Esophageal perforation and mediastinitis

John L. Sawyers, MD

Esophageal perforation is an acute surgical emergency. It is the most serious, and frequently the most rapidly lethal, perforation of the in- testinal tract. Contamination of the mediastinum with corrosive fluids, food matter, and bacteria leads to cardiorespiratory embarrassment, shock, major fluid losses and fulmi- nating infection. With prompt, ag- gressive surgical treatment, survival should be expected in most cases. But, in recent series of esophageal perfor- ations, mortality rates between 15 and 30 per cent are still reported.

The number of esophageal perfor- ations is increasing. A recent review of these a t the Vanderbilt University Hospital shows that during the period from 1950 to 1954 there was one case

John L. Sawyers, MD. is professor of surgery a t Vanderbilt University School of Medicine, and chief of surgery, Nashville Metropolitan General Hospital, Nashville, Tenn. H e received his BA de- gree a t the University of Rochester, and earned his MD degree at Johns Hopkins University School of Med:cine, Baltimore, Md.

per 20,000 admissions. In the last five year period there has been one case for every 8,000 admissions.

The various causes of esophageal perforations in our experience are shown in Table I. A total of 50 pa-

TABLE l CAUSES OF ESOPHAGEAL PERFORATION

Cenical (10) Dental prosthesis impacted in

cimopharyngeus ~ .-..._............. ~ ......___._______ 2 Endoscopy _.___________________.___._____________...........~. 4 Endoscopy and dilation ..__ ~ ..___.....______.._____ _ _ 1 Gunshot wounds _ _ _ __.___.__________ ~ ___. ~ ___._____._ ~ ___. 3

Thoracic (31)

Blunt trauma ~ .......................................... ~ ..._ 2 Dilation stricture ____________________...-........~.~.~~~. 5 Endoscopy .................................................... 5 Endoscopy and dilation _ _ _ _ _ ___._......._......... _._ 5 Esophagoscopy wilh biopsy __....._.____.________ 3 Open safety pin _ _ _ _ _ _ _ _ _ _ _ _ ~ ____________.._____.______ __. 1 Sengstaken tube .......................................... 2 Spontaneous rupture ________________._._____________ _ _ _ _ 7 Transthoracic vagotomy ______._..... ___._._ ...._._. 1

Abdominal ( 9 )

Cantor tube _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______....._.___._._...... 1 Paraesophageal surgery ___.___......_______~.~~~..~ 6 Spontaneous rupture _________.____....._______.. ~ ._.._ 2

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tients have been seen with esophageal perforation. Of this number, 33 (66% ) were iatrogenic perforations.

Diagnosis The most consistent symptom of

thoracic esophageal perforation is chest pain. It usually occurs a t the time of perforation, is frequently sub- sternal and quite severe. A significant temperature elevation is the next most frequent manifestation of eso- phageal perforation and occurs within a few hours, although in a few of our patients fever did not develop until 24 hours after perforation.

Of importance is the frequency of abdominal pain, tenderness and epi- gastric muscle spasm which often confuses the diagnosis. Subcutaneous emphysema manifested by crepitus in the neck, face, and chest wall is com- mon and was noted in one-third of our patients who had thoracic esophageal perforations. It was noted in eight of the ten patients with cervical esoph- ageal perforations, but in none of the patients who had abdominal esophageal perforations.

The diagnosis of a thoracic esoph- ageal perforation may be estab- lished by the clinical findings of the triad of fever, chest pain, and crepi- tus. Following esophageal instrumen- tation, the presence of chest or ab- dominal pain and crepitus are suf- ficient evidence to establish the di- agnosis of esophageal perforation. Signs and symptoms of cervical per- forations are less fulminating in onset than thoracic esophageal perfora- tions, and include a painful, tender, swollen neck, usually with crepitus, fever and dysphagia.

diagnosis in questionable cases. Hy- drothorax, or pneumothorax, and mediastinal emphysema are impor- tant diagnostic findings on chest x- ray when the thoracic esophagus has been violated. The diagnosis of an esophageal rupture may be confirmed by esophagogram in most patients (Figure 1).

Treatment Treatment for perforations of the

cervical esophagus is immediate op- eration. If the site of the perforation can be found, it should be closed with non-absorbable sutures. Drainage of the retroesophageal space should be done in all patients. We have had ex- perience with ten patients who had perforation of their cervical esoph- agus-eight had suture of their perforation and drainage done within the first 18 hours; seven made a prompt and uneventful recovery; and the eighth, who had sustained two perforations from a gunshot wound, developed a postoperative fistula which closed after eight weeks.

Figure I

Esophagogram shows extravaration of barium into mediastinum (ar row) . Barium fills the eso- phagus and continues past the point of perfora-

Roentgenographic studies are ex- in 'Onfirming the tremely

clinical diagnosis or establishing the tion into the stomach.

The ninth patient, with a stricture breakdown after prolonged morbidity secondary to laryngectomy and neck and subphrenic abscess, peritonitis dissection, sustained a perforation and sepsis. We believe that all pa- during dilation. Antibiotic therapy tients should have drainage even was started immediately, and an ab- though the suture repair of the scess developed which required in- esophagus appears adequate. cision and drainage on the-13th day. A chronic fistula resulted.

The mortality rate is three times as great when operative treatment

The tenth patient received a per- foration at the time of esophagoscopy. Operation was not done, but antibi- otic therapy was instituted 36 hours after his neck became painful and swollen. He was not seen by a sur- geon, and he died within 96 hours after sustaining esophageal perfora- tion because of laryngeal edema and extensive cellulitis.

We have had 24 patients treated for perforation of the thoracic esophagus not including spontaneous perfora- tions. Eighteen patients had early suture closure of the perforation and drainage of the mediastinum; of these, 17 survived and one died. The one death was in a patient with a Sengstaken balloon rupture of the esophagus. Closure of the perforation was promptly effected but the patient died a few hours later of persistent shock, peritonitis, and mediastinitis. In one patient, the suture closure of the perforation broke down; adequate drainage was provided and the re- sultant fistula closed three weeks later. Of the 18 primary closures, 15 were effected in less than 24 hours; closure was successful in the other three patients at 30, 48 and 72 hours.

was delayed for more than 24 hours. Perforations of the esophagus

should be treated surgically, and treatment s h o u 1 d be instituted promptly. The only delay should be for emergency resuscitative pro- cedures.

Inevitably, the availability of anti- biotics has induced the use of con- servative supportive measures and antibiotic therapy for small perfora- tions. Unfortunately, this misleading concept still remains. Many patients treated in this manner are ultimately recorded as failures of surgical treat- ment when, three to five days after institution of antibiotic therapy, de- terioration of the patient prompts belated surgical intervention. The fact that some small perforations often can be treated successfully by conservative management is not ques- tioned, but the difficulty in classi- fying a perforation as small or of pre- dicting the ultimate effects of a small perforation presents the real prob- lems. Early changes on chest x-ray or the size of the rent as determined by an esophagogram provides an un- reliable index to the future course of events.

Spontaneous perforation Suture of a surgically created per- foration of the abdominal esophagus

~~

was done in seven patients. Three The most difficult type of esoph- patients had no drainage performed; ageal perforation to diagnose is two made an uneventful recovery, spontaneous perforation of the esoph- but the third patient died two months agus. This condition, known as later as a result of early suture line Boerhaave’s syndrome, was first de-

June 1972 41

scribed in 1714. Even today, the di- agnosis is frequently delayed because the patient’s symptoms masquerade as acute pancreatitis, myocardial in- farction, perforated duodenal ulcer, or hiatal hernia. In our experience these were the most common erron- eous diagnoses in patients with spon- taneous esophageal perforation.

The characteristic findings of spon- taneous rupture of the esophagus are cyanosis, which occurred in over one- half of our patients, and subcutaneous emphysema as early as six hours after esophageal rupture. The ab- domen may be rigid and tender and there is usually an associated hydro- thorax (Figure 2).

The usual operative findings of spontaneous rupture of the esophagus are shown in Figure 3. The perfora-

tion usually develops in a normal esophagus. A linear tear, varying from 2 to 8 cms in length, occurs on the left side of the esophagus just above the diaphragm.

Once the diagnosis is made, the treatment is immediate thoractomy, suture of the tear in the esophagus in two layers using non-absorbable suture material, removal of debris, and very wide drainage of the medias- tinum and pleural cavity by a large thoracotomy tube (Figure 4). A temporary gastrostomy should be done because this allows earlier feed- ing and provides a means of maintain- ing nutrition should the esophageal repair fail to heal. We have recently employed total parenteral alimenta- tion in patients who had developed a prolonged esophageal fistula.

Figure 2

PHY S I CA L FINDINGS

@ SUBCUTANEOUS EMPHYSEMA

@ CYANOSIS /@ RIGID ABDOMEN -

HYDROTHORAX

Characteristic physical findings with spontaneous rupture of the esophagus.

42 A 0 RN Journal

Figure 3 Figure 4

TREATMENT 0 PE RAT1 V E FI N D I N G S

A 0 RTA ESOPHAGUS /-- ANTIBIOTICS IRR I GATlON

Sketch of usual operative findings with spontaneous rupture of the esophagus.

Wide mediastinal drainage, and ir- rigation of the mediastinum and pleural cavity, should be emphasized. There is a difference between spon- taneous esophageal perforation and traumatic e sop h age a 1 perforation. Spontaneous rupture, usually poste- metic rupture, is associated with forceful extrusion of gastric juice throughout the mediastinal planes with resultant severe mediastinitis. Pleural out-pouring of fluid in re- sponse to contamination, added to gastric juice losses, may amount to several thousand milliliters in only a few hours with development of hy- povolemic shock. Immediate intra- venous fluid replacement is manda- tory.

It is important to stress that even in the desperately ill patient the only chance of recovery lies in urgent thoracotomy with an attempt a t closure of the esophageal defect and wide mediastinal drainage. An esoph- ageal fistula developed in four of our nine patients, but all closed spon-

G ASTROSTO MY

Treatment for spontaneous rupture o f the esopha- gus. Emergency operation t o close the perforation and to drain the mediastinurn i s indicated.

taneously, although it took many weeks in some patients.

Summary The perforated esophagus is a

grave surgical emergency. When sus- pected, antibiotic therapy should be initiated and nasogastric suction in- stituted to minimize pleural or me- diastinal .contamination. The diag- nosis should be established promptly and confirmed by an esophagogram.

After resuscitative measures nec- essary to stabilize cardiovascular and respiratory function, immediate sur- gical treatment consisting of suture closure and adequate drainage of the mediastinurn should be instituted. /-J

REFERENCES I. Al ford, B. R., Johnson, R. L., and Harris,

H. H.: Penetrating lniuries o f the Esophagus. Ann. Otal., 72:995, 1963.

2. Mathewson, C., Jr., Dozier, W. E., Hamil l , J. P., and Smith, M.: Cl in ica l Experiences wi th Perforations o f the Esophagus. Amer. J. Surg., 104:257, 1962.

3. Foster, J. H., Jol ly, P. C. Sawyers, J. L.: and Daniel, R. A.: Esophageal Perforation: Di- agnosis and Treatment. Ann. Surg. I61 :701, 1965.

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