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Perforation of the esophagus
January
Volume 65, Number 1
The Journal of
1973
THORACIC AND
CARDIOVASCULAR SURGERY
Perforation of the esophagus A 30 year review B. Eugene Berry, M.D. (by invitation), and John L. Ochsner, M.D., New Orleans, La.
ESOPhageal perforation, regardless of the etiology, is a catastrophic event. It has been regarded as "the most rapidly fatal and most serious perforation of the gastrointestinal tract. "1 Successful management demands prompt and vigorous treatment. Once relatively rare, the recognition of esophageal disruption has greatly increased with advances in diagnostic technique and the greater frequency of endoscopic examinations. Early diagnosis is essential and, once the diagnosis is made, the physician must have guidelines by which he can promptly begin appropriate treatment. Boerhaave published his classic description of spontaneous rupture of the esophagus in 1724. 2 Not until 1941, however, was the first perforation successfully drained by Frink"; Barrett- reported the first successful closure in 1947. Since then many accounts From the Department of Surgery, Ochsner Clinic, New Orleans, La. Read at the Fifty-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., May I. 2, and 3. 1972. Address for reprints: John L. Ochsner, M.D., Ochsner Clinic, 1514 Jefferson Highway, New Orleans, La. 70121.
of the successful care of patients with esophageal perforation have appeared. Clinical material
In an effort to evaluate the results of therapy at our institution, the records of cases at the Ochsner Clinic during the previous 30 years were reviewed. Included in the study were all perforations of the esophagus, whether due to foreign bodies or instrumentation or as a result of so-called spontaneous rupture. During the 30 years between 1941 and 1971, 31 patients with rupture of the esophagus were treated. A general increase in incidence was noted: 5 cases in the period 1949 to 1953 and 10 cases between 1964 and 1968. The sex distribution was similar, with 16 male and 15 female patients in the series. Although the ages ranged from 16 months to 77 years, 75 per cent of the patients were older than 50 years of age. Etiology
The predominance of patients in the later decades of life is related to the underlying esophageal disease seen in this age group 1
2
The Journal of Thoracic and Cardiovascular Surgery
Berry and Ochsner
Table I. Underlying diseases associated with perforation of esophagus Underlying disease
Hiatus hernia with stenosis Hiatus hernia Esophageal stricture Carcinoma of stomach or esophagus Achalasia Achalasia with stenosis Others No underlying disease Total
Table II. Causes of perforation of esophagus Cause
Endoscopic Ingestion of foreign body Emergency endotracheal intubation Tracheostomy Spontaneous Total
Table III. Location of perforation of esophagus Region of esophagus
INa. of cases
Cervical Middle Lower Gastroesophageal junction Not determined
10 2 15 3 1
Total
31
(Table I). Hiatus hernia was the most common problem, affecting one third of the patients, often with varying degrees of esophagitis. Stenosis or stricture, with or without other disease, was also present in about one third. Other conditions included cardiospasm and carcinoma, of both esophageal and gastric origin. About 25 per cent of the patients had no underlying disease; most of them sustained perforation by an ingested foreign body (Table II). Benign neoplasms are occasionally encountered, and 1 patient in this series had a submucosal lipoma of the lower esophagus. There were no patients with perforation due to penetrating foreign bodies.
Esophageal perforation was most frequent (75 per cent) during endoscopic examination (Table II); endoscopy at times included dilatation with a bag or bougie. Four cases were due to perforation by an ingested foreign body. In 1 case, perforation followed an episode of vomiting, the socalled spontaneous rupture. One unusual case was the result of inadvertent entry into the esophagus during emergency tracheostomy. Another perforation resulted from attempted endotracheal intubation during emergency resuscitation. Location of perforation
In 10 cases the injury affected the cervical esophagus (Table III), primarily in the cricopharyngeal area. The four perforations caused by foreign bodies and the one surgical injury accounted for one half of the cervical perforations. All but one of the remainder were due to endoscopic examination. In over one half (18 cases), the distal one third of the esophagus or the gastroesophageal junction had perforated. Only two injuries of the middle third were noted. All but one of the twenty thoracic esophageal injuries were secondary to endoscopic procedure. The exception was the single case of postemetic rupture. In 1 case there was evidence of mediastinal air after esophagoscopy, but no hole could be localized by esophagogram or during thoracotomy. Symptoms and signs
The acute onset of severe and constant pain was the single most important symptom. Noted in all patients, it was most often localized along the course of the esophagus, that is, in the cervical, substernal, or epigastric region. Three patients described pain in the left chest, and 4 felt it posteriorly. Other sites included the right lower and left upper quadrants of the abdomen. Seven patients complained of a pleuritic type pain, or dyspnea, but in only 3 was dysphagia noticed. One patient had hematemesis. Fever was present in approximately two thirds of the patients at the time the problem presented. Most patients showed a leukocytosis
Volume 65
Perforation of esophagus
Number 1
3
Jonuory, 1973
Table IV. Results of treatment of perforation of esophagus Treatment
Medical only Surgical Initial medical treatment Surgical treatment only None Total
No. of cases
No. of deaths
3 27 6 21
0 4
0 14.8
1 5
100 16.1
0 4 1 31
Mortality rate* (per cent)
'The over-all mortality rate with treatment was 13.3 per cent.
or at least a shift to the left in the differential count. Subcutaneous crepitation was reported in 7 patients and neck swelling in 6 others. A systolic crunch was noted in 1 patient. Shock was observed in two patients, and acute abdominal signs in 2 others.
tients and provided positive information in each. Other urgent causes of acute pain, such as dissecting aneurysm, myocardial infarction, and pulmonary embolism, may require consideration in the differential diagnosis.
Diagnosis
Treatment
Many authors have pointed out that one of the most important diagnostic factors in rupture of the esophagus is awareness of its possibility. Since the majority of the patients in this series had just undergone esophageal instrumentation, the consideration of esophageal injury was fairly obvious. In only 1 patient was the diagnosis made after death; this was in an elderly woman with terminal carcinoma of the stomach. At no time during the 2 days from perforation to death did this patient have a febrile response, even though fibrinopurulent pleurisy was found at autopsy. Of the several diagnostic tests available, roentgenographic examination of the chest was the most valuable. In more than one half of the cases, the posteroanterior and lateral views of the chest showed abnormalities. These included mediastinal or subcutaneous air, pneumothorax, widening of the mediastinum, and evidence of pleural fluid. Films of the cervical spine may be more helpful if an injury to the cervical esophagus is suspected. Esophagograms showed extravasation of the contrast material in 12 of 16 patients. The finding that examinations were negative in 4, however, indicates that a negative esophagogram cannot be relied on absolutely if other suspicious findings are present. Esophagoscopy was performed on 3 pa-
Conservative nonsurgical treatment was attempted in 9 patients. This included administration of broad-spectrum antibiotics and intravenous infusions; nothing was given by mouth. Of these patients, 6 subsequently required surgical drainage from I to 5 days later; 3 had lower esophageal perforations. Primary surgical treatment was selected for 21 of the 31 patients. Five were treated by drainage alone and 10 by primary closure, with drainage. Six patients underwent simultaneous repair for the underlying esophageal disease. These patients also received broad-spectrum antibiotics, and many had nasogastric suction, often placed under direct visualization at the time of surgery. Gastrostomy was performed in some cases. One patient was not treated: In this case, the diagnosis was made at autopsy. Results The over-all mortality rate in this series was 16.1 per cent (Table IV). The mortality rate of the patients who were treated, 13.3 per cent, compares favorably with other reported series.': 5-0 None of the 3 patients treated by medical means alone died, nor were there any deaths among the 6 other patients who received medical treatment initially but required surgical drainage of an abscess or empyema later. Among the patients who
The Journal of
4
Berry and Ochsner
Thoracic and Cardiovascular Surgery
Table V. Mortality rate and area of perforation of esophagus
Area
Cervical Thoracic Middle Distal Undetermined
I No. of
patients
No. of deaths
10
Mortality rate (per cent)
10
2 18
0
I
0
4
0 22 100
were treated surgically as a primary method, 4 died, a mortality rate of 14.8 per cent. One of the 6 patients who had a definitive procedure on exploration died after esophagogastrectomy for carcinoma of the stomach. The single untreated patient died 2 days after perforation. The location of the perforation influenced the prognosis. Perforation in the lower thoracic esophagus appeared to be about twice as lethal as cervical perforations (Table V). As frequently happens with perforation of the esophagus, all 5 patients who died had complicating conditions. Four of these had perforations of the distal esophagus. Two patients had carcinoma of the stomach, 1 of whom was the patient who received no treatment. One patient, an alcoholic, developed irreversible shock from upper gastrointestinal bleeding on the eighth postoperative day. Another patient, an elderly lady with perforation of the cervical esophagus caused by a chicken bone, died of myocardial infarction 2 days after the neck had been drained. The other death occurred in an elderly lady whose perforation was closed 2 days after an injury associated with dilatation. In an unusual series of events, the bougie was discovered to have tunneled some 15 em. within the wall of the esophagus and stomach, emerging finally through the gastric serosa into the peritoneal cavity. Discussion Several factors account for the increasing incidence of perforation of the esophagus. The importance of the physician's cogni-
zance of the disease is one factor. Another is age: The majority of patients in this series were past the fifth decade. As longevity is increased, more diseases of the esophagus will predispose to disruption; similarly, more diagnostic procedures will be required and performed. Over three fourths of our cases resulted from endoscopic examination. As instrumentation increases, this factor may be expected to become even more important. Endoscopic examinations of the esophagus carry a small but definite risk. Strong and colleagues," in 1951, reported an incidence of one esophageal perforation for every 125 esophagoscopic examinations (0.8 per cent). By 1965, Foster's group!' noted the incidence to be one per 200 to 250 examinations (0.44 per cent to 0.5 per cent). Hopefully, the incidence will continue to decrease. The diagnosis of esophageal perforation begins with awareness of this condition. The physician can then proceed logically and quickly to determine its presence or absence. Delay in diagnosis is further fostered by the variety of acute thoracic and abdominal conditions which may present in a similar manner. In recent years several authors have advocated the medical management of esophageal perforation. Blalock" stated that medical therapy was justified for questionable or small perforations. However, Foster and associates" warned that the diagnosis of a "small" perforation was difficult to make and stated that "early changes on chest roentgenogram or the size of the rent as determined by esophagography provide an unreliable index to the future course of events." Mengoli and Klassen" reported good results with medical management of 18 patients. These authors thought that vigorous antibiotic therapy and decompression, combined with early diagnosis, were fundamental to success. Treatment was begun within 24 hours in 14 of the patients. Initially, there was a high fever, and most remained febrile for 1 week. Hospital time averaged 18 days. No drainage was required of mediastinal abscesses, and none developed chronic empyema. The one death in
Volume 65 Number 1
Perforation of esophagus
5
January, 1973
their series occurred in a patient with carcinoma of the esophagus. On the basis of this report, one editorial" favored medical management of esophageal perforation. Our own experience suggests that there is a place for medical therapy in selected cases, but we realize that subsequent drainage may be necessary (6 of 9 cases in this series). It is difficult to state categorically which clinical situations should be managed by nonsurgical procedures. However, the 3 patients in this series who responded to medical therapy exhibit principles which may serve as guidelines for therapy in other patients-namely, that surgery may not be required in (1) those patients seen late, in whom the perforations are resolving by natural defense processes, (2) certain patients with small perforations and minimal signs of leakage, and (3) some cervical perforations which may resolve without drainage. The details of the 3 cases in this series are as follows. Case reports A healthy 39-year-old woman was seen 3 days after an ingested foreign body had perforated the cervical esophagus. At esophagoscopy, the paraesophageal abscess was noted to drain into the lumen. She promptly became asymptomatic without further sequelae. Another patient, a 54-year-old man, sustained a small distal esophageal perforation at endoscopy. The only clinical manifestations were swelling at the suprasternal notch and back pain. The third patient treated medically was a 64year-old woman whose cervical esophagus was perforated at endoscopy. She developed subcutaneous and mediastinal emphysema and subsequently required tracheostomy. Although no suppurative process developed, she may have been afforded some cervical drainage by the tracheostomy. She recovered completely without sequelae.
On the other hand, a review of the literature- 4-8, 11, 1~, 15, 1G indicates a marked preference for surgical treatment of this condition. Paulson and colleagues,G from a collected series, reported mortality rates, from rupture of the esophagus, as follows: (1) untreated, 70 per cent; (2) antibiotics, 30 per cent but with high morbidity also; and. (3) surgical, 20 per cent. Groves" recorded
a surgical mortality rate of 12 per cent in 17 patients treated at the Cleveland Clinic; there were no deaths in those patients who had no organic esophageal lesion. Nealon and his colleagues' reported a 28 per cent surgical mortality rate among 18 patients, remarking that treatment had been delayed over 24 hours in 4 of the 5 who died. The specific surgical approach depends primarily on the area of injury, the nature of underlying esophageal disease, and the time interval between perforation and surgery. In injuries of the cervical esophagus, simple drainage is usually adequate unless the tear is large or unless there is distal obstruction." Drainage through an incision anterior to the sternomastoid should be established upon diagnosis. As many as 25 per cent of these patients may require subsequent drainage if treated medically." Early drainage is thought to reduce morbidity and the length of hospitalization.' Injury to the intrathoracic esophagus requires thoracotomy, usually with tube drainage and a two-layer closure of the perforation. If operation is done within 24 hours of perforation, a definitive procedure correcting the underlying esophageal disease can be considered. Blalock" reported successful esophagogastrectomy in 2 patients who were treated 8 and 15 hours after endoscopic perforation; 1 patient had a benign stricture, and the other had esophageal carcinoma. Other authors'< 18. 19 have reported tears of the distal esophagus in cases in which resection for the associated disease was successful. Mortality rate should not be the only factor in determining the efficacy of a method of treatment. Morbidity is also important. Mathewson and his colleagues," in a review of 54 cases, noted a long and complicated convalescence in a number of patients who were treated conservatively. They remarked that "five of the eleven deaths . . . might have been prevented had a more aggressive surgical approach been adopted." Nealon's group' recorded a higher morbidity in cervical perforations when drainage was delayed. In Groves" series, the average hospital
The Journal of
6
Berry and Ochsner
Thoracic and Cardiovascular Surgery
stay was 8 and 15 days, for patients without and with local esophageal lesions, respectively. Symbas and associates-'' reported an average stay of 15 days with closure and drainage and 36 days with drainage only. In our experience, there was only a small increase in the average hospital stay with conservative as opposed to surgical treatment. Evaluation of treatment modalities is made more complex because of the great importance of early treatment. Nealon and his colleagues' reported a 10 per cent surgical mortality rate in those treated within 24 hours but a 50 per cent rate in those treated after 24 hours. Most of the medically managed patients of Mengoli and Klassen" were treated within 24 hours. Conclusions
Perforation of the esophagus, potentially a lethal condition, is being seen with increasing frequency. The mortality rate, though lower today than formerly, still remains high and must be further lessened. A fundamental aspect of treatment is early diagnosis, often suggested by the case history. In more than 75 per cent of the cases in this series, perforation resulted from endoscopic injuries; approximately 75 per cent of these occurred in the distal esophagus. Cervical esophageal perforations were caused by foreign bodies in nearly one half of the cases. With evidence of subcutaneous or pleural free air, the history and physical examination alone may establish the diagnosis. Chest or cervical roentgenography and esophagography confirm the diagnosis in the majority of cases and localize the site of perforation. Appropriate management requires a thorough understanding of each case and keen clinical judgement. Rigid adherence to solely surgical or medical regimens will not result in the best patient care. An individualized plan of therapy is necessary in each case. A nonsurgical or "medical" approach may be indicated in the small or indefinite perforation, especially if it is cervical in location. The consensus in the literature, how-
ever, emphasizes surgical drainage of the larger perforations and suture closure of those in the intrathoracic esophagus. This approach may be recommended as a basic guideline; variations may be indicated by the underlying pathology and general medical condition. A definitive surgical procedure should be considered for cases diagnosed early which are complicated by underlying surgical problems of the esophagus.
Summary Thirty-one cases of esophageal perforation, collected during a 30 year period at the Ochsner Clinic, have been reviewed. The incidence of the condition has increased during that period. More than 75 per cent of the cases in this series followed endoscopic instrumentation. Diagnosis was usually made from the history of endoscopy or trauma, the findings of subcutaneous air on physical examination and free air on chest or cervical roentgenograms, and extravasation during barium esophagogram. In" general, prompt diagnosis and treatment are essential. Although some patients can be managed conservatively, our experience, and that of others, indicates that surgical treatment is usually preferred. For cervical esophageal perforations, drainage alone usually suffices. Suture-closure and drainage are recommended for perforations of the intrathoracic esophagus. A definitive procedure may be possible in those cases diagnosed early in which there are underlying surgical problems of the esophagus. The mortality rate of 13.3 per cent in the treated patients in this series compares favorably with other reported series. REFERENCES Sealy, W. c.: Rupture of the Esophagus, Am. J. Surg. 105: 505, 1963. 2 Derbes, V. J., and Mitchell, R. E., Jr.: Hermann Boerhaave's (I) Atrocis, nee Descripti prius, Morbi Historia; (2) The First Translation of the Classic Case Report of Rupture of the Esophagus, With Annotations, Bull. Med. Ubr. Assoc. 43: 217, 1955. 3 Frink, N. W.: Spontaneous Rupture of Esoph-
Volume 65 Number 1 January, 1973
agus: Report of a Case With Recovery, I. THORAC. SURG. 16: 291, 1947. 4 Barrett, N. R.: Report of a Case of Spontaneous Perforation of the Oesophagus Successfully Treated by Operation, Br. I. Surg. 35: 216, 1947. 5 Marston, E. L., and Valk, H. L.: Spontaneous Perforation of the Esophagus: Review of the Literature and Report of a Case, Ann. Intern. Med. 51: 590, 1959. 6 Paulson, D. L., Shaw, R. R., and Kee, I. L.: Recognition and Treatment of Esophageal Perforations, Ann. Surg. 152: 13, 1960. 7 Nealon, T. F., Jr., Templeton, I. Y., III, Cuddy, V. D., and Gibbon, I. H., Jr.: Instrumental Perforation of the Esophagus, I. THoRAc. CARDIOVASC. SURG. 41: 75, 1961. 8 Mathewson, C., Ir., Schaupp, W. c., Dimond, F. c., and French, S. W.: Traumatic Rupture of the Esophagus, Am. I. Surg. 93: 616, 1957. 9 Groves, L. K.: Instrumental Perforation of the Esophagus: What Is Conservative Management? I. THORAc. CARDIOVASC. SURG. 52: 1, 1966. 10 Strong, G. F., Wilson, R., and Taylor, H. E.: Rupture of the Oesophagus, Can. Med, Assoc. I. 65: 455, 1951. 11 Foster, I. H., lolly, P. c., Sawyers, I. L., and Daniel, R. A: Esophageal Perforation: Diagnosis and Treatment, Ann. Surg. 161: 701, 1965. 12 Blalock, I.: Primary Esophagogastrectomy for Instrumental Perforation of the Esophagus: With a Report of Two Cases, Am. I. Surg. 94: 393, 1957. 13 Mengoli, L. R., and Klassen, K. P.: Conservative Management of Esophageal Perforation, Arch. Surg. 91: 238, 1965. 14 Editorial: Conservative Management of Esophageal Perforation, I. A M. A 193: 537, 1965. 15 Overstreet, I. W., and Ochsner, A.: Traumatic Rupture of the Esophagus (With a Report of 13 Cases), I. THoRAc. SURG. 30: 164, 1955. 16 Iohnson, I., and Schwegman, C. W.: Iatrogenic and Spontaneous Perforation of the Esophagus, Am. I. Gastroenterol. 47: 365, 1967. 17 Loop, L. D., and Groves, L. K.: Esophageal Perforations, Ann. Thorac. Surg. 10: 571, 1970. 18 Hendren, W. H., and Henderson, B. M.: Immediate Esophagectomy for Instrumental
Perforation of esophagus
7
Perforation of the Thoracic Esophagus, Ann. Surg. 168: 997, 1968. 19 Johnson, I., Schwegman, C. W., and MacVaugh, H., III: Early Esophagogastrostomy in the Treatment of Iatrogenic Perforation of the Distal Esophagus, I. THORAc. CARDIOVASC. SURG. 55: 24, 1968. 20 Symbas, P. N., Logan, W. D., Hatcher, C. R., Jr., and Abbott, O. A: Factors in the Successful Recognition and Management of Esophageal Perforation, South. Moo. 1. 59: 1090, 1966.
Discussion DR. AGUSTIN ARBULU Detroit, Mich.
I want to congratulate Drs. Ochsner and Berry for their review of perforation of the esophagus. At Wayne State University in Detroit, we reviewed 24 spontaneous perforations of the esophagus. One of the most important features that we found in the treatment and the survival of these patients was early diagnosis. I don't have any slides with me, but I want to mention a technical maneuver in the early diagnosis of perforation of the esophagus, especially perforations that are caused by instrumentation. I had to treat a patient wth this complication about 2 years ago. As we usually do our esophagoscopies under general anesthesia, it is very difficult to make the diagnosis with a plain chest x-ray film or with contrast esophagography. Confronted with this problem, I passed a No. 16 rubber Levin tube through the esophagoscope and got a plain chest x-ray film while the patient was asleep. In this particular instance, the Levin tube was within the left pleural cavity. This maneuver was very valuable because it localized the perforation and enabled me to perform immediate surgical correction. This patient did quite well. DR. EUGENE BERRY (Closing) I would like to thank Dr. Arbulu for his comments. I feel compelled to add that, lest this paper appeared to cast aspersions on our Gastrointestinal Section, we have performed about 12,000 endoscopic procedures during this 30 year period, causing only the 24 injuries which were mentioned in our paper here.
Volume 65, Number 1
The Journal of
1973
THORACIC AND
CARDIOVASCULAR SURGERY
Perforation of the esophagus A 30 year review B. Eugene Berry, M.D. (by invitation), and John L. Ochsner, M.D., New Orleans, La.
ESOPhageal perforation, regardless of the etiology, is a catastrophic event. It has been regarded as "the most rapidly fatal and most serious perforation of the gastrointestinal tract. "1 Successful management demands prompt and vigorous treatment. Once relatively rare, the recognition of esophageal disruption has greatly increased with advances in diagnostic technique and the greater frequency of endoscopic examinations. Early diagnosis is essential and, once the diagnosis is made, the physician must have guidelines by which he can promptly begin appropriate treatment. Boerhaave published his classic description of spontaneous rupture of the esophagus in 1724. 2 Not until 1941, however, was the first perforation successfully drained by Frink"; Barrett- reported the first successful closure in 1947. Since then many accounts From the Department of Surgery, Ochsner Clinic, New Orleans, La. Read at the Fifty-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., May I. 2, and 3. 1972. Address for reprints: John L. Ochsner, M.D., Ochsner Clinic, 1514 Jefferson Highway, New Orleans, La. 70121.
of the successful care of patients with esophageal perforation have appeared. Clinical material
In an effort to evaluate the results of therapy at our institution, the records of cases at the Ochsner Clinic during the previous 30 years were reviewed. Included in the study were all perforations of the esophagus, whether due to foreign bodies or instrumentation or as a result of so-called spontaneous rupture. During the 30 years between 1941 and 1971, 31 patients with rupture of the esophagus were treated. A general increase in incidence was noted: 5 cases in the period 1949 to 1953 and 10 cases between 1964 and 1968. The sex distribution was similar, with 16 male and 15 female patients in the series. Although the ages ranged from 16 months to 77 years, 75 per cent of the patients were older than 50 years of age. Etiology
The predominance of patients in the later decades of life is related to the underlying esophageal disease seen in this age group 1
2
The Journal of Thoracic and Cardiovascular Surgery
Berry and Ochsner
Table I. Underlying diseases associated with perforation of esophagus Underlying disease
Hiatus hernia with stenosis Hiatus hernia Esophageal stricture Carcinoma of stomach or esophagus Achalasia Achalasia with stenosis Others No underlying disease Total
Table II. Causes of perforation of esophagus Cause
Endoscopic Ingestion of foreign body Emergency endotracheal intubation Tracheostomy Spontaneous Total
Table III. Location of perforation of esophagus Region of esophagus
INa. of cases
Cervical Middle Lower Gastroesophageal junction Not determined
10 2 15 3 1
Total
31
(Table I). Hiatus hernia was the most common problem, affecting one third of the patients, often with varying degrees of esophagitis. Stenosis or stricture, with or without other disease, was also present in about one third. Other conditions included cardiospasm and carcinoma, of both esophageal and gastric origin. About 25 per cent of the patients had no underlying disease; most of them sustained perforation by an ingested foreign body (Table II). Benign neoplasms are occasionally encountered, and 1 patient in this series had a submucosal lipoma of the lower esophagus. There were no patients with perforation due to penetrating foreign bodies.
Esophageal perforation was most frequent (75 per cent) during endoscopic examination (Table II); endoscopy at times included dilatation with a bag or bougie. Four cases were due to perforation by an ingested foreign body. In 1 case, perforation followed an episode of vomiting, the socalled spontaneous rupture. One unusual case was the result of inadvertent entry into the esophagus during emergency tracheostomy. Another perforation resulted from attempted endotracheal intubation during emergency resuscitation. Location of perforation
In 10 cases the injury affected the cervical esophagus (Table III), primarily in the cricopharyngeal area. The four perforations caused by foreign bodies and the one surgical injury accounted for one half of the cervical perforations. All but one of the remainder were due to endoscopic examination. In over one half (18 cases), the distal one third of the esophagus or the gastroesophageal junction had perforated. Only two injuries of the middle third were noted. All but one of the twenty thoracic esophageal injuries were secondary to endoscopic procedure. The exception was the single case of postemetic rupture. In 1 case there was evidence of mediastinal air after esophagoscopy, but no hole could be localized by esophagogram or during thoracotomy. Symptoms and signs
The acute onset of severe and constant pain was the single most important symptom. Noted in all patients, it was most often localized along the course of the esophagus, that is, in the cervical, substernal, or epigastric region. Three patients described pain in the left chest, and 4 felt it posteriorly. Other sites included the right lower and left upper quadrants of the abdomen. Seven patients complained of a pleuritic type pain, or dyspnea, but in only 3 was dysphagia noticed. One patient had hematemesis. Fever was present in approximately two thirds of the patients at the time the problem presented. Most patients showed a leukocytosis
Volume 65
Perforation of esophagus
Number 1
3
Jonuory, 1973
Table IV. Results of treatment of perforation of esophagus Treatment
Medical only Surgical Initial medical treatment Surgical treatment only None Total
No. of cases
No. of deaths
3 27 6 21
0 4
0 14.8
1 5
100 16.1
0 4 1 31
Mortality rate* (per cent)
'The over-all mortality rate with treatment was 13.3 per cent.
or at least a shift to the left in the differential count. Subcutaneous crepitation was reported in 7 patients and neck swelling in 6 others. A systolic crunch was noted in 1 patient. Shock was observed in two patients, and acute abdominal signs in 2 others.
tients and provided positive information in each. Other urgent causes of acute pain, such as dissecting aneurysm, myocardial infarction, and pulmonary embolism, may require consideration in the differential diagnosis.
Diagnosis
Treatment
Many authors have pointed out that one of the most important diagnostic factors in rupture of the esophagus is awareness of its possibility. Since the majority of the patients in this series had just undergone esophageal instrumentation, the consideration of esophageal injury was fairly obvious. In only 1 patient was the diagnosis made after death; this was in an elderly woman with terminal carcinoma of the stomach. At no time during the 2 days from perforation to death did this patient have a febrile response, even though fibrinopurulent pleurisy was found at autopsy. Of the several diagnostic tests available, roentgenographic examination of the chest was the most valuable. In more than one half of the cases, the posteroanterior and lateral views of the chest showed abnormalities. These included mediastinal or subcutaneous air, pneumothorax, widening of the mediastinum, and evidence of pleural fluid. Films of the cervical spine may be more helpful if an injury to the cervical esophagus is suspected. Esophagograms showed extravasation of the contrast material in 12 of 16 patients. The finding that examinations were negative in 4, however, indicates that a negative esophagogram cannot be relied on absolutely if other suspicious findings are present. Esophagoscopy was performed on 3 pa-
Conservative nonsurgical treatment was attempted in 9 patients. This included administration of broad-spectrum antibiotics and intravenous infusions; nothing was given by mouth. Of these patients, 6 subsequently required surgical drainage from I to 5 days later; 3 had lower esophageal perforations. Primary surgical treatment was selected for 21 of the 31 patients. Five were treated by drainage alone and 10 by primary closure, with drainage. Six patients underwent simultaneous repair for the underlying esophageal disease. These patients also received broad-spectrum antibiotics, and many had nasogastric suction, often placed under direct visualization at the time of surgery. Gastrostomy was performed in some cases. One patient was not treated: In this case, the diagnosis was made at autopsy. Results The over-all mortality rate in this series was 16.1 per cent (Table IV). The mortality rate of the patients who were treated, 13.3 per cent, compares favorably with other reported series.': 5-0 None of the 3 patients treated by medical means alone died, nor were there any deaths among the 6 other patients who received medical treatment initially but required surgical drainage of an abscess or empyema later. Among the patients who
The Journal of
4
Berry and Ochsner
Thoracic and Cardiovascular Surgery
Table V. Mortality rate and area of perforation of esophagus
Area
Cervical Thoracic Middle Distal Undetermined
I No. of
patients
No. of deaths
10
Mortality rate (per cent)
10
2 18
0
I
0
4
0 22 100
were treated surgically as a primary method, 4 died, a mortality rate of 14.8 per cent. One of the 6 patients who had a definitive procedure on exploration died after esophagogastrectomy for carcinoma of the stomach. The single untreated patient died 2 days after perforation. The location of the perforation influenced the prognosis. Perforation in the lower thoracic esophagus appeared to be about twice as lethal as cervical perforations (Table V). As frequently happens with perforation of the esophagus, all 5 patients who died had complicating conditions. Four of these had perforations of the distal esophagus. Two patients had carcinoma of the stomach, 1 of whom was the patient who received no treatment. One patient, an alcoholic, developed irreversible shock from upper gastrointestinal bleeding on the eighth postoperative day. Another patient, an elderly lady with perforation of the cervical esophagus caused by a chicken bone, died of myocardial infarction 2 days after the neck had been drained. The other death occurred in an elderly lady whose perforation was closed 2 days after an injury associated with dilatation. In an unusual series of events, the bougie was discovered to have tunneled some 15 em. within the wall of the esophagus and stomach, emerging finally through the gastric serosa into the peritoneal cavity. Discussion Several factors account for the increasing incidence of perforation of the esophagus. The importance of the physician's cogni-
zance of the disease is one factor. Another is age: The majority of patients in this series were past the fifth decade. As longevity is increased, more diseases of the esophagus will predispose to disruption; similarly, more diagnostic procedures will be required and performed. Over three fourths of our cases resulted from endoscopic examination. As instrumentation increases, this factor may be expected to become even more important. Endoscopic examinations of the esophagus carry a small but definite risk. Strong and colleagues," in 1951, reported an incidence of one esophageal perforation for every 125 esophagoscopic examinations (0.8 per cent). By 1965, Foster's group!' noted the incidence to be one per 200 to 250 examinations (0.44 per cent to 0.5 per cent). Hopefully, the incidence will continue to decrease. The diagnosis of esophageal perforation begins with awareness of this condition. The physician can then proceed logically and quickly to determine its presence or absence. Delay in diagnosis is further fostered by the variety of acute thoracic and abdominal conditions which may present in a similar manner. In recent years several authors have advocated the medical management of esophageal perforation. Blalock" stated that medical therapy was justified for questionable or small perforations. However, Foster and associates" warned that the diagnosis of a "small" perforation was difficult to make and stated that "early changes on chest roentgenogram or the size of the rent as determined by esophagography provide an unreliable index to the future course of events." Mengoli and Klassen" reported good results with medical management of 18 patients. These authors thought that vigorous antibiotic therapy and decompression, combined with early diagnosis, were fundamental to success. Treatment was begun within 24 hours in 14 of the patients. Initially, there was a high fever, and most remained febrile for 1 week. Hospital time averaged 18 days. No drainage was required of mediastinal abscesses, and none developed chronic empyema. The one death in
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their series occurred in a patient with carcinoma of the esophagus. On the basis of this report, one editorial" favored medical management of esophageal perforation. Our own experience suggests that there is a place for medical therapy in selected cases, but we realize that subsequent drainage may be necessary (6 of 9 cases in this series). It is difficult to state categorically which clinical situations should be managed by nonsurgical procedures. However, the 3 patients in this series who responded to medical therapy exhibit principles which may serve as guidelines for therapy in other patients-namely, that surgery may not be required in (1) those patients seen late, in whom the perforations are resolving by natural defense processes, (2) certain patients with small perforations and minimal signs of leakage, and (3) some cervical perforations which may resolve without drainage. The details of the 3 cases in this series are as follows. Case reports A healthy 39-year-old woman was seen 3 days after an ingested foreign body had perforated the cervical esophagus. At esophagoscopy, the paraesophageal abscess was noted to drain into the lumen. She promptly became asymptomatic without further sequelae. Another patient, a 54-year-old man, sustained a small distal esophageal perforation at endoscopy. The only clinical manifestations were swelling at the suprasternal notch and back pain. The third patient treated medically was a 64year-old woman whose cervical esophagus was perforated at endoscopy. She developed subcutaneous and mediastinal emphysema and subsequently required tracheostomy. Although no suppurative process developed, she may have been afforded some cervical drainage by the tracheostomy. She recovered completely without sequelae.
On the other hand, a review of the literature- 4-8, 11, 1~, 15, 1G indicates a marked preference for surgical treatment of this condition. Paulson and colleagues,G from a collected series, reported mortality rates, from rupture of the esophagus, as follows: (1) untreated, 70 per cent; (2) antibiotics, 30 per cent but with high morbidity also; and. (3) surgical, 20 per cent. Groves" recorded
a surgical mortality rate of 12 per cent in 17 patients treated at the Cleveland Clinic; there were no deaths in those patients who had no organic esophageal lesion. Nealon and his colleagues' reported a 28 per cent surgical mortality rate among 18 patients, remarking that treatment had been delayed over 24 hours in 4 of the 5 who died. The specific surgical approach depends primarily on the area of injury, the nature of underlying esophageal disease, and the time interval between perforation and surgery. In injuries of the cervical esophagus, simple drainage is usually adequate unless the tear is large or unless there is distal obstruction." Drainage through an incision anterior to the sternomastoid should be established upon diagnosis. As many as 25 per cent of these patients may require subsequent drainage if treated medically." Early drainage is thought to reduce morbidity and the length of hospitalization.' Injury to the intrathoracic esophagus requires thoracotomy, usually with tube drainage and a two-layer closure of the perforation. If operation is done within 24 hours of perforation, a definitive procedure correcting the underlying esophageal disease can be considered. Blalock" reported successful esophagogastrectomy in 2 patients who were treated 8 and 15 hours after endoscopic perforation; 1 patient had a benign stricture, and the other had esophageal carcinoma. Other authors'< 18. 19 have reported tears of the distal esophagus in cases in which resection for the associated disease was successful. Mortality rate should not be the only factor in determining the efficacy of a method of treatment. Morbidity is also important. Mathewson and his colleagues," in a review of 54 cases, noted a long and complicated convalescence in a number of patients who were treated conservatively. They remarked that "five of the eleven deaths . . . might have been prevented had a more aggressive surgical approach been adopted." Nealon's group' recorded a higher morbidity in cervical perforations when drainage was delayed. In Groves" series, the average hospital
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Berry and Ochsner
Thoracic and Cardiovascular Surgery
stay was 8 and 15 days, for patients without and with local esophageal lesions, respectively. Symbas and associates-'' reported an average stay of 15 days with closure and drainage and 36 days with drainage only. In our experience, there was only a small increase in the average hospital stay with conservative as opposed to surgical treatment. Evaluation of treatment modalities is made more complex because of the great importance of early treatment. Nealon and his colleagues' reported a 10 per cent surgical mortality rate in those treated within 24 hours but a 50 per cent rate in those treated after 24 hours. Most of the medically managed patients of Mengoli and Klassen" were treated within 24 hours. Conclusions
Perforation of the esophagus, potentially a lethal condition, is being seen with increasing frequency. The mortality rate, though lower today than formerly, still remains high and must be further lessened. A fundamental aspect of treatment is early diagnosis, often suggested by the case history. In more than 75 per cent of the cases in this series, perforation resulted from endoscopic injuries; approximately 75 per cent of these occurred in the distal esophagus. Cervical esophageal perforations were caused by foreign bodies in nearly one half of the cases. With evidence of subcutaneous or pleural free air, the history and physical examination alone may establish the diagnosis. Chest or cervical roentgenography and esophagography confirm the diagnosis in the majority of cases and localize the site of perforation. Appropriate management requires a thorough understanding of each case and keen clinical judgement. Rigid adherence to solely surgical or medical regimens will not result in the best patient care. An individualized plan of therapy is necessary in each case. A nonsurgical or "medical" approach may be indicated in the small or indefinite perforation, especially if it is cervical in location. The consensus in the literature, how-
ever, emphasizes surgical drainage of the larger perforations and suture closure of those in the intrathoracic esophagus. This approach may be recommended as a basic guideline; variations may be indicated by the underlying pathology and general medical condition. A definitive surgical procedure should be considered for cases diagnosed early which are complicated by underlying surgical problems of the esophagus.
Summary Thirty-one cases of esophageal perforation, collected during a 30 year period at the Ochsner Clinic, have been reviewed. The incidence of the condition has increased during that period. More than 75 per cent of the cases in this series followed endoscopic instrumentation. Diagnosis was usually made from the history of endoscopy or trauma, the findings of subcutaneous air on physical examination and free air on chest or cervical roentgenograms, and extravasation during barium esophagogram. In" general, prompt diagnosis and treatment are essential. Although some patients can be managed conservatively, our experience, and that of others, indicates that surgical treatment is usually preferred. For cervical esophageal perforations, drainage alone usually suffices. Suture-closure and drainage are recommended for perforations of the intrathoracic esophagus. A definitive procedure may be possible in those cases diagnosed early in which there are underlying surgical problems of the esophagus. The mortality rate of 13.3 per cent in the treated patients in this series compares favorably with other reported series. REFERENCES Sealy, W. c.: Rupture of the Esophagus, Am. J. Surg. 105: 505, 1963. 2 Derbes, V. J., and Mitchell, R. E., Jr.: Hermann Boerhaave's (I) Atrocis, nee Descripti prius, Morbi Historia; (2) The First Translation of the Classic Case Report of Rupture of the Esophagus, With Annotations, Bull. Med. Ubr. Assoc. 43: 217, 1955. 3 Frink, N. W.: Spontaneous Rupture of Esoph-
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agus: Report of a Case With Recovery, I. THORAC. SURG. 16: 291, 1947. 4 Barrett, N. R.: Report of a Case of Spontaneous Perforation of the Oesophagus Successfully Treated by Operation, Br. I. Surg. 35: 216, 1947. 5 Marston, E. L., and Valk, H. L.: Spontaneous Perforation of the Esophagus: Review of the Literature and Report of a Case, Ann. Intern. Med. 51: 590, 1959. 6 Paulson, D. L., Shaw, R. R., and Kee, I. L.: Recognition and Treatment of Esophageal Perforations, Ann. Surg. 152: 13, 1960. 7 Nealon, T. F., Jr., Templeton, I. Y., III, Cuddy, V. D., and Gibbon, I. H., Jr.: Instrumental Perforation of the Esophagus, I. THoRAc. CARDIOVASC. SURG. 41: 75, 1961. 8 Mathewson, C., Ir., Schaupp, W. c., Dimond, F. c., and French, S. W.: Traumatic Rupture of the Esophagus, Am. I. Surg. 93: 616, 1957. 9 Groves, L. K.: Instrumental Perforation of the Esophagus: What Is Conservative Management? I. THORAc. CARDIOVASC. SURG. 52: 1, 1966. 10 Strong, G. F., Wilson, R., and Taylor, H. E.: Rupture of the Oesophagus, Can. Med, Assoc. I. 65: 455, 1951. 11 Foster, I. H., lolly, P. c., Sawyers, I. L., and Daniel, R. A: Esophageal Perforation: Diagnosis and Treatment, Ann. Surg. 161: 701, 1965. 12 Blalock, I.: Primary Esophagogastrectomy for Instrumental Perforation of the Esophagus: With a Report of Two Cases, Am. I. Surg. 94: 393, 1957. 13 Mengoli, L. R., and Klassen, K. P.: Conservative Management of Esophageal Perforation, Arch. Surg. 91: 238, 1965. 14 Editorial: Conservative Management of Esophageal Perforation, I. A M. A 193: 537, 1965. 15 Overstreet, I. W., and Ochsner, A.: Traumatic Rupture of the Esophagus (With a Report of 13 Cases), I. THoRAc. SURG. 30: 164, 1955. 16 Iohnson, I., and Schwegman, C. W.: Iatrogenic and Spontaneous Perforation of the Esophagus, Am. I. Gastroenterol. 47: 365, 1967. 17 Loop, L. D., and Groves, L. K.: Esophageal Perforations, Ann. Thorac. Surg. 10: 571, 1970. 18 Hendren, W. H., and Henderson, B. M.: Immediate Esophagectomy for Instrumental
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Perforation of the Thoracic Esophagus, Ann. Surg. 168: 997, 1968. 19 Johnson, I., Schwegman, C. W., and MacVaugh, H., III: Early Esophagogastrostomy in the Treatment of Iatrogenic Perforation of the Distal Esophagus, I. THORAc. CARDIOVASC. SURG. 55: 24, 1968. 20 Symbas, P. N., Logan, W. D., Hatcher, C. R., Jr., and Abbott, O. A: Factors in the Successful Recognition and Management of Esophageal Perforation, South. Moo. 1. 59: 1090, 1966.
Discussion DR. AGUSTIN ARBULU Detroit, Mich.
I want to congratulate Drs. Ochsner and Berry for their review of perforation of the esophagus. At Wayne State University in Detroit, we reviewed 24 spontaneous perforations of the esophagus. One of the most important features that we found in the treatment and the survival of these patients was early diagnosis. I don't have any slides with me, but I want to mention a technical maneuver in the early diagnosis of perforation of the esophagus, especially perforations that are caused by instrumentation. I had to treat a patient wth this complication about 2 years ago. As we usually do our esophagoscopies under general anesthesia, it is very difficult to make the diagnosis with a plain chest x-ray film or with contrast esophagography. Confronted with this problem, I passed a No. 16 rubber Levin tube through the esophagoscope and got a plain chest x-ray film while the patient was asleep. In this particular instance, the Levin tube was within the left pleural cavity. This maneuver was very valuable because it localized the perforation and enabled me to perform immediate surgical correction. This patient did quite well. DR. EUGENE BERRY (Closing) I would like to thank Dr. Arbulu for his comments. I feel compelled to add that, lest this paper appeared to cast aspersions on our Gastrointestinal Section, we have performed about 12,000 endoscopic procedures during this 30 year period, causing only the 24 injuries which were mentioned in our paper here.