Oesophageal perforation

Section: UGI Sub-section: Oesophagus Curriculum: Curriculum, page 95

Definition

• Rupture of the oesophagus
  • Most common site (70%)
    • Left posterolateral oesophagus
      • Usually 3-5cm above GOJ
  • Second most common site (20%)
    • Mid-thoracic, Right side, at level of Azygous Vein (T4)
• May be bilateral (10%)

Aetiology and Pathophysiology

• Iatrogenic Perforation > 50%
• Spontaneous Perforation 15%
• Penetrating and blunt trauma 10%
• Foreign Body 14%
• Neoplastic
• Caustic Ingestion

Is this a healthy or unhealthy oesphgaus Location - neck, chest, abdo Contained or unconfined

Iatrogenic Perforation

• Iatrogenic to oesophagus leading to full thickness disruption
• 60-70% endoscopic (increasing with increased use of endoscopy)
• Remainder for para-oesophageal surgery
  • Anti-reflux, spine, thoracic, neck surgery etc.
• Proximal oesophagus at risk with oesophageal intubation
  • Particularly if neck hyperextended, or Zenker’s
• Distal oesophagus most commonly injured in diagnostic cases (75-90%)
  • Usually associated with other pathology
• Therapeutic endoscopy has 200 x greater risk (around 5%)
  • Mostly therapeutic dilatation (perf at stricture or just above)
  • Further increased if previous chemo/rad

Spontaneous Perforation

• Complete disruption of the oesophageal wall in the absence of pre-existing pathology
• Boerhaave’s Syndrome
  • Barogenic oesophageal injury leading to immediate and gross gastric content contamination of the mediastinal/pleural cavity
• NB: Can have spontaneous perforation without as much contamination
• No serosa – oesophagogastric contents pulled into chest by negative pressure
  • Leads to rapid chemical and septic mediastinitis
• Caused by sudden rise in intra-abdo pressure
  • 90% by vomiting
  • Others: Trauma, defecation, weightlifting, the Heimlich manoeuvre, epilepsy
• Underlying pathology only found in 10-20% of cases
  • Malignancy, ulcers, infection etc.
• NB: Different pathological process to Mallory-Weiss tear
• Usually single, longitudinal, 1-8cm long
  • Occur most commonly in left posterolateral position above GOJ
• Previously associated with high morbidity and 50% mortality
  • Now ~ 20% mortality
  • Usually secondary to Mediastinitis, Pneumonitis, Pericarditis or Empyema

Traumatic Perforation

• Penetrating Injury
  • Usually in conjunction with serious injuries to surrounding viscera, so often missed
  • Delay and contamination greatly increase morbidity and mortality
  • Suspect with any trans-cervical or trans-mediastinal injuries
• Blunt injury
  • Very uncommon
  • Exclusive to high impact injuries
  • Associated with more immediate life-threatening injuries to airway or cardiopulmonary system
  • Can get cervical injury in whiplash
  • Traction injury in rapid deceleration
    • Cricoid
    • Carina
    • Pharyngo-oesophageal junction

Classification

• Early
  • Presenting within 24hrs of injury
  • 80-90% survival
• Late
  • Presenting > 24hrs from injury
  • 50% survival

Clinical Presentation

• Depends on cause, site and duration of injury
• Pain is the most striking symptom
• Mackler’s Triad for Boerhaave’s syndrome (only 20% accurate):
  • History of vomiting/barogenic injury
  • Sudden onset intense chest / lower thoracic pain – “boring” nature
  • Subcutaneous emphysema
• Symptoms usually to left hand side, especially in spontaneous ruptures
• Cervical perforation
  • Pain in neck, torticollis
  • Dysphagia/odynophagia +/- dysphonia / hoarseness
  • Fever
  • Surgical emphysema +/- local inflammation
• Thoracic perforation
  • Chest / back / abdo pain
  • SOB
  • Fever +/- hypotension, followed by septic shock
  • Surgical emphysema
• Hamman’s sign
  • Mediastinal crunch synchronous with heartbeat heard over the precordium in mediastinal emphysema

Pathology

• 50% of patients with spontaneous rupture have history of GORD
  • ? Allows easier transmission of high intra-gastric pressure into the oesophagus
  • During vomiting an intra-gastric pressure of > 200mmHg can be generated
• Thin mediastinal pleura is easily ruptured by the inflammatory process or tear
  • Then the negative intrathoracic pressure sucks gastric contents into the chest
• Extent of mucosal injury is usually greater than muscular injury
• Infection usually polymicrobial:
  • Staph, Step, Pseudomonas, Bacteroides, Candida

Investigations

CXR

• Typical findings
  • Pleural Effusion
  • Pneumomediastinum
  • Subcutaneous emphysema
  • Hydropneumothorax
  • Pneumothorax
  • Collapse/consolidation
• Not Sensitive

Contrast Swallow

• Initially use water-soluble contrast (Gastrograffin)
  • Barium causes inflammatory response
  • If negative, then use ½ strength barium
• Need to ensure aspiration avoided as aspirated gastrograffin causes life-threatening pneumonitis
• 10% false negative rate
  • Minimize by doing the study in left lateral position
• Not easy in hypotensive shocked pt
• Can tell you: location, side, intramural vs transmural, localised vs diffuse leak, ? pleural involvement, ? underlying malignancy

CT with PO Contrast

• Highly sensitive
• Very useful if patient well enough to go through scanner
• Esp. good in multi-trauma, and critically ill patients with an atypical presentation
• If patient intubated, can place NGT just past cricopharyngeus and trickle contrast in

Endoscopy

• Can give information on
  • Diagnosis
  • If foreign body suspected
  • Site and extent of defect
  • Exclude underlying pathologies
• Also empties stomach and facilitates NJ placement.
• Should perform if negative swallow and still high suspicion
  • 100% sensitivity, 96% specificity for perforation
  • No extra associated morbidity
    • Theoretical risk of extending perforation

Other Investigations

• Thoracocentesis
  • Can give diagnosis if difficult
    • pH < 6
    • High salivary amylase
    • Microscopic squamous cells
    • Or if methylene blue used

Management

Management Algorithm

Factors to Consider with Management

Principles of management

1. Timely intervention
2. Control of sepsis and contamination
3. Restoration of GI continuity and adequate nutrition support.

• Iatrogenic
  • Common
  • Patient fasted
  • Patient in hospital
  • Rapid/Early diagnosis
  • But may have underlying pathology
    • Cancer/stricture
• Spontaneous
  • Rare
  • Often misdiagnosed with delayed diagnosis
  • Large variation in degree of contamination and trauma
  • Generally grossly dirty with trauma to tissues, and associated sepsis

Initial Resuscitation

• Involve ICU early
  • Low threshold for definitive airway
  • Consider transfer to larger centre
• IVL x 2
• IVF
• IDC
• NBM
• Broad-spec IV Abx/antifungals
• IV Omeprazole
• NGT
  • Only placed endoscopically or under fluoroscopy
• Large bore chest drain if large chest contamination
  • Bilaterally if needed

Non-Operative Management

• Criteria
  • Perforation contained within the mediastinum
  • Free drainage of contrast back into oesophagus
  • No symptoms or signs of mediastinitis
  • No evidence of solid food contamination of pleural or mediastinal cavities
• Other factors to consider
  • Perforation is controlled
  • No underlying oesophageal disease
  • No septic shock
  • Availability for intensive observation and access to multidisciplinary care
  • Low threshold for aggressive intervention
  • Long delay in diagnosis such that the patient has already demonstrated tolerance
  • Enteral feeding
• Management
  • ICU/HDU monitoring
  • Initial resus as previous
  • NBM with enteral feeding
    • Feeding jejunostomy placed if needed
    • NG should be in placed to decompress stomach
  • Continue broad spec abx, antifungals and PPIs
  • Monitor closely with contrast radiology, CT or endoscopy
    • E.g. Weekly serial CT or contrast studies
  • If collection found – perc drain
  • If clinical deterioration or free perforation - surgery
  • Low threshold for operative intervention
    • 20% will eventually need this

Endoscopic Management

• Endoscopic treatment is usually used to treat endoscopic perforations which are recognised early/straight away.
• Closure – Clips and sealants
  • Can consider endoclip in small clean defects post EMR etc
  • Must be in the absence of significant perforation
  • NB: Challenging skill
• Stents
  • Self-expanding metal stent (SEMS)
  • Not designed for use in normal oesophagus
  • Migration in up to 30%
  • May extend defect due to pressure necrosis and trauma when removed
  • At present insufficient evidence
  • Don’t stent a dirty injury!
  • May use in highly selective circumstances
  • Usually saved for those deemed initially not fit for surgery
  • Need to remove in 6 weeks to avoid erosion into surrounding structures
• Endoscopic lavage and drainage
  • Endoscopic lavage and drainage of contained perforations
  • Can also place endo-VAC
    • Required repeated endoscopy, labour intensive
    • Not suitable for gross contamination

Operative Management

Options

1. Primary repair with a patch
2. Drainage and fistula formation
3. Resection and anastomosis
4. Resection and diversion

Indications for Surgery

• Sepsis/shock
• Gross contamination
• Retained FB or obstructing pathology
  • (incl. Achalasia megaoesophagus)
• Malignancy (if operable)
• Caustic injury, severe peptic disease
• Gunshot wound

Principles of Surgery

• Restore oesophageal integrity and prevent further soiling
• Approach appropriate to the cavity – use contrast imaging studies to guide where to go
• Debride, drainage, lavage and irrigation
• Most important - eradicates mediastinal/pleural sepsis
• Re-expand lung
• Drain widely (Thoracic ± Abdominal)
  • May result in establishment of a controlled fistula
  • Jackson-Pratt/Blakes drain at perforation + ≥ 2 large bore ICDs

Exposure and Approaches

Cervical Perforation

• Usually posterior, where the wall is thinnest
• Incision parallel to ant border of SCM, retract Carotid Sheath laterally & Thyroid medially (finger retraction on thyroid to avoid RLN injury)
• Prevertebral Fascial plane entered, and pus/contrast/leak identified
• Suture with interrupted 3-0 Prolene +/- strap muscle buttress and then drain widely
• If not found,
  • Place drains inferiorly into the mediastinum and superiorly along the post-vertebral gutter
  • Most will close in 2-3 weeks if pt NBM

Thoracic Perforation

• LOWER 1/3 – Left thoracotomy (7th IC space)
  • Most common site of perforation left postero-lateral, 3-5cm above GOJ
• PROXIMAL 2/3 - Right posterolateral thoracotomy
  • At/above carina – 4th IC space
  • Mid-oesophagus – 6th IC space
  • Incising the mediastinal pleura to expose entire thoracic oesophagus from aortic arch to oesophageal hiatus

Closure Techniques

Primary Repair

• High leak rate (20-50%)
• Only consider if
  • Early presentation
  • < 1/3 of oesophagus
  • Minimal inflammation
• Steps
  • Debride necrotic tissue
  • Primary 2-layer closure:
    • Mucosa (absorbable)
    • Muscle (2/0 or 3/0 interrupted absorbable suture)
    • NB: Mucosal injury often more extensive than muscular
      • Need to do a myotomy to carefully inspect extent of mucosal defect during closure
  • Consider contralateral myotomy if achalasia an underlying issue!
  • Ideally buttress/patch
    • Pleural based Grillo flap: surrounding parietal pleura wrapped around oesophagus 360°
    • Intercostal muscle pedicle
    • Pericardial fat
  • Drain placement
    • Luminal (NG closed to repair)
    • Mediastinal +/- abdomen
  • Consider nutrition
    • Feeding jejunostomy AND venting gastrostomy

Drainage

• Indications
  • Delayed presentation - not amenable to primary repair
  • Damage control situation in a very septic patient
• Steps
  • Closure over an 18G T-tube
    • Concept is to form controlled fistula
    • Split the end 15cm of a chest drain
    • Oesophageal wall closed loosely over the two ends with fine absorbable interrupted sutures
    • Anchor to the diaphragm to prevent aortic erosion
    • Initially attach to an under water sealed drains
      • Then change to free drainage
      • Then progressively shorten after 4-6 weeks post-surgery, when lung fully re-expanded
    • Drain placement
      • Mediastinal +/- abdomen
    • Consider nutrition
      • Feeding jejunostomy AND venting gastrostomy

Resection and anastomosis

• Consider if following underlying conditions
  • Megaoesophagus from end stage Achalasia
  • Resectable oesophageal cancer
    • DO NOT operate on unresectable cancer - stent and drain
  • Severe peptic ulcer disease
  • Caustic injury
• Major undertaking with very high mortality
• If stable: Consider primary resection + immediate reconstruction
• If unstable: Resection and cervical oesophagostomy, gastrostomy and feeding jejunostomy

Exclusion and Diversion

• Situation where patient has presented late with significant contamination and significant OE damage
• Exclusion
  • Resection of the damaged oesophagus
  • Or staple/tie off the distal end
• Diversion
  • Oesophagostomy
    • Cervical oesophagostomy in the neck
    • Thoracic oesophagostomy
• Venting
  • Venting gastrostomy very important otherwise can blow out the stump
• Nutrition
  • Feeding jejunostomy

Post-Operative Management

• After primary repair:
  • IV Abx
  • NBM for 10/7 with TPN & NGT on continuous suction
  • Re-image at 10/7 with gastrograffin before feeding
  • Usually follow with weekly contrast swallows until leak resolved then begin feeding
• If T-tube begin to shorten at 6/52 once tract formed
• If resection
  • Will need reconstruction
  • At least 6/52 down the line
  • Likely need colonic conduit as may have used stomach for gastrostomy

Natural Hx/Prognosis

• If undiagnosed
  • Shock and death can occur within 48hrs
• If recognised within 24hrs = 10% mortality
• If > 24hrs ≈ 50% mortality
• Non-operative management → 12% mortality
• Surgical management required → 30% mortality
• Cervical perf → mortality 0-20%
• Thoracic perf → mortality rate 5-50%

Boerhaave’s Syndrome

Management

• Options
  • Non-operative
  • Endoscopic - endospong, clips, stent
  • Operative
    1. Endoscopy to determine side of operation
    2. Double lumen tube
    3. Thoracotomy depending on side
       • Lower down then an elective operation so 7-8th intercostal space
    4. Debridement
    5. Options
       • Primary repair +/- buttress
       • Controlled fistula - T tube with pursesstring (6-8 weeks)
       • Not that relevent to the exam
         • Diverting cervical oesophagostomy
         • Oesophagectomy
    6. Drain placement
    7. Nutrition
       • Feeding jujunostomy
    8. Decompressive NGT