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Perforation of the Esophagus as a Surgical Emergency
PERFORATION OF THE ESOPHAGUS AS A SURGICAL EMERGENCY JOHN D. KERNAN, M.D.* THERE is probably no surgical condition which offers a greater threat to the life of a patient than a perforation of the esophageal wall. Up to very recent times, this condition was almost invariably fatal. Even now, in spite of the advances in thoracic surgery and the antibiotics, the best judgment and greatest skill of the surgeon are called for in order to avoid a fatal outcome. The esophagus is lined by a vascular mucous membrane, reinforced by a strong layer of muscle, and has a tough fibrous covering. The wall thus formed is decidedly resistant. The mucous membrane is frequently damaged by foreign bodies and the manipulations necessary for their removal. This damage, however, does not necessarily lead to a serious result. Only the actual penetration of the muscular and fibrous layers of the wall permits leakage of the esophageal contents into the neck and mediastinum and the consequent development of periesophageal cellulitis. To accomplish such a rupture, it has been shown experimentally that a pressure of 5 to 10 pounds per square inch must be developed; far more than should be used in any intra-esophageal procedure. The esophagus is surrounded throughout its course in the neck and mediastinum with loose connective tissue. This explains the rapid spread of infection through the whole mediastinum, once the wall is open. In its course through the mediastinum, the esophagus is related to the trachea, the aorta, the pleural cavities, and lungs on each side. These relationships explain the occasional occurrence of empyemas and fatal hemorrhage from the aorta in connection with esophageal perforations. Perforation of the esophagus may occur as a result of trauma from within or from without, from extension of disease, or from inherent weakness in the wall. Its occurrence, therefore, is spoken of as a complication of other conditions of the esophagus. Spontaneous perforation of any normal esophagus performing its normal function rarely happens. The speed with which the perforation takes place can be very slow or extremely fast. This factor varies the symptoms and influences the management of the individual case. In this paper the subject has been divided into perforation due to (1) trauma from within, (2) trauma from without, (3) spontaneous rupture, (4) extension of disease through the esophageal wall, and (5) congenital bronchoesophageal fistula. PERFORATION DUE TO INTERNAL TRAUMA
This category can be subdivided into (1) perforations occurring in connection with the ingestion of foreign bodies and the endoscopic pro-
* Professor Emeritus of Otolaryngology, College of Physicians and Surgeons, Columbia University; Consulting Otolaryngologist, Presbyterian Hospital, New York. 405
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cedures for their removal, (2) perforations occurring during the dilatation of strictures, (3) perforations occurring during endoscopy to explain dysphagia, hemorrhage or x-ray evidence of esophageal disease, and (4) perforation occurring during the taking of biopsies.
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pe THE INGESTION OF FOREIGN BODIES AND THEIR REMOVAL
The ingestion and impaction of a foreign body in the esophagus is always an emergency calling for prompt hospitalization and treatment. Removal of foreign bodies is never a wholly safe procedure. It is still necessary to warn against attempts by lay people either to pull them up or push them down with the forefinger, as is so often done, especially when the patient is a child. Such endeavors as a rule result in firmer impaction, which increases the danger. Especially dangerous is an attempt to push them down with a stomach tube. This results in propelling the body to a deeper andmore inaccessible region of the esophagus injuring the mucous membrane and even causing immediate perforation. Most foreign bodies if undisturbed lodge in the upper end of the esophagus, where they are accessible for either endoscopic or external removal, and where any periesophagitis can be more easily drained. The possibility that these procedures may be called for emphasizes the advantage of immediate hospitalization before anything is done. Once in the hospital, time should be taken for proper examination and good x-ray films. These are necessary to ascertain the size and shape of the foreign body and its location. If the patient is dehydrated, due to dysphagia,' this condition should be corrected before any operative procedure isattempted. Hasty attempts at removal are always dangerous. The foreign bodies which become impacted are legion in size, shape, and degree of impaction. The danger they cause varies with their nature and the length of time they have been retained. Rough and sharp pieces of bone are likely to lacerate the mucous membrane in the mere act of swallowing. Smooth .objects such as coins, marbles, collar buttons and the like do no harm of themselves and can be retained for a considerable time 'without harm. An exception must be made to this statement. If the foreign body is large enough to block the lumen of the esophagus in such a way as to prevent swallowing even of fluids and subsequent dehydration, or if such a foreign body is close to the mouth of the esophagus, it may cause overflow of food and saliva into the lungs and cause bronchopneumonia. Endoscopy for Removal of Impacted Bodies. It must be stated at:once that this procedure is always dangerous, and should be undertaken only by an experienced and skillful operator and under the best of conditions. It is our practice to insist upon adequate relaxation of patients by the administration of a general anesthetic. In the ordinary case, oxygen-ether is administered to the level of deep surgical anesthesia, and an intratracheal tube is inserted and connected with a can of ether (Flagg technic). This method presents a minimum of annoyance during the opera-
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tion. It can be given by the operator in, the absence of an anesthetist, it can be maintained as long as necessary," it excludes regurgitating foreign matter from the trachea, and no manipulation can aspyyxiate the patient by narrowing the airway. The use of curare in conjunction with pentothal sodium or with ether can be of great help in selected cases. Small sharp foreign bodies buried in the wall of the esophagus present special dfliculty. The most dangerous and the most frequently ingested are splinters of chicken or fish bones. The mere swallowing and subsequent inadvisable attempts at removal may lacerate the mucous membrane and open a pathway for infectiori.Bmall splinters can also be very dangerous. One of us saw a case of a woman who swallowed a small bone when eating chicken. She resorted to the dangerous expedient of attempting to push it down by eating crusts of hard bread. She was already having severe pain under the sternum when admitted to the hospital. A careful search under general anesthesia revealed no bone, yet her pain persisted. It was considered inadvisable to explore further. She died several days later of a hemorrhage, almost instantaneously, evidently from a perforation of the aorta. In such cases. where the pain persists and there is question of continued retention of the foreign object the question always arises as to whether another esophagoscopy should be performed. This is at times very difficult to decide. If the bone is left, it may, as in this case, bring about a fatal result. On the other hand, it may be encysted and cause no further trouble. The best surgical judgment is called for. Considering the extreme danger, even an exploration of the thoracic esophagus through the chest wall might be justified. The removal of such bodies presents special difficulty. The availability of a biplane fluoroscope for localization is absolutely necessary, as are adequate choice of tubes and forceps; most of the unsuccessful attempts are due to inadequate anesthesia or armamentarium. Even with the finest tools, good anesthesia, and many years of experience in applying the most gentle approach, perforation may occur. Infants frequently swallow open safety pins, which should be removed promptly since the point will ultimately penetrate the esophageal wall. An infant was seen at the Lenox Hill Hospital who had retained an open safety pin for a month. The mother had missed the pin but the possibility of its being swallowed was rejected by the family doctor. At the end of a month, continuing cough led to the taking of x-rays, when the pin was discovered. It was then removed, but had already penetrated the right pleural cavity, causing an empyema which ultimately proved fatal. Coins cause very few symptoms unless they block the mouth of the esophagus and lead to aspiration of food and consequent bronchopneumonia. On this account, although they do not penetrate, they should be promptly removed. A word of advice to the endoscopist: If an attempt has already been made to remove the foreign bodies by unskillful operators, the patient should be scrutinized with especial care. Injury may have already been caused and a fatal complication set in motion. Under these circumstances,
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immediate endoscopy would only make matters worse.. An attempt should be made to halt the course of the complication and get the patient into better condition to stand operation. After-treatment. It is often impossible for the endoscopist to be sure, during an operation, that the procedure which he has just completed has not perforated the wall of the esophagus, at least to some degree. It is unusual for any impacted sharp meat bone, fish bone, wire, pin, needle, denture, nail, or any sharp object to be removed without some blood being visible at the site of the impaction. It is our custom to reinsert the esophagoscope (if it had to be removed with the forceps and foreign body) and to inspect the damage to the esophageal wall. This is done with careful suction, and careful probing of any laceration present is performed with a gauze wipe on an applicator. If any evidence of laceration involving more than the mucosa is found, the patient should be placed on a very strict regimen in the hospital. Temperature and pulse should be taken every four hours, intravenous feeding instituted, all liquids and solids by mouth stopped, heavy doses of antibiotics administered, and the patient kept under careful nursing and medical scrutiny, including adequate x-ray examination. In this way, many perforations of the esophagus heal by primary union without complications such as abscess formation or extension to adjacent structures. Absence of symptoms, normal temperature for twenty-four hours after antibiotics are discontinued, and lack of pathological x-ray findings, are a guide as to when mouth feedings can be safely started. The usual.progressive diet of water, then other liquids, then soft diet, then finally regular diet is the safest method of testing healing of the perforation. The following case history is typical of a perforation of the esophagus in the neck by manipulation of a foreign body (fish bone) by the patient and her family. CASE I. A 70 year old Austrian housewife (S. R.) swallowed a fish bone which lodged in her throat one week before she came to the hospital. During this period many attempts were made to dislodge the bone with the finger and swallowing bread. The pain finally became so severe that she applied at the hospital for relief. The only relevant physical finding was tenderness over the right side of the neck in the region of the thyroid gland. X-ray examination of the neck was reported as follows: "There is a fish bone in or near the upper end of the esophagus at the level of the cricoid cartilage. There is marked swelling of the soft tissues surrounding the foreign body, with bulging of the esophagus forward into the posterior wall of the trachea." (Fig. 98.) The fish bone was removed without difficulty through the esophagoscope. In the region of the bone, the esophageal wall was edematous and infiltrated. It bled spontaneously from the pinpoint perforation in the wall and at the slightest touch of the suction to the rest of the wall. The patient was kept in the hospital where she ran a febrile course during the following twenty days. The patient was put to bed and fed intravenous drip for the first three postoperative days. Then she was fed restricted fluids by mouth, aided by fluids per
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ctum and by clysis. She was placed on soft diet on the twelfth postoperative ay. On the sixteenth postoperative day a barium study of the esophagus revealed e presence of a perforation of the wall of the esophagus communicating with a verticulum-like excavation lying in the soft tissue swelling (Fig. 99). On the twenty-second postoperative day the patient could swallow a restricted et, was afebrile, and was discharged. She never returned to the follow-up clinic.
The case of this patient, who was treated before the days of antiiotics, shows that the perforation was probably unnecessary in the first lace, that mediastinitis may localize without antibiotics, and that rdinary supportive treatment may be sufficient to secure a recovery.
Fig. 98 Fig. 99 Fig. 98 (Case I). Fish bone in position. Fig. 99 (Case I). Excavation in esophagus wall sixteen days later. SYMPTOMS OF PERFORATION OF THE ESOPHAGUS IN THE NECK
Not all cases turn out so fortunately as the one just cited. Since, as has een stated, the great majority of foreign bodies lodge in or near the mouth of the esophagus, if there has been a really serious penetration f the esophageal wall, the symptoms and signs will be first evident in he lower part of the neck. The patient will complain of pain and diffiulty on swallowing. Examination reveals exquisite tenderness, and repitus will be felt due to extravasation of air. These signs rapidly inrease until the whole neck is involved and possibly also the chest. Uness the spreading infection can be halted, the clinical picture becomes ne of dramatic collapse as the inflammation spreads downwards into he chest. The patient experiences excruciating pain in chest, back, or bdomen which is continuous and not relieved by sedation until death
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occurs. There may be some vomiting of blood-stained stomach content. Nausea may occur at intervals or be continuous. The patient is constantly thirsty, anxious, restless, and resentful of movement or examination. Physical examination reveals an individual in a state of shock, gray in color, with a weak thready pulse usually rapid from the onset. There is usually some degree of cyanosis, and the respiration is grunting and shallow. Examination of the chest reveals physical signs of effusion in the posterior mediastinum, with possible collapse of one or both lungs. The abdomen has boardlike rigidity. X-ray films of the chest, if they can be taken, show widening of the mediastinal area and compression of the lun~s. These signs make positive the diagnosis of a posterior mediastinal emergency. Before the discovery of the antibiotics, the first objective symptoms in the neck called for prompt external drainage in the hope that by this means extension to the mediastinum could be prevented. Now, however, one can wait and vigorously apply antibiotic treatment and supportive measures. The inflammation, even when well established, may subside or localize and be more easily drained. At the first sign of spread, the neck should be opened. Should symptoms and signs of posterior mediastinitis develop, that area should be drained through the back.
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PERFORATIONS DUE TO THE INGESTION OF CORROSIVE FLUIDS AND
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DILATING STRICTURES
Sloughing of the esophageal wall with secondary perforations is always a possibility following the ingestion of corrosive fluids. In the United States, lye is still a common kitchen chemical, and there are numbers of lye burns in children from accidental ingestion. These accidents are more common in the southern part of the country than in the north, though it cannot be said that conditions are much better in the northern states, since other corrosive chemicals have been substituted for lye. These acute cases of lye burn are usually seen by general practitioners who institute emergency treatment. This, of course, should consist in the administration of a weak acid solution. No intraesophageal manipulation should be instituted in the home. It is especially important to avoid the administration of emetics, since the resulting excessive vomiting may cause rupture of a badly burned esophagus. Once the immediate emergency is overcome, the important part of the management of the case is to keep the lumen open without engaging in any procedure which entails undue risk of perforation. There is considerable divergence of opinion as to the best immediate treatment of burns of the esophagus. This divergence has been well discussed recently by Lynch.' Lynch feels that after forty-eight hours esophagoscopy is dangerous, and believes that the fluoroscope and x-ray examination should be used to determine the degree of the lye burn. Others feel that there is no contraindication to the passage of the esophagoscope down to the level of the upper edge of the burn, but not beyond it. The judicious use of the mercury-weighted bougie allowed to fall of
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its own weight through the burned esophagus seems safe and the best way to avoid injury. The caliber of the bougie is increased daily at the time of the passage. It is allowed to remain in place for thirty minutes. The treatment is continued each day for twelve to twenty-five weeks, then the interval between treatments is lengthened until only an occasional stretching is done. Another method of treatment is to perform gastrostomy and maintain the child's nourishment through that opening. At the same time the gastrostomy is performed, a thread is passed through the esophagus and brought out the mouth. This is left in place until the burns are healed. Then retrograde bougienage is carried out. Both of these methods are very successful, though the tendency now is to start treatment at once and not let the stricture form. It is the feeling of the present authors that a child who has evidence of a recent lye burn should be examined with an esophagoscope as soon as possible after the ingestion of the lye or other corrosive fluid. The esophagoscope should not be passed beyond a point slightly above the upper margin of the burn. The patient should then receive supportive treatment, gastrostomy performed if necessary, and retrograde or oral dilatation of the esophagus carried out until the healing period is over. Up to the present, no case of perforation has been reported in the literature from use of weighted mercury bougie in lye burns. Wells, Hughes, Edwards and Marcus" reported on a case of cardiospasm in which the esophagus was ruptured during dilatation with a mercuryweighted bougie. . Dilation of strictures of the esophagus once the burns have healed and adult scar tissue has closed the lumen presents an equally difficult problem, which calls for technical skill rather than a surgical decision. These cases were seen much more frequently in the days when it was considered dangerous to do any manipulation in a freshly burned esophagus. Frequently the lumen will be so narrowed that only small amounts of fluids will pass; and the patients are likely to be in very poor physical condition. The urgent indication is to establish adequate nourishment of the patient. This is done by an immediate gastrostomy. An attack can be made on the stricture from above or from below or both at the same time. All blind bougienage must be avoided. Even bougienage from above through an esophagoscope is dangerous, as there may be pockets below the visible stricture, which will engage the point of the bougie; and a pressure applied to that instrument may push it through the esophageal wall. Safe bougienage can be carried out only over a guide, either swallowing string or a filiform bougie, which is passed through the esophagoscope and manipulated into the stomach. This bougie should have a flexible tip and no force should be used in this passage. The use of the fluoroscope makes the introduction of the bougie much easier and safer. Once the thread or the bougie is in place, larger bougies may be passed over it, starting with a very small size and applying little force. Although the use of the bougie or thread will prevent the plunging of the tip through the wall of the esophagus or through the bottom of a di-
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verticulum, if the bougie is too large it may actually split the wall of the esophagus, with equally disastrous effect. After the initial examination and the passage of the first bougies it may be safe to use unguided bougies. The few cases listed in the literature of perforation of the esophagus following the use of unguided bougies is a tribute to the care with which this procedure is performed or to the embarrassment which prevents the reporting the cases. (Wells, Hughes, Edwards and Marcus report three cases with recovery.") Lye burns are not the only causes of scar strictures of the esophagus. Pressure necrosis from a long-retained feeding tube, postoperative complications of esophageal resection, or poorly performed excision of a diverticulum may close the esophagus. Stricture may also occur as an end result of cardiospasm or peptic ulcer of the lower esophagus," The treatment of these strictures is the same as that carried out for lye burns. We have seen one case in which the esophagus was completely closed by a fibrous web, following the excision of a diverticulum. Continuity of the lumen was established by passing a bougie from below and cutting down on its point through the esophagoscope. A thread was passed through this opening and dilatation carried out in the ordinary fashion. It is suggested that an esophagoscope in the lumen of the esophagus as a guide will prevent many such accidents.
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PERFORATIONS FOLLOWING ENDOSCOPY FOR D-rSPHAGIA OR HEMORRHAGE
The walls of the esophagus vary greatly in thickness, tensile strength, and resistance to trauma. It is much more of a risk to inspect this structure in the aged, the debilitated, or patients suffering from avitaminosis, than it is to use the esophagoscope in a person in good health. In these patients atrophic changes in the walls of the esophagus are liable to occur which greatly weaken it. They are especially liable to occur in patients who have been dieting for gastric ulcer, chronic gastritis, or excessive weight. Any patient in these categories who complains of dysphagia should be approached with the utmost caution if an esophagoscopy is proposed. The wall of the esophagus may have been greatly thinned by. ulcers which penetrate all the layers. As the ulcers heal, bands are formed across the lumen, which result in difficulty in swallowing. When ulcers have not healed, a little blood may be raised on occasions. These are the cases in which the greatest care has been used in the esophagoscopy, no force has been applied, and no hint suggests that a perforation has occurred. A little blood may be seen, and perhaps very friable webs across the lumen. Yet symptoms of perforation appear almost immediately after withdrawing the tube. The best treatment of these patients is to suspect the presence of the atrophic lesion and not to perform an esophagoscopy. The patient should be put on a proper diet, which will probably result in healing of the ulcers. Then, if there is difficulty in swallowing, bougienage may be used over a swallowed thread, using a very small instrument at the first attempt. Blind passage of the stomach tube is very likely to be fatal.
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CASE II. Mrs. B. J., aged 57, complained of "spasms while swallowing" for even years, following the nervous shock attendant on the death of her son in he Spanish Civil War. The dysphagia was associated with vague pains in the bdomen and chest, and often she was unable to swallow, without first "taking drink of whiskey which relaxed the spasm." She limited her diet on account of his dysphagia.
Fig. 100 (Case II). Perforation following esophagoscopy for dysphagia. An bscess cavity is present in the superior mediastinum communicating with the sophagus.
X-ray examination by barium (both films and fluoroscopy) revealed that there was a uniform narrowing about 5 em. in length of the lumen of the esophagus in s upper third. A diaphragmatic hernia containing a pouch of stomach about em. in its largest diameter was present (see Fig. 100). Esophagoscopy was begun under ideal circumstances, and after the tube had rogressed 18 em. from the upper teeth, esophageal adhesions were encountered nd the esophageal wall began to bleed. No rupture was seen, but was suspected, nd the tube was withdrawn at once. A diagnosis of Plummer-Vinson syndrome was made. The patient was returned to bed with a diagnosis of possible perforation of the sophagus. She was denied all fluids and solids by mouth. Twice a day 300,000 nits of penicillin were given. The temperature rose to 102.5°F., pulse was weak nd thready with a rate of 100. In the next twenty-four hours the patient suffered ain in the chest and back and had a chill. On the fourth post-esophagoscopy ay, a barium study of the esophagus revealed an abscess cavity in the superior mediastinum communicating with the esophagus (Fig. 100).
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On the fifth post-esophagoscopy day a thoracic surgeon evacuated a well walled-off abscess of the superior mediastinum, drained it, and passed a stomach tube for feeding, which worked well. The patient made an uneventful recovery from the operation, but developed a stricture at the site of the perforation. This was dilated and the patient is symptom-free at the present time. PERFORATION OF THE ESOPHAGUS FOLLOWING THE TAKING OF A BIOPSY
Perforation of the esophagus as a result of a biopsy may occur without the operator being in any way cognizant that he has cut a hole through the wall. It is the practice of most operators to "inspect any neoplasm very carefully and to choose a site for biopsy on some portion of the tumor which projects into the lumen. In spite of every precaution, choosing a proper site, and using proper manipulation of the forceps, it is possible to cause a perforation of the esophageal wall at a point where the protective coats have been weakened by inflammation or tumefaction. When this occurs, symptoms of a rapidly spreading mediastinitis will occur. PERFORATION OF THE ESOPHAGUS FROM EXTERNAL CAUSES
The esophagus may also be in the site of a perforation from external trauma in the form of stab wounds, bullet holes, shell fragments, or other propelled foreign bodies. These conditions are usually not brought to the attention of the endoscopist, since the injury always involves other structures, and the patient is channeled into the surgical emergency ward, where the injury to the gullet is found and treated by the chest surgeon. The perforation of the esophagus is seldom the major problem, and the outcome depends on the concomitant injuries, blood loss, shock, and degree of infection, rather than on local treatment of the esophageal wound. The choice is. immediate repair with wire suture. Should a stricture form at the site of the injury during healing, it is treated by dilatation or secondary resection. SPONTANEOUS RUPTURE OF THE ESOPHAGUS
Of all the types of acute perforation, the most challenging to the skill of the physician is the spontaneous perforation of the esophagus in persons who heretofore have been in good health and who have shown no signs of pre-existing disease. The physician who is called is usually a general practitioner, internist, or general surgeon. Each sees an acutely ill patient who sinks so rapidly that the diagnosis is seldom made in the living patient. Barrett has made a study of fifty-one cases listed in the literature during the period between 1724 and 1944. 4 No patient lived, and the recorder in each case listed what he considered the differential diagnosis. These listings showed that the bias of the physician tended to influence the tentative diagnosis. The internist thought of coronary disease, the surgeon thought of acute pancreatitis, the general practi-
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ioner was in doubt,etc. Spontaneous rupture is a rare but definite clinical entity. The lesion consists of a perforation usually longitudinal rom a pinpoint to 8 em. in length in the lowest quarter of the esophagus communicating by direct extension with cellulitis in the mediastinum, or empyema in one or both of the pleura. The pleural cavity found at operation or autopsy is full of fetid food and stomach content. There is autolysis and gangrene of the tissues so that the microscopic anatomy is usually destroyed at the time of the autopsy. The clinical picture is that already described in connection with perforations which have extended o the mediastinum. There is the same excruciating pain, nausea, vomitng, and collapse. The physical examination shows the patient in extreme shock. It is difficult to think that such a rupture can occur in connection with a normal esophagus. In reviewing the cases listed by Barrett it is evident that contributing causes were often present. Gluttony, excessive use of alcohol, persistent vomiting, particularly in pregnancy or seasickness, epileptic seizures, sudden application of high pressure to the abdomen or lower chest by falling weights are mentioned as preceding spontaneous rupture. Once the diagnosis is made, the patient should be hospitalized and the chest opened. The stomach contents in the chest should be flushed out with saline solution and the perforation searched or. If found, it should be closed by wire sutures and the chest drained. The usual supportive treatment should be pushed vigorously. The role of the endoscopist in these cases is a very minor one, since esophagoscopy s one of the last things thought of when dealing with the early stages of a spontaneously ruptured esophagus. However, it is possible that the nformation to be gained by esophagoscopy might nullify the attendant isk, and an unnecessary laparotomy may be avoided.
CASE III. A seventy-five year old American housewife (L.B.) consulted her general practitioner about some vague abdominal distress which had been diagnosed clinically as duodenal ulcer. A gastrointestinal examination with barium was begun in the doctor's office at 10:30 A.M. After the patient had wallowed a small amount of barium mixture she vomited about 600 cc. of bright ed blood. She began to complain of very severe epigastric and midback pain. She insisted on going home, where she was seen in consultation by several doctors and was urged to go to the hospital. She was admitted at 3 :30 P.M. (five hours after the onset of the symptoms). The admission diagnosis was "possible upture of the esophagus." Physical examination showed that the patient was acutely ill, temperature 99.6°F., pulse weak at 116, blood pressure 168/94. Both eyes were swollen shut by subcutaneous emphysema which seemed to involve all tissue above the waist Fig. 101). The chest was otherwise normal in expansion and the breath sounds were normal. X-ray of the chest and barium study of the esophagus were performed at 5 :00 .M. (six and one-half hours after onset of symptoms) and a diagnosis of perforaion of the esophagus at the level of the diaphragm was confirmed (Fig. 102). At 7 :45 P.M. a superior mediastinotomy was performed without undue shock o the patient and drainage instituted. No free pus was encountered in the uperior mediastinum, and only barium in the posterior mediastinum. During
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her stay in the hospital, 'the patient received the entire category of supportive treatment and antibiotics. The patient followed a rapidly progressive downhill course and expired at 3 :30 A.M., seventeen hours after the onset of symptoms, Necropsy diagnosis was as follows: Primary: Acute nonsuppurative mediastinitis. Secondary: Arteriosclerosis generalized, duodenal ulcer healed, pyloric stenosis, fibrosis of the uterus, atelectasis of the left lung (postoperative). General: Perforation of the esophagus (clinical), opening not seen, mediastinotomy with drainage.
Fig. 101.
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Fig. 101 (Case III). Wide mediastinal and subcutaneous emphysema following spontaneous rupture of the esophagus. Fig. 102 (Case III). Pinhole perforation and barium reflex along esophagus.
PERFORATIONS DUE TO DISEASE
In distinction to the dramatic symptoms and management of acute perforations of the esophagus there are some other conditions found in which there is a slow penetration of the esophageal wall associated with the formation of a protective zone of reaction around the area of perforation. The patient then develops a perforation of the esophagus without being made acutely ill. Neoplasm, usually squamous carcinoma, may form in the wall of the esophagus and replace a portion of that wall without much sign of the obstruction to the passage of food. As the tumor grows it may undergo necrosis and finally perforate the wall of the esophagus. There is usually a dense zone of reaction thrown out by the adjacent mediastinum, or pleura, so that the hole in the wall merely communicates with the pocket, or loculation, and the condition is of interest merely to the pathologist or roentgenologist. Carcinoma involving mediastinal lymph nodes may also extend to the wall of the esophagus and cause perforation.
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CASE IV. A fifty-six year old German salesman (J. K.) came to the dispensary complaining of hoarseness and difficulty in swallowing for three months. This had become progressive. In the past twenty-four hours the patient regurgiated everything he swallowed. Examination revealed a chronically ill looking white man, who spoke with a hoarse voice. There was paralysis of the right vocal cord. X-ray study with 'barium revealed the presence. of multiple lesions of the sophagus (Fig. 103), probably due to infiltration from extrinsic neoplastic mass, ossibly lymphosarcoma. Esophagoscopy was performed but no material could be obtained for biopsy s the stricture, 22 em. from the upper teeth, completely closed the esophagus.
Fig. 103. Fig. 104. Fig. 103 (Case IV). Multiple lesions of esophagus from extrinsic neoplasm. Fig. 104 (Case IV). Perforation of esophagus in superior mediastinum cometely walled off by mediastinal reaction and malignancy.
Gastrostomy was performed. During the next five weeks the patient went progressively downhill and during is period approximately 4800 high-voltage roentgen units were applied to the ediastinum. A check-up examination of the esophagus, by means of barium, vealed a perforation in the superior mediastinum which was completely walled f by mediastinal reaction and malignancy (Fig. 104). Ten weeks later the patient expired and no autopsy was performed.
Tuberculosis may be the underlying cause in the formation of the ophagus. There are many cases on record of the extrusion of calcified odes through the mucosa of the bronchi.
CASE V. The following illustration through the courtesy of Dr. H. C. Maier ows the x-ray appearance of a patient in whom a node ulcerated simultaneously
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Fig. 106 (Case VI). Tracheo-esophageal fistula.
the wall of the esophagus and the adjacent bronchus (Fig. 105). The injected iodized oil (lipiodol) passed only as far as the node which occludes the major portion of the fistula. The fistula between the bronchus and the esophagus was resected successfully and the patient was relieved until chronic pulmonary hemor-
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rhage began. A lobectomy was then performed and the patient has made a complete recovery. CONGENITAL BRONCHOESOPHAGEAL FISTULA
In addition to the cases in which acute or chronic perforations occur, there are a large number of cases in which there is an congenital defect in the esophageal wall communicating with the trachea, with the skin, or with the bronchi. Most of these cases come to the attention of the pediatricians as feeding problems, since choking spells and regurgitation during feeding are the prominent symptoms. At times the fistula is very small and is not evident even with repeated examinations by endoscopy or x-ray. Fluoroscopy with barium is the most satisfactory diagnostic method. If a communicating fistula can be found between the upper and lower stump of the esophagus it is possible to use dilatation to restore a functioning lumen. Otherwise only prompt surgery will save the life of the patient.
CASE VI. This one day old 8 pound term baby (W. R.) was admitted to the nursery from the delivery room at 8 :00 A.M. Two hours later it became cyanotic and vomited a lot of mucus. It was placed in an oxygen tent. Attempts to pass a catheter into the stomach were futile. X-ray examination revealed total obstruction of esophagus at the level of the clavicle (Fig. 106). This obstruction plus the extreme distention of the bowel indicated the presence of tracheo-esophageal fistula. The child was moved at once to another hospital for surgery and expired following operation.
1. 2. 3. 4. 5.
REFERENCES Lynch, M. C.: South. M. J. 42: 635-640 (August) 1949. Wells, Hughes, Edwards and Marcus: Thorax 4: 119 (June) 1949. Allison, P. R.: Thorax 3: 20-42 (March) 1948. Barrett, N. R.: Thorax 1: 48-70, (July) 1948. Culver, G. J., and Clark, S. B.: Surgery 22: 458-565 (Sept.) 1947.
This category can be subdivided into (1) perforations occurring in connection with the ingestion of foreign bodies and the endoscopic pro-
* Professor Emeritus of Otolaryngology, College of Physicians and Surgeons, Columbia University; Consulting Otolaryngologist, Presbyterian Hospital, New York. 405
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cedures for their removal, (2) perforations occurring during the dilatation of strictures, (3) perforations occurring during endoscopy to explain dysphagia, hemorrhage or x-ray evidence of esophageal disease, and (4) perforation occurring during the taking of biopsies.
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pe THE INGESTION OF FOREIGN BODIES AND THEIR REMOVAL
The ingestion and impaction of a foreign body in the esophagus is always an emergency calling for prompt hospitalization and treatment. Removal of foreign bodies is never a wholly safe procedure. It is still necessary to warn against attempts by lay people either to pull them up or push them down with the forefinger, as is so often done, especially when the patient is a child. Such endeavors as a rule result in firmer impaction, which increases the danger. Especially dangerous is an attempt to push them down with a stomach tube. This results in propelling the body to a deeper andmore inaccessible region of the esophagus injuring the mucous membrane and even causing immediate perforation. Most foreign bodies if undisturbed lodge in the upper end of the esophagus, where they are accessible for either endoscopic or external removal, and where any periesophagitis can be more easily drained. The possibility that these procedures may be called for emphasizes the advantage of immediate hospitalization before anything is done. Once in the hospital, time should be taken for proper examination and good x-ray films. These are necessary to ascertain the size and shape of the foreign body and its location. If the patient is dehydrated, due to dysphagia,' this condition should be corrected before any operative procedure isattempted. Hasty attempts at removal are always dangerous. The foreign bodies which become impacted are legion in size, shape, and degree of impaction. The danger they cause varies with their nature and the length of time they have been retained. Rough and sharp pieces of bone are likely to lacerate the mucous membrane in the mere act of swallowing. Smooth .objects such as coins, marbles, collar buttons and the like do no harm of themselves and can be retained for a considerable time 'without harm. An exception must be made to this statement. If the foreign body is large enough to block the lumen of the esophagus in such a way as to prevent swallowing even of fluids and subsequent dehydration, or if such a foreign body is close to the mouth of the esophagus, it may cause overflow of food and saliva into the lungs and cause bronchopneumonia. Endoscopy for Removal of Impacted Bodies. It must be stated at:once that this procedure is always dangerous, and should be undertaken only by an experienced and skillful operator and under the best of conditions. It is our practice to insist upon adequate relaxation of patients by the administration of a general anesthetic. In the ordinary case, oxygen-ether is administered to the level of deep surgical anesthesia, and an intratracheal tube is inserted and connected with a can of ether (Flagg technic). This method presents a minimum of annoyance during the opera-
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tion. It can be given by the operator in, the absence of an anesthetist, it can be maintained as long as necessary," it excludes regurgitating foreign matter from the trachea, and no manipulation can aspyyxiate the patient by narrowing the airway. The use of curare in conjunction with pentothal sodium or with ether can be of great help in selected cases. Small sharp foreign bodies buried in the wall of the esophagus present special dfliculty. The most dangerous and the most frequently ingested are splinters of chicken or fish bones. The mere swallowing and subsequent inadvisable attempts at removal may lacerate the mucous membrane and open a pathway for infectiori.Bmall splinters can also be very dangerous. One of us saw a case of a woman who swallowed a small bone when eating chicken. She resorted to the dangerous expedient of attempting to push it down by eating crusts of hard bread. She was already having severe pain under the sternum when admitted to the hospital. A careful search under general anesthesia revealed no bone, yet her pain persisted. It was considered inadvisable to explore further. She died several days later of a hemorrhage, almost instantaneously, evidently from a perforation of the aorta. In such cases. where the pain persists and there is question of continued retention of the foreign object the question always arises as to whether another esophagoscopy should be performed. This is at times very difficult to decide. If the bone is left, it may, as in this case, bring about a fatal result. On the other hand, it may be encysted and cause no further trouble. The best surgical judgment is called for. Considering the extreme danger, even an exploration of the thoracic esophagus through the chest wall might be justified. The removal of such bodies presents special difficulty. The availability of a biplane fluoroscope for localization is absolutely necessary, as are adequate choice of tubes and forceps; most of the unsuccessful attempts are due to inadequate anesthesia or armamentarium. Even with the finest tools, good anesthesia, and many years of experience in applying the most gentle approach, perforation may occur. Infants frequently swallow open safety pins, which should be removed promptly since the point will ultimately penetrate the esophageal wall. An infant was seen at the Lenox Hill Hospital who had retained an open safety pin for a month. The mother had missed the pin but the possibility of its being swallowed was rejected by the family doctor. At the end of a month, continuing cough led to the taking of x-rays, when the pin was discovered. It was then removed, but had already penetrated the right pleural cavity, causing an empyema which ultimately proved fatal. Coins cause very few symptoms unless they block the mouth of the esophagus and lead to aspiration of food and consequent bronchopneumonia. On this account, although they do not penetrate, they should be promptly removed. A word of advice to the endoscopist: If an attempt has already been made to remove the foreign bodies by unskillful operators, the patient should be scrutinized with especial care. Injury may have already been caused and a fatal complication set in motion. Under these circumstances,
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immediate endoscopy would only make matters worse.. An attempt should be made to halt the course of the complication and get the patient into better condition to stand operation. After-treatment. It is often impossible for the endoscopist to be sure, during an operation, that the procedure which he has just completed has not perforated the wall of the esophagus, at least to some degree. It is unusual for any impacted sharp meat bone, fish bone, wire, pin, needle, denture, nail, or any sharp object to be removed without some blood being visible at the site of the impaction. It is our custom to reinsert the esophagoscope (if it had to be removed with the forceps and foreign body) and to inspect the damage to the esophageal wall. This is done with careful suction, and careful probing of any laceration present is performed with a gauze wipe on an applicator. If any evidence of laceration involving more than the mucosa is found, the patient should be placed on a very strict regimen in the hospital. Temperature and pulse should be taken every four hours, intravenous feeding instituted, all liquids and solids by mouth stopped, heavy doses of antibiotics administered, and the patient kept under careful nursing and medical scrutiny, including adequate x-ray examination. In this way, many perforations of the esophagus heal by primary union without complications such as abscess formation or extension to adjacent structures. Absence of symptoms, normal temperature for twenty-four hours after antibiotics are discontinued, and lack of pathological x-ray findings, are a guide as to when mouth feedings can be safely started. The usual.progressive diet of water, then other liquids, then soft diet, then finally regular diet is the safest method of testing healing of the perforation. The following case history is typical of a perforation of the esophagus in the neck by manipulation of a foreign body (fish bone) by the patient and her family. CASE I. A 70 year old Austrian housewife (S. R.) swallowed a fish bone which lodged in her throat one week before she came to the hospital. During this period many attempts were made to dislodge the bone with the finger and swallowing bread. The pain finally became so severe that she applied at the hospital for relief. The only relevant physical finding was tenderness over the right side of the neck in the region of the thyroid gland. X-ray examination of the neck was reported as follows: "There is a fish bone in or near the upper end of the esophagus at the level of the cricoid cartilage. There is marked swelling of the soft tissues surrounding the foreign body, with bulging of the esophagus forward into the posterior wall of the trachea." (Fig. 98.) The fish bone was removed without difficulty through the esophagoscope. In the region of the bone, the esophageal wall was edematous and infiltrated. It bled spontaneously from the pinpoint perforation in the wall and at the slightest touch of the suction to the rest of the wall. The patient was kept in the hospital where she ran a febrile course during the following twenty days. The patient was put to bed and fed intravenous drip for the first three postoperative days. Then she was fed restricted fluids by mouth, aided by fluids per
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ctum and by clysis. She was placed on soft diet on the twelfth postoperative ay. On the sixteenth postoperative day a barium study of the esophagus revealed e presence of a perforation of the wall of the esophagus communicating with a verticulum-like excavation lying in the soft tissue swelling (Fig. 99). On the twenty-second postoperative day the patient could swallow a restricted et, was afebrile, and was discharged. She never returned to the follow-up clinic.
The case of this patient, who was treated before the days of antiiotics, shows that the perforation was probably unnecessary in the first lace, that mediastinitis may localize without antibiotics, and that rdinary supportive treatment may be sufficient to secure a recovery.
Fig. 98 Fig. 99 Fig. 98 (Case I). Fish bone in position. Fig. 99 (Case I). Excavation in esophagus wall sixteen days later. SYMPTOMS OF PERFORATION OF THE ESOPHAGUS IN THE NECK
Not all cases turn out so fortunately as the one just cited. Since, as has een stated, the great majority of foreign bodies lodge in or near the mouth of the esophagus, if there has been a really serious penetration f the esophageal wall, the symptoms and signs will be first evident in he lower part of the neck. The patient will complain of pain and diffiulty on swallowing. Examination reveals exquisite tenderness, and repitus will be felt due to extravasation of air. These signs rapidly inrease until the whole neck is involved and possibly also the chest. Uness the spreading infection can be halted, the clinical picture becomes ne of dramatic collapse as the inflammation spreads downwards into he chest. The patient experiences excruciating pain in chest, back, or bdomen which is continuous and not relieved by sedation until death
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occurs. There may be some vomiting of blood-stained stomach content. Nausea may occur at intervals or be continuous. The patient is constantly thirsty, anxious, restless, and resentful of movement or examination. Physical examination reveals an individual in a state of shock, gray in color, with a weak thready pulse usually rapid from the onset. There is usually some degree of cyanosis, and the respiration is grunting and shallow. Examination of the chest reveals physical signs of effusion in the posterior mediastinum, with possible collapse of one or both lungs. The abdomen has boardlike rigidity. X-ray films of the chest, if they can be taken, show widening of the mediastinal area and compression of the lun~s. These signs make positive the diagnosis of a posterior mediastinal emergency. Before the discovery of the antibiotics, the first objective symptoms in the neck called for prompt external drainage in the hope that by this means extension to the mediastinum could be prevented. Now, however, one can wait and vigorously apply antibiotic treatment and supportive measures. The inflammation, even when well established, may subside or localize and be more easily drained. At the first sign of spread, the neck should be opened. Should symptoms and signs of posterior mediastinitis develop, that area should be drained through the back.
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PERFORATIONS DUE TO THE INGESTION OF CORROSIVE FLUIDS AND
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DILATING STRICTURES
Sloughing of the esophageal wall with secondary perforations is always a possibility following the ingestion of corrosive fluids. In the United States, lye is still a common kitchen chemical, and there are numbers of lye burns in children from accidental ingestion. These accidents are more common in the southern part of the country than in the north, though it cannot be said that conditions are much better in the northern states, since other corrosive chemicals have been substituted for lye. These acute cases of lye burn are usually seen by general practitioners who institute emergency treatment. This, of course, should consist in the administration of a weak acid solution. No intraesophageal manipulation should be instituted in the home. It is especially important to avoid the administration of emetics, since the resulting excessive vomiting may cause rupture of a badly burned esophagus. Once the immediate emergency is overcome, the important part of the management of the case is to keep the lumen open without engaging in any procedure which entails undue risk of perforation. There is considerable divergence of opinion as to the best immediate treatment of burns of the esophagus. This divergence has been well discussed recently by Lynch.' Lynch feels that after forty-eight hours esophagoscopy is dangerous, and believes that the fluoroscope and x-ray examination should be used to determine the degree of the lye burn. Others feel that there is no contraindication to the passage of the esophagoscope down to the level of the upper edge of the burn, but not beyond it. The judicious use of the mercury-weighted bougie allowed to fall of
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its own weight through the burned esophagus seems safe and the best way to avoid injury. The caliber of the bougie is increased daily at the time of the passage. It is allowed to remain in place for thirty minutes. The treatment is continued each day for twelve to twenty-five weeks, then the interval between treatments is lengthened until only an occasional stretching is done. Another method of treatment is to perform gastrostomy and maintain the child's nourishment through that opening. At the same time the gastrostomy is performed, a thread is passed through the esophagus and brought out the mouth. This is left in place until the burns are healed. Then retrograde bougienage is carried out. Both of these methods are very successful, though the tendency now is to start treatment at once and not let the stricture form. It is the feeling of the present authors that a child who has evidence of a recent lye burn should be examined with an esophagoscope as soon as possible after the ingestion of the lye or other corrosive fluid. The esophagoscope should not be passed beyond a point slightly above the upper margin of the burn. The patient should then receive supportive treatment, gastrostomy performed if necessary, and retrograde or oral dilatation of the esophagus carried out until the healing period is over. Up to the present, no case of perforation has been reported in the literature from use of weighted mercury bougie in lye burns. Wells, Hughes, Edwards and Marcus" reported on a case of cardiospasm in which the esophagus was ruptured during dilatation with a mercuryweighted bougie. . Dilation of strictures of the esophagus once the burns have healed and adult scar tissue has closed the lumen presents an equally difficult problem, which calls for technical skill rather than a surgical decision. These cases were seen much more frequently in the days when it was considered dangerous to do any manipulation in a freshly burned esophagus. Frequently the lumen will be so narrowed that only small amounts of fluids will pass; and the patients are likely to be in very poor physical condition. The urgent indication is to establish adequate nourishment of the patient. This is done by an immediate gastrostomy. An attack can be made on the stricture from above or from below or both at the same time. All blind bougienage must be avoided. Even bougienage from above through an esophagoscope is dangerous, as there may be pockets below the visible stricture, which will engage the point of the bougie; and a pressure applied to that instrument may push it through the esophageal wall. Safe bougienage can be carried out only over a guide, either swallowing string or a filiform bougie, which is passed through the esophagoscope and manipulated into the stomach. This bougie should have a flexible tip and no force should be used in this passage. The use of the fluoroscope makes the introduction of the bougie much easier and safer. Once the thread or the bougie is in place, larger bougies may be passed over it, starting with a very small size and applying little force. Although the use of the bougie or thread will prevent the plunging of the tip through the wall of the esophagus or through the bottom of a di-
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verticulum, if the bougie is too large it may actually split the wall of the esophagus, with equally disastrous effect. After the initial examination and the passage of the first bougies it may be safe to use unguided bougies. The few cases listed in the literature of perforation of the esophagus following the use of unguided bougies is a tribute to the care with which this procedure is performed or to the embarrassment which prevents the reporting the cases. (Wells, Hughes, Edwards and Marcus report three cases with recovery.") Lye burns are not the only causes of scar strictures of the esophagus. Pressure necrosis from a long-retained feeding tube, postoperative complications of esophageal resection, or poorly performed excision of a diverticulum may close the esophagus. Stricture may also occur as an end result of cardiospasm or peptic ulcer of the lower esophagus," The treatment of these strictures is the same as that carried out for lye burns. We have seen one case in which the esophagus was completely closed by a fibrous web, following the excision of a diverticulum. Continuity of the lumen was established by passing a bougie from below and cutting down on its point through the esophagoscope. A thread was passed through this opening and dilatation carried out in the ordinary fashion. It is suggested that an esophagoscope in the lumen of the esophagus as a guide will prevent many such accidents.
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PERFORATIONS FOLLOWING ENDOSCOPY FOR D-rSPHAGIA OR HEMORRHAGE
The walls of the esophagus vary greatly in thickness, tensile strength, and resistance to trauma. It is much more of a risk to inspect this structure in the aged, the debilitated, or patients suffering from avitaminosis, than it is to use the esophagoscope in a person in good health. In these patients atrophic changes in the walls of the esophagus are liable to occur which greatly weaken it. They are especially liable to occur in patients who have been dieting for gastric ulcer, chronic gastritis, or excessive weight. Any patient in these categories who complains of dysphagia should be approached with the utmost caution if an esophagoscopy is proposed. The wall of the esophagus may have been greatly thinned by. ulcers which penetrate all the layers. As the ulcers heal, bands are formed across the lumen, which result in difficulty in swallowing. When ulcers have not healed, a little blood may be raised on occasions. These are the cases in which the greatest care has been used in the esophagoscopy, no force has been applied, and no hint suggests that a perforation has occurred. A little blood may be seen, and perhaps very friable webs across the lumen. Yet symptoms of perforation appear almost immediately after withdrawing the tube. The best treatment of these patients is to suspect the presence of the atrophic lesion and not to perform an esophagoscopy. The patient should be put on a proper diet, which will probably result in healing of the ulcers. Then, if there is difficulty in swallowing, bougienage may be used over a swallowed thread, using a very small instrument at the first attempt. Blind passage of the stomach tube is very likely to be fatal.
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CASE II. Mrs. B. J., aged 57, complained of "spasms while swallowing" for even years, following the nervous shock attendant on the death of her son in he Spanish Civil War. The dysphagia was associated with vague pains in the bdomen and chest, and often she was unable to swallow, without first "taking drink of whiskey which relaxed the spasm." She limited her diet on account of his dysphagia.
Fig. 100 (Case II). Perforation following esophagoscopy for dysphagia. An bscess cavity is present in the superior mediastinum communicating with the sophagus.
X-ray examination by barium (both films and fluoroscopy) revealed that there was a uniform narrowing about 5 em. in length of the lumen of the esophagus in s upper third. A diaphragmatic hernia containing a pouch of stomach about em. in its largest diameter was present (see Fig. 100). Esophagoscopy was begun under ideal circumstances, and after the tube had rogressed 18 em. from the upper teeth, esophageal adhesions were encountered nd the esophageal wall began to bleed. No rupture was seen, but was suspected, nd the tube was withdrawn at once. A diagnosis of Plummer-Vinson syndrome was made. The patient was returned to bed with a diagnosis of possible perforation of the sophagus. She was denied all fluids and solids by mouth. Twice a day 300,000 nits of penicillin were given. The temperature rose to 102.5°F., pulse was weak nd thready with a rate of 100. In the next twenty-four hours the patient suffered ain in the chest and back and had a chill. On the fourth post-esophagoscopy ay, a barium study of the esophagus revealed an abscess cavity in the superior mediastinum communicating with the esophagus (Fig. 100).
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On the fifth post-esophagoscopy day a thoracic surgeon evacuated a well walled-off abscess of the superior mediastinum, drained it, and passed a stomach tube for feeding, which worked well. The patient made an uneventful recovery from the operation, but developed a stricture at the site of the perforation. This was dilated and the patient is symptom-free at the present time. PERFORATION OF THE ESOPHAGUS FOLLOWING THE TAKING OF A BIOPSY
Perforation of the esophagus as a result of a biopsy may occur without the operator being in any way cognizant that he has cut a hole through the wall. It is the practice of most operators to "inspect any neoplasm very carefully and to choose a site for biopsy on some portion of the tumor which projects into the lumen. In spite of every precaution, choosing a proper site, and using proper manipulation of the forceps, it is possible to cause a perforation of the esophageal wall at a point where the protective coats have been weakened by inflammation or tumefaction. When this occurs, symptoms of a rapidly spreading mediastinitis will occur. PERFORATION OF THE ESOPHAGUS FROM EXTERNAL CAUSES
The esophagus may also be in the site of a perforation from external trauma in the form of stab wounds, bullet holes, shell fragments, or other propelled foreign bodies. These conditions are usually not brought to the attention of the endoscopist, since the injury always involves other structures, and the patient is channeled into the surgical emergency ward, where the injury to the gullet is found and treated by the chest surgeon. The perforation of the esophagus is seldom the major problem, and the outcome depends on the concomitant injuries, blood loss, shock, and degree of infection, rather than on local treatment of the esophageal wound. The choice is. immediate repair with wire suture. Should a stricture form at the site of the injury during healing, it is treated by dilatation or secondary resection. SPONTANEOUS RUPTURE OF THE ESOPHAGUS
Of all the types of acute perforation, the most challenging to the skill of the physician is the spontaneous perforation of the esophagus in persons who heretofore have been in good health and who have shown no signs of pre-existing disease. The physician who is called is usually a general practitioner, internist, or general surgeon. Each sees an acutely ill patient who sinks so rapidly that the diagnosis is seldom made in the living patient. Barrett has made a study of fifty-one cases listed in the literature during the period between 1724 and 1944. 4 No patient lived, and the recorder in each case listed what he considered the differential diagnosis. These listings showed that the bias of the physician tended to influence the tentative diagnosis. The internist thought of coronary disease, the surgeon thought of acute pancreatitis, the general practi-
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ioner was in doubt,etc. Spontaneous rupture is a rare but definite clinical entity. The lesion consists of a perforation usually longitudinal rom a pinpoint to 8 em. in length in the lowest quarter of the esophagus communicating by direct extension with cellulitis in the mediastinum, or empyema in one or both of the pleura. The pleural cavity found at operation or autopsy is full of fetid food and stomach content. There is autolysis and gangrene of the tissues so that the microscopic anatomy is usually destroyed at the time of the autopsy. The clinical picture is that already described in connection with perforations which have extended o the mediastinum. There is the same excruciating pain, nausea, vomitng, and collapse. The physical examination shows the patient in extreme shock. It is difficult to think that such a rupture can occur in connection with a normal esophagus. In reviewing the cases listed by Barrett it is evident that contributing causes were often present. Gluttony, excessive use of alcohol, persistent vomiting, particularly in pregnancy or seasickness, epileptic seizures, sudden application of high pressure to the abdomen or lower chest by falling weights are mentioned as preceding spontaneous rupture. Once the diagnosis is made, the patient should be hospitalized and the chest opened. The stomach contents in the chest should be flushed out with saline solution and the perforation searched or. If found, it should be closed by wire sutures and the chest drained. The usual supportive treatment should be pushed vigorously. The role of the endoscopist in these cases is a very minor one, since esophagoscopy s one of the last things thought of when dealing with the early stages of a spontaneously ruptured esophagus. However, it is possible that the nformation to be gained by esophagoscopy might nullify the attendant isk, and an unnecessary laparotomy may be avoided.
CASE III. A seventy-five year old American housewife (L.B.) consulted her general practitioner about some vague abdominal distress which had been diagnosed clinically as duodenal ulcer. A gastrointestinal examination with barium was begun in the doctor's office at 10:30 A.M. After the patient had wallowed a small amount of barium mixture she vomited about 600 cc. of bright ed blood. She began to complain of very severe epigastric and midback pain. She insisted on going home, where she was seen in consultation by several doctors and was urged to go to the hospital. She was admitted at 3 :30 P.M. (five hours after the onset of the symptoms). The admission diagnosis was "possible upture of the esophagus." Physical examination showed that the patient was acutely ill, temperature 99.6°F., pulse weak at 116, blood pressure 168/94. Both eyes were swollen shut by subcutaneous emphysema which seemed to involve all tissue above the waist Fig. 101). The chest was otherwise normal in expansion and the breath sounds were normal. X-ray of the chest and barium study of the esophagus were performed at 5 :00 .M. (six and one-half hours after onset of symptoms) and a diagnosis of perforaion of the esophagus at the level of the diaphragm was confirmed (Fig. 102). At 7 :45 P.M. a superior mediastinotomy was performed without undue shock o the patient and drainage instituted. No free pus was encountered in the uperior mediastinum, and only barium in the posterior mediastinum. During
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her stay in the hospital, 'the patient received the entire category of supportive treatment and antibiotics. The patient followed a rapidly progressive downhill course and expired at 3 :30 A.M., seventeen hours after the onset of symptoms, Necropsy diagnosis was as follows: Primary: Acute nonsuppurative mediastinitis. Secondary: Arteriosclerosis generalized, duodenal ulcer healed, pyloric stenosis, fibrosis of the uterus, atelectasis of the left lung (postoperative). General: Perforation of the esophagus (clinical), opening not seen, mediastinotomy with drainage.
Fig. 101.
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Fig. 102.
Fig. 101 (Case III). Wide mediastinal and subcutaneous emphysema following spontaneous rupture of the esophagus. Fig. 102 (Case III). Pinhole perforation and barium reflex along esophagus.
PERFORATIONS DUE TO DISEASE
In distinction to the dramatic symptoms and management of acute perforations of the esophagus there are some other conditions found in which there is a slow penetration of the esophageal wall associated with the formation of a protective zone of reaction around the area of perforation. The patient then develops a perforation of the esophagus without being made acutely ill. Neoplasm, usually squamous carcinoma, may form in the wall of the esophagus and replace a portion of that wall without much sign of the obstruction to the passage of food. As the tumor grows it may undergo necrosis and finally perforate the wall of the esophagus. There is usually a dense zone of reaction thrown out by the adjacent mediastinum, or pleura, so that the hole in the wall merely communicates with the pocket, or loculation, and the condition is of interest merely to the pathologist or roentgenologist. Carcinoma involving mediastinal lymph nodes may also extend to the wall of the esophagus and cause perforation.
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CASE IV. A fifty-six year old German salesman (J. K.) came to the dispensary complaining of hoarseness and difficulty in swallowing for three months. This had become progressive. In the past twenty-four hours the patient regurgiated everything he swallowed. Examination revealed a chronically ill looking white man, who spoke with a hoarse voice. There was paralysis of the right vocal cord. X-ray study with 'barium revealed the presence. of multiple lesions of the sophagus (Fig. 103), probably due to infiltration from extrinsic neoplastic mass, ossibly lymphosarcoma. Esophagoscopy was performed but no material could be obtained for biopsy s the stricture, 22 em. from the upper teeth, completely closed the esophagus.
Fig. 103. Fig. 104. Fig. 103 (Case IV). Multiple lesions of esophagus from extrinsic neoplasm. Fig. 104 (Case IV). Perforation of esophagus in superior mediastinum cometely walled off by mediastinal reaction and malignancy.
Gastrostomy was performed. During the next five weeks the patient went progressively downhill and during is period approximately 4800 high-voltage roentgen units were applied to the ediastinum. A check-up examination of the esophagus, by means of barium, vealed a perforation in the superior mediastinum which was completely walled f by mediastinal reaction and malignancy (Fig. 104). Ten weeks later the patient expired and no autopsy was performed.
Tuberculosis may be the underlying cause in the formation of the ophagus. There are many cases on record of the extrusion of calcified odes through the mucosa of the bronchi.
CASE V. The following illustration through the courtesy of Dr. H. C. Maier ows the x-ray appearance of a patient in whom a node ulcerated simultaneously
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Fig. 106 (Case VI). Tracheo-esophageal fistula.
the wall of the esophagus and the adjacent bronchus (Fig. 105). The injected iodized oil (lipiodol) passed only as far as the node which occludes the major portion of the fistula. The fistula between the bronchus and the esophagus was resected successfully and the patient was relieved until chronic pulmonary hemor-
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rhage began. A lobectomy was then performed and the patient has made a complete recovery. CONGENITAL BRONCHOESOPHAGEAL FISTULA
In addition to the cases in which acute or chronic perforations occur, there are a large number of cases in which there is an congenital defect in the esophageal wall communicating with the trachea, with the skin, or with the bronchi. Most of these cases come to the attention of the pediatricians as feeding problems, since choking spells and regurgitation during feeding are the prominent symptoms. At times the fistula is very small and is not evident even with repeated examinations by endoscopy or x-ray. Fluoroscopy with barium is the most satisfactory diagnostic method. If a communicating fistula can be found between the upper and lower stump of the esophagus it is possible to use dilatation to restore a functioning lumen. Otherwise only prompt surgery will save the life of the patient.
CASE VI. This one day old 8 pound term baby (W. R.) was admitted to the nursery from the delivery room at 8 :00 A.M. Two hours later it became cyanotic and vomited a lot of mucus. It was placed in an oxygen tent. Attempts to pass a catheter into the stomach were futile. X-ray examination revealed total obstruction of esophagus at the level of the clavicle (Fig. 106). This obstruction plus the extreme distention of the bowel indicated the presence of tracheo-esophageal fistula. The child was moved at once to another hospital for surgery and expired following operation.
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REFERENCES Lynch, M. C.: South. M. J. 42: 635-640 (August) 1949. Wells, Hughes, Edwards and Marcus: Thorax 4: 119 (June) 1949. Allison, P. R.: Thorax 3: 20-42 (March) 1948. Barrett, N. R.: Thorax 1: 48-70, (July) 1948. Culver, G. J., and Clark, S. B.: Surgery 22: 458-565 (Sept.) 1947.