Esophageal Perforation

Question 1

Why is intrathoracic esophageal perforation so lethal?

Answer 1

Leakage of gastric contents into mediastinum, leading to chemical burns, tissue destruction and sepsis.

Question 2

How does a cervical esophageal perforation typically present?

Answer 2

Neck tenderness, odynophagia, and subcutaneous emphysema.

Question 3

How does an intrathoracic esophageal perforation typically present?

Answer 3

Dysphagia, pain, tachycardia and fever

Question 4

Name the major causes of esophageal perforations.

Answer 4

Iatrogenic (endoscopy/surgery), trauma (penetrating/blunt injury, foreign body, caustic ingestion), malignancy, inflammation, and infection.

Question 5

Spontaneous perforation (not iatrogenic) is usually associated with what?

Answer 5

Emesis

Question 6

What is the best way to visualize an esophageal perforation?

Answer 6

With a contrast swallow (gastrograffin, then thin barium if none seen with water soluble contrast).

Question 7

Surgical treatment option for a patient with an intra-abdominal perforation and severe reflux disease?

Answer 7

Esophageal preservation, repair of perforation, and an antireflux procedure.

Question 8

What is the surgical approach for intra-abdominal perforations?

Answer 8

Laparotomy or laparoscopy

Question 9

What is the surgical approach for mid (middle third) intrathoracic esophageal perforations?

Answer 9

Right thoracotomy, debridement of necrotic tissue, drainage and closure of injury. Esophageal muscle layers are opened above and below injury, and closed 2 layers, and repair buttressed.

Question 10

What is the surgical approach for lower (intrathoracic) esophageal perforations?

Answer 10

Left thoracotomy, debridement of necrotic tissue, drainage and closure of injury. Repair performed in two layers, and buttressed.

Question 11

Can esophageal injuries be repaired primarily after 24-48 hours?

Answer 11

Yes.

Question 12

Surgical approach in a patient with achalasia and perforation after dilatation.

Answer 12

Two layer closure and myotomy on opposite side of perforation with partial fundoplication to cover site of perforation.

Question 13

When can nonoperative management be employed in patients with esophageal perforations?

Answer 13

If leak is contained, and patient has no signs of sepsis. Also, intraluminal dissection, transmural perforations that drain back into esophagus, no distal obstruction, and perforations not in abdominal cavity.

Question 14

How are cervical perforations unique?

Answer 14

Often can be successfully treated nonoperatively and will heal after a short course.

Question 15

What is the leading cause of esophageal perforations?

Answer 15

Instrumentation (endoscopy, dilatation, etc)