Oesophageal perforation

Aetiology:

• Iatrogenic (60%)
  • Endoscopy - diagnostic and therapeutic - usually in distal oesophagus with an associated pathology
  • Intra-operative - especially cervical
  • Intubation - NGT and ETT
  • Overall mortality 19%
• Boerhaave's - spontaneous rupture of oesophagus in the absence of prior pathology
  • Secondary to barogenic trauma, likely caused by failure of cricopharyngeus relaxation, leading to immediate and gross gastric content contamination of the mediastinum +/- pleural cavity. There may be an underlying anatomical predisposition to this which we have not yet discovered.
  • Differs from a Mallory-Weiss tear (shearing forces) vs barogenic forces in a perforation
  • Most common injury location is just above GOJ in the left posterolateral position
  • Mackler's triad: vomiting, chest pain, surgical emphysema - uncommon
  • Pleural effusion on left (can go to right in hiatus hernia)
  • Endoscope: visual defect
• FB
• Caustic ingestion
• Malignancy
• Trauma
  • Penetrating - cervical stab wounds, mediastinal gunshot wounds
  • Blunt - rare - secondary to blast
  • Needs high index of suspicion to diagnose

Medical Instrumentation	Percentage Risk of Iatrogenic Oesophageal Disruption
Dilatation Dilatation for achalasia Endoscopic mucosal resection Stent placement Endoscopic thermal therapy Treatment of variceal bleeding Endoscopic laser therapy Photodynamic therapy Stent placement	0.5 2 2 2 1–2 1–6 1–5 5 5-25

Presentation

• Vague complaints are common, and thus the diagnosis is often delayed, and confused with other medical or surgical catastrophes
  • Pain
  • Dyspnoea
  • Nausea
  • Dysphagia
  • Fever
  • Sepsis
  • Mediastinitis (tachycardia, hypotension)
• Differentiate between cervical (localised) and thoracic (severe chest and back pain, sepsis and mediastinitis more common)
• Check for crepitus, neck swelling, epigastric tenderness, and nasal voice
• Hamman's sign - a crunching, rasping sound, synchronous with the heartbeat, hard over the precordium in spontaneous mediastinal emphysema

Imaging

• CXR - pneumomediastinum, pleural effusion, PTX, subcutaneous emphysema, abnormal cardiomediastinal contour

• CT - first-choice investigation
  • PO contrast is not strictly necessary in most cases
  • Mediastinal air, or peri-oesophageal air or fluid
• Gastrografin swallow (preferred over barium due to risk of mediastinitis) is the standard for diagnosis
  • Can subsequently get barium swallow if necessary for improved sensitivity/specificity, but only if it's contained perf
• Endoscopy (gastroscopy or laryngoscopy) - use if high suspicion, but no evidence of injury on non-invasive imaging
  • Careful not to make the injury larger with investigation
  • Highly sensitive and specific for diagnosis

Principles of management

• Treat sepsis
• Provide organ support as required
• Source control of leak
• Evacuate/drain contamination from mediastinal and pleural cavities
• Enteral feeding access

Approach

• Important questions:
  • Degree of contamination, and clean/dirty
  • Size and location of defect
• Non-operative if possible
• If not meeting criteria for non-op management:
  • Endoscopic if possible - small/clean perforations
    • Clips
    • Stents - rarely used in benign
    • Endo-VAC
  • Surgical
    • Indications
      • Sepsis/shock
      • Gross contamination
      • Obstructing pathology
      • Retained foreign body
      • Major caustic injury
      • Failed non-op management
    • Primary repair
    • T-tube repair
    • Resection

Initial management

• Non-operative management (majority of patients can be managed non-op!)
  • Contained perforation
    • Cavity confined to mediastinum on endoscopy
    • Drains back into oesophagus on contrast radiography
  • No symptoms or signs of mediastinitis
  • Haemodynamically stable with no evidence of ongoing sepsis, or only low-grade fevers
  • No solid food contamination of mediastinum OR tolerance to pleural contamination (over 72 hours)
  • Perforation through an oesophageal malignancy
  • ICU for 2-3 days - if deteriorates, will need intervention still
  • NPO, head of bed elevated
  • NGT decompression
  • Broad-spectrum Abx, and consider antifungal cover for distal perfs
  • PPI
  • Consider TPN/distal enteral nutrition
  • Repeat imaging in 3-4 days, and if no further free perf, consider upgrading to liquid diet (serial contrast studies)
• Source control in chest
  • Chest tubes can be used to drain the area in some cases
  • Radiologically-guided drains also useful
  • VATS/open thoracic washout with decortication might be necessary

Endoscopy

Stenting

• • Very commonly migrate with benign perforations - not a good option
  • Good option in frail patients or patients with small, early perforations and minimal contamination
  • Can also be considered with a delay to diagnosis, where tissue would be of poor quality. Will generally need VATS and chest tube placement in that situation.
  • May need VATS after 2-3 days for debridement of pleural space
  • Need to do regular CXR to monitor for stent migration. Plastic stents have higher rate of migration compared to metal stents, but lower rate of stricture

Endoscopic vacuum therapy

• • Described for both oesophageal perforation and anastomotic leak after oesophagectomy
  • Endoscopic placement of a sponge to the site of perforation
  • Tubing from the sponge connected externally to a vacuum device with continuous negative pressure
  • Serial endoscopies every several days to weeks to evaluate for granulation tissue and exchange the sponge
  • Once the mucosa has sufficiently healed, the sponge is removed and diet liberalised

Over-the-scope clips

• • Good for early leaks
  • May need wide local drainage, decortication and feeding access still

Surgery

• Trans-hiatal vs trans-pleural
  • Distal perforations where contamination is confined to mediastinum can have laparoscopic trans-hiatal drainage
  • If pleura is breached, won't be able to drain it adequately from abdomen, need thoracic approach via either VATS or thoracotomy
• Exposure:
  • Cervical perf
    • Left-sided neck incision along anterior SCM (?ligate middle thyroid vein)
    • Enter retrooesophageal space bluntly along prevertebral fascia (preserve RLN)
    • Identify defect and repair primarily
    • Closed drainage if not identified
    • Can buttress with strap muscles
    • Gastrografin on day 5 to demonstrate healing
  • Thoracic perf - upper 2/3
    • Left lateral decubitus
    • Double-lumen ETT for single-lung ventilation
    • Right posterolateral thoracotomy (fifth interspace)
    • Open pleura, dissect oesophagus free
    • Close mucosa with PDS
    • Close muscularis with PDS
    • Irrigate
    • Intercostal muscle flap
    • Drainage tube
  • Thoracic perf - lower third
    • Left posterolateral thoracotomy in seventh interspace
    • Same as above
    • Can also use abdominal approach
  • Abdominal perf
    • Upper midline incision
    • Can use rotational flap
• Repair technique:
  • Solid debris removed, and the pleural cavity thoroughly cleaned
  • Debride devitalised tissues
  • Longitudinal myotomy to expose the full extent of mucosal injury (mucosal injury usually longer)
  • Closure over T-tube (recommended if damage control surgery required by general surgeon)
    • 6-10mm T-tube placed into the defect, and close oesophageal wall loosely over the tube with interrupted absorbable sutures (PDS)
    • Consider anchoring the tube to the oesophagus
    • Place at least one more Blakes drain around the repair
    • Monitor with Gastrografin swallows
    • Aim to remove around six weeks post-op

• Primary closure (not recommended for general surgeons)
  • Assess the injury and repair, in two layers if possible, using a 2/0 or 3/0 interrupted absorbable suture, perhaps over a 40-46Fr bougie
  • Leak rate of primary repair is 20-50% so should be reserved for the best candidates
  • Tissue flap coverage (intercostal muscles, pericardial flat, pleura, omentum) is preferred
  • Extensive injuries with devitalised tissues can be managed with controlled fistulisation over a T-tube
  • Very large or devitalised defects will require oesophageal exclusion with creation of a cervical oesophagostomy and gastrostomy tube, and planned for future oesophagectomy and conduit reconstruction
• Consider remedying any sign of obstruction (achalasia, stricture, tumour) at the index operation
  • See below

• Oesophagectomy

• Resection
  • Major undertaking
  • Reserved for damage to a diseased oesophagus or in cases of extensive oesophageal trauma

Specific situations:

Malignancy

• • Perforation through a cancer makes the cancer incurable
  • Stenting is favoured - get situation under control, then resect later
  • Disseminated disease, unfit for surgery -> palliation
  • Problem is that any perforation means disease dissemination and survival is hopeless (0% at 2 years in one series) - therefore shouldn't be dilating potentially operable tumours
  • Could consider resection if the perforation is separate to the malignancy

Achalasia

• • Healing is often worsened because of higher pressures
  • Most of the time, perf will be distal
  • Myotomy should be done at same time - on opposite side of oesophagus to perforation

Perforation as a complication of fundoplication

• • Laparotomy, dismantle fundoplication, primary repair, repeat fundoplication

Leak after oesophagectomy

• • Bad
  • Evaluate conduit for viability
    • If it's necrotic, will have to resect everything

Prognosis

• Overall mortality 15-30%
• Worse prognosis with increased time to intervention