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1. Esophageal Perforation
Facebook: Happy Friday Knight
February, 2nd, 2018
General Surgical Residency Program
Thailand

2. • Can be from iatrogenic (most common -
during diagnostic or therapeutic endoscopic
procedures), spontaneous, foreign body,
trauma, operative injury, and tumor.
• Regardless of etiology, it is surgical emergency
• Surgical therapy is mainstay treatment

3. Basic Anatomy of Esophagus

4. • A muscular tube
• From pharynx to cardia of stomach
• 3 narrowing points: tend to hold up objects and
injured when ingesting corrosive agent
– Uppermost: entrance of esophagus caused by
cricopharyngeal muscle (1.5 cm)
– Middle: caused by crossing of Lt main stem bronchus
and aortic arch (1.6 cm)
– Lowermost: hiatus caused by sphincter (1.6-1.9 cm)

5. • In normal anatomic position, transition from
oropharynx to esophagus is lower border of 6th cervical
vertebra
• Attach to cricoid cartilage
• It lies in the midline, with a deviation to the
left in the lower portion of the neck and upper portion
of the thorax, and returns to the midline in the
midportion of the thorax near the bifurcation of the
trachea In the lower portion of the thorax, the
esophagus again deviates to the left and
anteriorly to pass through the diaphragmatic hiatus

6. Netter’s Atlas of anatomy

7. Netter’s Atlas of anatomy

8. Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education, 2015

9. Brunicardi FC et al.
Schwartz’s Principles of
Surgery. 10th ed. McGraw-
Hill Education, 2015

10. • Cervical portion: 5 cm
• Thoracic portion: 20 cm
• Abdominal portion: 2 cm
• Musculature:
– Outer longitudinal and inner circular layer
– 2 – 6 cm uppermost contains only striated muscle,
then smooth muscle gradually becomes more
abundant

11. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

12. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

13. • Primary function of esophagus is to transport
materials from pharynx to stomach
• Swallowing – three phases: oral, pharyngeal,
esophageal

14. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

15. Clinical Presentation
• Depends on
– the mechanism of injury
– time elapsed from injury
– location of the perforation
– associated comorbid conditions
• Pain
• Fever
• Dyspnea
• crepitus

16. Clinical Presentation
• Cervical perforation:
– Pain
– Dysphagia
– Odynophagia worsening when swallowing and
neck flexion
– Crepitus
– Fever
– Right-sided pleural effusion

17. Clinical Presentation
• Midthoracic perforation:
– Fever
– Right-sided pleural effusion
– Substernal and epigastric pain
– Mediastinal air

18. Clinical Presentation
• In spontaneous perforation of distal thoracic
esophagus (Boerhaave syndrome) : Mackler triad:
– Thoracic pain
– Vomiting
– Subcutaneous emphysema
• Perforation of abdominal portion:
– severe epigastric pain radiate to back and left
shoulder
– Generalized peritonitis suggests diffuse contamination

19. Diagnosis
• Critical period of 24 hours is essential
• Wide range of diagnostic option can guide the
clinician:
– CXR
– Oral contrast studies
– CT
– Direct endoscope
• Which to choose depends on clinical screnario

20. Diagnosis
• In stable and cooperative patient  CXR PA
upright with lateral CXR
– Mediastinal emphysema
– Mediastinal widening
– In cervical perforation  subcutaneous
emphysema

21. http://www.anmjournal.com/article.asp?issn=0331-
3131;year=2015;volume=9;issue=1;spage=30;epage=32;aulast=Nair

22. Diagnosis
• Stable patient suspected endoscopic injury:
contrast esophagogram
– Standard confirmatory study
– maybe non-operative management
– Most protocols initially utilize water-soluble
iodinated radiopaque medium (Gastrograffin)
followed by dilute barium

23. https://thoracickey.com/esophageal-perforation/

24. Diagnosis
• More urgent presentations often come with
CT scan
– Used in atypical presentation, unable to tolerate
oral study, critically ill, intubated
– Good for identify extraluminal air and fluid

25. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

26. Diagnosis
• Next is to do endoscopic assessment
– direct visualization of the esophageal mucosa for
tears, perforations, and pathologic lesions
– useful in assessing the extent of injury and its
location, thus guiding surgical decision making and
operative approach
– Therapeutic benefit in removing foreign body and
placement of stent
– Air insufflation may exacerbate pneumothorax
– Best perform in OR
– ICD before performing

27. Management
• Principles
– Accurate diagnosis
– Resuscitation
– Control of extraluminal contamination
– Broad spectrum antibiotic coverage – both aerobe
and anaerobe
– NPO and nutritional support
– Restoration of GI tract continuity

28. Management
• Choices
– Nonoperative management
– Placement of a covered stent
– Primary surgical repair
– Drainage
– Esophageal resection and exclusion or proximal
diversion

29. Management
• Factors that guide the choice
– location of perforation
– degree of contamination
– sepsis
– Tissue destruction
– preexisting esophageal disease
– comorbidities
– time from the diagnosis

30. Yeo CJ et al. Shackelford’s surgery of
alimentary tract. 7th ed. Philadelphia:
Elsevier Saunders, 2013.

32. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

33. Nonoperative and Endoscopic Managemtn
• Cameron and Altorjay proposed criteria for
nonoperative management:
– Perforation within neck or mediastinum with free
drainage back into the esophagus on
esophagogram
– Minimal symptom without evidence of sepsis
– Early diagnosis of intramural perforation
– Absence of benign or malignant obstructive
disease

34. Nonoperative and Endoscopic Managemtn
• Observe the patient for 3 – 5 days then repeat
esophagogram and step diet
• Stent can be used to seal perforation and
control a leak but debridement and drainage
must be ensured

35. Operative Management
• Gold standard
• Best outcomes when early identification (<24h)
• Surgical exploration allows
– direct visualization of the perforation
– drainage of contaminated spaces
– debridement of devitalized tissue
– followed by a primary repair, resection, or diversion if
necessary.

36. Operative Management
• Cervical esophagus
– Left neck incision
– Anterior to SCM
– Drainage
– 2-layer primary repair
– containment of the cervical esophageal
perforation by the surrounding cervical structures
limits contamination

37. https://www.ctsnet.org/article/exposure-cervical-esophagus
2 FB below
cricoid cartilage,
horizontally
from anterior to
posterior SCM

38. https://www.ctsnet.org/article/exposure-cervical-esophagus
- Short
subplastymal
flaps are elevated
- Fascial incised

39. https://www.ctsnet.org/article/exposure-cervical-esophagus

40. https://www.ctsnet.org/article/exp
osure-cervical-esophagus

41. Operative Management
• In contrast, perforation of the thoracic or
abdominal esophagus is associated with
contamination of larger, free spaces (i.e.,
pleura or peritoneum) and therefore requires
a more aggressive surgical approach in order
to obtain source control of the underlying
infection and prevent continued soilage

42. Operative Management
• Abdominal esophagus: explore laparotomy
• Thoracic esophagus
– Right thoracotomy through 6th ICS for proximal
and middle esophagus
– Left thoracotomy through 8th ICS for distal
esophagus

43. Operative Management
• Principles: debridement devitalized tissue and
primary closure
• Mucosal repair by interrupted absorbable suture
• Minimize esophageal stricture
• Muscular layer is reapproximated with
interrupted or running suture
• Subsequent coverage with a vascular pedicle,
such as an intercostal muscle flap, and pleural,
pericardial, or omental pedicle allows further
buttressing of a repair and is recommended
whenever feasible

44. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

45. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

46. Operative Management
• Any of the antireflux procedures (Belsey Mark
IV, Nissen, Dor, Toupet) may be used to
buttress the repair
• Alternative choices when extensive tissue
necrosis:
– T-tube placement
– stent placement with muscle flap coverage
– esophageal resection with proximal esophageal
diversion and distal feeding access

47. • In setting of underlying esophageal diseases may
complicate the choice  absolute
contraindications to primary esophageal repair
unless distal obstruction can be relieved :
– Achalasia
– Chronic stricture
– eosinophilic esophagitis
– severe reflux disease
– malignancy
Operative Management

48. • Achalasia, repaired primarily in two layers,
and esophageal myotomy performed on the
contralateral side of the LES
• end-stage achalasia with sigmoid esophagus,
malignancy, retractory esophageal stricture,
esophagectomy with gastric pull-up
Operative Management

49. • Esophagectomy with reconstruction VS
proximal diversion and distal enteral access:
– Remain challenging
– judging from the degree of contamination
– the patient’s physiologic status
– suitability of a conduit for esophageal
replacement
Operative Management

50. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015.
Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia:
Elsevier Saunders, 2013.
Netter’s Atlas of anatomy
https://www.ctsnet.org/article/exposure-cervical-esophagus