting of a benign stricture during dilatation is exceedingly rare
and is not a significant risk. Most perforations that occur during dilatation of
benign strictures are probably due to movement of the guidewire that allows the
dilator to move in an unpredictable direction. For this reason guidewires should
always be held firmly against an unmoving object during the passage of dilators.
This single act provides the greatest protection against injury. If dilatation
of a stricture is done during rigid endoscopy the unconstrained dilator may be
passed through the oesophagus above or, less commonly, below the stricture.
Cancers may be dilated safely, but it should be remembered that they are
unpredictably friable and may split as the dilator passes. It is therefore
prudent to limit the dilatation of a cancer to the extent that is necessary for
the matter in hand, such as passage of the endoscope for laser treatment of a
cancer. A side viewing duodenoscope [for an endoscopic retrograde
cholangiopancreatography
(ERCP)] that forms a loop in the oesophagus during insertion may cause a split.
This is a particularly unpleasant situation because if a loop does form there
is no safe method of undoing the loop. The oesophagus may be perforated by the
large balloons that are used for the treatment of achalasia by forceful
dilatation since these are inflated to a diameter (30—40 mm, 94—125 Fr) that
is greater than that of the normal oesophagus. The incidence of perforation
appears greater with the larger balloons and these should probably be reserved
for repeat dilatations if a smaller balloon has failed to achieve the desired
effect. Perforation may occur during the insertion of plastic tubes or expanding
stents for the palliation of cancer. In such cases the leak may be sealed
partially or completely once the stent is in place.
Diagnosis
Beware and be aware of perforation
Look for surgical emphysema
Perforation of the oesophagus usually produces
severe chest pain and should be suspected if this occurs after instrumentation.
Subcutaneous emphysema may be present in the neck and sometimes over the upper
chest as well. Emphysema is more likely to appear if the oesophagus is
perforated during flexible endoscopy because of the air insufflation that is an
essential part of the procedure. Emphysema around the pericardium can sometimes
be detected on auscultation as a mediastinal ‘crunch’ which sounds like
footsteps in soft snow A chest X-ray may show gas in the mediastinum, a pleural
effusion or a pneumothorax (Fig. 50.18).
Water-soluble
contrast media may miss small perforations
It
is essential to obtain a contrast swallow whenever a perforation is suspected.
The only possible exception to this rule is when the diagnosis is obvious, for
example when subcutaneous emphysema is present, and the management policy is
nonoperative. In such cases it may be reasonable to avoid the additional small
risk of worsening the contamination of the mediastinum by giving contrast.
Contrary to popular opinion Gastrograffin should not be used. This agent is
hypertonic and can cause severe lung injury if aspirated. Modern nonionic
contrast media are safer, but still give poorer images than barium suspension.
In the author’s opinion barium is the contrast material of choice. There is no
evidence that the judicious use of barium suspension is clinically harmful in
Treatment
Perforation of the oesophagus usually leads to
mediastinitis which is a very dangerous condition. The loose areolar tissues of
the posterior mediastinum allow rapid spread of gastrointestinal contents. There
may be marked systemic disturbance with cardiovascular collapse. Dysrhythmias
are common, especially atrial fibrillation. The aim of treatment is to limit
mediastinal contamination and deal with the existing infection. Operative repair
deals with the injury directly, but imposes risks of its own. Nonoperative
treatment aims to limit the effects of mediastinitis and provide an environment
in which healing can take place.
Prompt
diagnosis and treatment is essential for the best results
The
management of oesophageal perforation remains controversial with strong
opinions in favour of operative and nonoperative treatment. Both schools of
thought have their merits. The majority of perforations can nowadays be managed
nonoperatively, but it is still important to keep an open mind, to tailor
management to the individual patient and to be prepared to change the treatment
plan in the light of clinical progress. The essential determinants of management
are the septic load, the response of the patient to the septic challenge, the
age and general condition of the patient and whether the perforation is confined
to the mediastinum. Perforations of the abdominal oesophagus are probably best
managed by operative repair as is Boerhaave’s syndrome in which the septic
load is high. Most endoscopic perforations involve minimal contamination and are
ideal for non-operative management, particularly if the patient is a poor risk
for a thoracotomy. The relative indications for the two forms of management are
listed in Table 50.1.
The
key elements of nonoperative management are analgesia, nil by mouth,
antibiotics and general supportive care. When the patient is stable enteral or
parenteral nutrition is started. Enteral feeding is best given by feeding
jejunostomy.
Some authorities advocate a double-lumen
suction catheter in the oesophagus, but this is not universally agreed. There is
nothing to commend the use of a nasogastric tube which simply encourages
gastro-oesophageal
reflux and increases the risk of respiratory infection. Rather surprisingly even
a perforated cancer will heal, given adequate time.
Nonoperative
management of perforatred oesophagus
•
Analgesia
•
Nil by mouth
•
Antibiotics
•
Intravenous fluids/nutrition
The
management of oesophageal perforation can be difficult and it is important to be
prepared for complications, such as the tracheo-oesophageal fistula in Fig.
50.19.
Operative
management usually involves thoracotomy and repair of the perforation. This is
best done within a few hours of perforation. After 12 hours the tissues become
swollen and friable, and less suitable for direct suture. The hole in the mucosa
is always bigger than the hole in the muscle and the muscle should be incised to
see the mucosal edges clearly. It is essential that there should be no
obstruction distal to the repair. Ideally the repair should be strengthened with
adjacent gastric fundus, diaphragm or intercostal muscle. If the site of the perforation is not healthy,
oesophageal resection should be performed.
An
intermediate form of management is the insertion of a stent. This is now well
established for the treatment of perforated cancers. Expanding metal stents are
ideal for this purpose since they can be inserted with minimal trauma. Some
clinicians use the more traditional plastic or silicone tubes for this purpose,
but additional dilatation may be required for their insertion with the risk of
worsening the injury.
There
is a wide range of options for salvage following late diagnosis or failed
nonoperative management including multiple tube drainage, oesophageal exclusion
and resection, oesophagostomy, gastrostomy and delayed reconstruction. The
management of such cases is challenging and highly specialised.