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 been a major factor in improving safety. It can readily be imagined that passing a rigid metal tube down the oesophagus of an elderly patient with a kyphotic spine is a haz­ardous undertaking. The pharynx may be perforated above the cricopharyngeal sphincter; the oesophagus may be crushed against osteophytes in the cervical spine (Fig. 50.17), particularly during the extension of the neck that is necessary to get the instrument down to the distal oesophagus. Perfora­tions caused by rigid endoscopes are often large and gen­erally require more energetic surgical treatment than those that occur during flexible endoscopy.

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 this setting and it is important to obtain good quality images. It should also be emphasised that water-soluble contrast media may miss small perforations of the oesophagus or small anastomotic disruptions.

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.