I thoracic surgeon as mortality rates of more than 20%

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1 CURRENT REVIEW Management of Esophageal Injuries Herbert E. Cohn, MD, Alan Hubbard, MD, and Gerald Patton, MD Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania A multiinstitutional study of 39 esophageal injuries treated between 1982 and 1988 and a comprehensive review of the literature revealed an unacceptably high mortality rate of more than 20%. Results of the current study indicated that prompt diagnosis and aggressive surgical management of esophageal injuries could im- prove the outcome and lower the associated mortality. The clinical experience and literature review allowed us to elaborate caveats and principles that, if adhered to, should improve the outcome in esophageal injuries. (Ann Thorac Surg 1989;48:309-14) njuries to the esophagus remain a challenge to the I thoracic surgeon as mortality rates of more than 20% continue to be reported. Although the cervical esophagus is the most frequently injured portion as a result of external penetrating trauma, iatrogenic perforation and spontaneous rupture occur often enough in the thoracic and abdominal portions to warrant inclusion in any discussion. Because much has been written about esophageal injury [l-31, methods of diagnosis and treatment options should be well known to all of us, yet controversy exists as to the appropriate management of esophageal injuries [4, 51. Part of the problem in making an early diagnosis is that esophageal perforation is not a singular entity. The patients are a heterogenous group, with perforations occurring from the cervical region to the intraabdominal esophagus. Each location of injury poses its own particular problems in diagnosis and treatment. The causes of injury also vary greatly, from instrumentation or penetrating wounds to spontaneous rupture. Proponents of prompt aggressive operative management after early diagnosis have reported marked reductions in overall mortality [13, 51. Nonetheless, some clinicians who advocate nonoperative management have reported equally impressive results [4, 6, 71. A multiinstitutional analysis of esophageal injuries occurring in the greater Delaware Valley area between 1982 and 1988 was performed, and the pertinent literature was reviewed in an attempt to organize and clarify the factors that affect the cause, diagnosis, and treatment of such injuries. Material and Methods A retrospective review of the charts of patients with a discharge diagnosis of esophageal perforation at five institutions* in the greater Delaware Valley area between the years 1982 and 1988 revealed 39 patients with esophageal injuries. The following data were collected: age, sex, Address reprint requests to Dr Cohn, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA * The five institutions were Thomas Jefferson University Hospital, Temple University Hospital, Hospital of the University of Pennsylvania, Albert Einstein Medical Center, Northern Division, and New Jersey College of Medicine & Dentistry (Cooper). history, physical findings, cause and site of perforation, method of diagnosis (eg, chest roentgenogram, contrast radiography, endoscopy, computed tomography, or operative exploration), treatment, and outcome. Excluded were patients with anastomotic leaks or perforations secondary to neoplasm, or those in whom the diagnosis was made on clinical grounds alone (eg, fever or leukocytosis after endoscopic procedures). Thirty-nine patients were identified with confirmed esophageal perforation. There were 21 men and 18 women with a median age of 55 years. The most frequent cause of perforation was instrumentation. Other causes were penetrating trauma, spontaneous rupture, paraesophageal operation, foreign body, and blunt trauma (Table 1). Most perforations occurred in the thoracic esophagus; the fewest occurred in the abdominal esophagus. Seventeen of the 23 thoracic esophageal injuries were caused by instrumentation, 12 of which were sustained during therapeutic dilation and 5 of which were sustained during diagnostic endoscopy. Six were spontaneous ruptures. The abdominal esophageal injuries comprised 2 spontaneous ruptures and 1 injury from therapeutic dilation. There were 13 cervical perforations. Eight were penetrating wounds, 2 resulted from foreign bodies and 2 resulted from instrumentation; 1 blunt trauma injury occurred. In all, there were 21 iatrogenic injuries: 2 subsequent to diagnostic endoscopy, 13 resulting from therapeutic dilation, 3 secondary to paraesophageal operation, 1 resulting from an esophageal obturator airway, 1 resulting from cricothyroidotomy, and 1 resulting from variceal sclerotherapy. Pain was the most frequent symptom (69%), with hematemesis, dyspnea, fever, and dysphagia occurring in 8% to 33% of the patients, respectively. A penetrating wound or subcutaneous crepitus suggested the diagnosis in 18%. Diagnosis was confirmed by contrast radiography in 23 patients (60%) and by endoscopy in 5 (13%). Roentgenograms showed abnormal air in soft tissues or free air in 10 patients (25%) and pleural effusion in 8 (21%). Operation was needed to confirm the diagnosis in 6 patients (15%). All patients received antibiotic therapy and fluid resuscitation. The mainstay of nonoperative treatment was by The Society of Thoracic Surgeons /89/$3.50

2 310 REVIEW COHNETAL Ann Thorac Surg 1989;48:309-I4 Table 1. Causes of Esophageal Perforation Cause n % Instrumentation Spontaneous rupture 7 18 Penetrating trauma 7 18 Paraesophageal operation Foreign body Blunt trauma Total ) SURVIVAL 0 MORTALITY broad-spectrum antibiotics, hyperalimentation, and nasogastric suction. Cervical Esophagus Eleven wounds in the cervical esophagus were treated with primary closure and drainage and 2 were treated nonoperatively. The only patient in this group who died had been treated operatively within 24 hours of sustaining the injury but had suffered major associated injuries. Thoracic Esophagus Thirteen wounds in the thoracic esophagus were treated operatively and 10 were treated nonoperatively. In the operative group, 3 simple drainages, 7 primary closures with wide mediastinal drainage, 2 exclusions and drainage, and 1 resection were performed. Patients who had severe associated disease and were not considered suitable for surgical intervention were treated with simple drainage. There were 9 deaths (39%) in this group. Only 1 death occurred in patients treated within 24 hours of injury. Eight of the 13 patients treated after 24 hours died, 4 in the operative group and 4 in the nonoperative group. Abdominal Esophagus All three abdominal esophageal injuries were treated with primary closure and drainage. Two patients survived. Treatment of the patient who died had been delayed for more than 24 hours. Overall mortality for the entire study group was 28% (11 deaths). Of 26 patients in whom definitive therapy was instituted within 24 hours, only 2 (8%) died, but 9 (69%) of 13 for whom treatment was delayed longer than 24 hours died (Figs 1 and 2). The outcomes in nine reported series of esophageal injuries, including our own, are shown in Table 2. Overall mortality from esophageal perforations varied from 9% to 28%. Mortality among patients treated within 24 hours of sustaining the injury was substantially less than among those for whom diagnosis and treatment were delayed. Injuries to the cervical esophagus were associated with less mortality than were injuries to the thoracic or abdominal esophagus. Comment The esophagus is a unique organ in the gastrointestinal tract in that it traverses three anatomical zones, namely the neck, the thorax, and the abdomen. Because in each of 1 NON-OR I OR NON-OR I OR CERVICAL I THORACIC I ABD Fig 1. Outcome of esophageal injuries relative to mode of therapy, (operative lorl or nonoperative INON-OR]) and anatomical site. these areas it is in intimate contact with other vital organs, penetrating injuries rarely involve only the esophagus. Injuries to the great vessels, whether in the thorax, neck, or abdomen, increase the morbidity and mortality associated with esophageal injury. Obviously, any injury to contiguous structures such as the heart, lungs, larynx and trachea, stomach, pancreas, spleen, or spinal cord have further negative impact on outcome. In a collected series of esophageal injuries, Mulder and Barkun (151 reported mortality rates of 9% to 23%; the latter was associated with intrathoracic injuries. Even in a series of more recent esophageal injuries, a mortality rate of more than 20% was reported. Isolated injuries to the esophagus from ri SURVIVAL 0 MORTALITY Fig 2. Outcome of esophageal injuries relative to time interval between injury and subsequent treatment (<24 h or >24 h) according to anatomical site.

3 Table 2. Esophageal lnjuries Observed and Treated in Nine Series Death Ratea Number Author (year) of Cases Anatomical Location Cause of Injury <24 hb >24 hb Combined Bladergroen et a1 [l] cervical, 90 thoracic/ 70 iatrogenic, 11/72 (15) 26/55 (47) (29) ( ) abdominal 19 spontaneous, 38 traumalother Cohn et a1 [present study] cervical, 23 thoracic, 22 iatrogenic, 2/25 (8) 9/14 (64) 11/29 (28) ( ) 3 abdominal 7 spontaneous, 10 trauma Kostiainan et a1 [8] ( ) 29 3 cervical, 26 thoracic/ 12 iatrogenic, 2/15 (13) 4/7 (57) 7/29' (24) abdominal 12 spontaneous, 5 foreign body Larsen et a1 [9] ( ) 57 7 cervical, 50 thoracic/ 42 iatrogenic, 7/37 (19) 7/20 (35) 14/57 (25) abdominal 26 spontaneous1 other Larsson et a1 [lo] ( ) thoracic 23 iatrogenic 1/20 (5) 113 (33) 2/23 (9) Nesbit et a1 [ll] ( ) cervical, 30 thoracic, 23 iatrogenic, 4/36 (11) 4/15 (26) 8/51 (16) 4 abdominal 12 spontaneous, 16 trauma Radmark et a1 [12] ( ) 39 1 cervical, 37 thoracic, 39 iatrogenic I7 7/39 (18) 1 abdominal (esophagoscopy) Shockley et a1 [13] ( ) 9 9 cervical 7 iatrogenic, 016 (0) 113 (33) 119 (1 1) 2 foreign body Skinner et a1 [14] 47 Unspecified 26 iatrogenic, 2/23 (9) 7/24 (29) 9/47 (19) 13 neoplasm, 8 other a Numbers in parentheses are percentages. From time of injury to diagnosis and treatment for all injuries regardless of location. The time from injury to treatment was unspecified for 7 patients.

4 312 REVIEW COHNETAL Ann Thorac Surg 1989:48:30%14 other causes, however, have occurred in sufficient numbers to create a body of information that provides surgeons with an understanding of the seriousness of such injuries and lends direction to the diagnosis and management of them. Cervical Esophagus Most cervical esophageal injuries are due to the penetrating trauma of gunshot and stab wounds. Far fewer penetrating wounds in the cervical esophagus are due to instrumentation, blunt trauma, foreign bodies, or endotracheal or nasogastric intubations [16, 171. Ordog and colleagues [18] reported injuries to the pharynx and esophagus in only 6% of 110 bullet wounds of the neck; these were primarily associated with wounds in zones I1 and 111. Pain, dysphagia, bleeding from the mouth, and hemotemesis or hemoptysis signal penetrating esophageal injury. However, after instrumentation, pain, dysphagia, fever, and subcutaneous emphysema may herald perforation. Soft tissue x-ray films of the neck or of the cervical spine suggest an esophageal injury if air is present in the soft tissues or if the prevertebral shadow is wide. Air in the soft tissues is occasionally misleading because injuries to the airway present a similar picture. Contrast radiography and endoscopy provide the highest diagnostic yield in such injuries. In a study by Weigelt and co-workers (Weigelt JA, Thal ER, Snyder WH, et al, unpublished observations), penetrating cervical esophageal injuries were investigated by contrast radiography, rigid endoscopy, and fiberoptic endoscopy. Eighty percent were diagnosed by contrast radiography or rigid endoscopy, and only 50% were detected by flexible endoscopy. That 20% of the lesions can be missed by all of these diagnostic techniques is of paramount importance. Chest roentgenography should always be performed in cases of injury to the cervical esophagus to rule out hemothorax or pneumothorax. Angiography may be necessary if an associated vascular injury is suspected. Although some penetrating neck wounds can be treated nonoperatively, all esophageal and airway injuries should be managed operatively. There is nothing more devastating than "spit-fistula" contamination of a vascular suture line or an airway repair. A two-layered repair accurately approximating mucosa to mucosa and muscularis to muscularis is accomplished with 3-0 or 4-0 polyglactin or polydiozanone suture. The suture line is buttressed with a pedicle strap muscle flap, and the area is thoroughly drained. Broad-spectrum antibiotics are administered perioperatively. Occasionally, a perforation cannot be identified even with the esophagus insufflated with air under a layer of sterile water. In these instances, simple drainage and antibiotic therapy should suffice. Select patients with well-localized and contained instrumental perforations that meet the Cameron criteria [4] may be managed nonoperatively with antibiotics and hyperalimentation. However, the perforation must be well contained and drain into the esophagus, and the patient must be relatively asymptomatic with minimal signs of clinical sepsis. Thoracic Esophagus In injuries to the intrathoracic esophagus, instrumental perforation and spontaneous perforation remain the major causes of esophageal injury. Some are caused by foreign body penetration, paraesophageal operation, manipulation of indwelling therapeutic tubes, traumatic intubation, external penetrating wounds, variceal sclerotherapy [19, 201, and penetration due to Angelchik antireflux prosthesis [21]. Perforations of the intrathoracic esophagus are potentially lethal because they can result in extensive infection of both the mediastinum and pleural spaces with myriad organisms, including virulent anaerobic mouth organisms [3]. Decisions regarding appropriate therapy require consideration of the cause of perforation and any underlying disease process(es). All penetrating wounds of the thoracic esophagus, all spontaneous ruptures, and all perforations associated with distal esophageal obstruction must be promptly diagnosed and managed operatively. Delays in diagnosis or management are associated with pronounced increases in mortality. A report from our institution in 1960 [22] advocated a high index of suspicion, early diagnosis, and prompt surgical intervention with primary repair and adequate drainage in an effort to reduce the morbidity and mortality associated with instrumental perforation of the esophagus. Delays in diagnosis and treatment produced greater morbidity and mortality. As a rule, perforations should be suspected in any patient who complains of persistent chest or abdominal pain after esophageal instrumentation. Contrast radiography should be performed to confirm the diagnosis. Widening of the mediastinum, pneumomediastinum, pneumothorax, or pleural effusion evident on chest roentgenogram may suggest esophageal injury. With rare exception, operative intervention should be carried out immediately after the diagnosis is established. After the edges of the wound are freshened a twolayered repair of the perforation should be performed, with wide drainage of the mediastinum. The repair is always buttressed with a pedicle flap from adjacent pleura [23] or intercostal muscle. Any distal esophageal obstruction must be attended to appropriately. Strictures can be dilated under direct vision or opened longitudinally and closed transversely; when such strictures are associated with esophageal reflux accompanied by an antireflux procedure, the area of repair can be buttressed with a fundoplication [ 141. Esophagomyotomy should be performed for achalasia, and the area of perforation should be buttressed by a Thal patch or the fundoplication of an antireflux procedure. If the distal obstruction is a tumor and contamination is not extensive, and if the condition of the patient will permit, resection and primary anastamosis is undertaken. Indwelling or fundoplication to buttress the anastamosis, or reinforcement of the anastomosis with a pleural or intercostal muscle flap, may minimize anastomotic leaks, which are associated with a high mortality. Spontaneous perforation of the esophagus, first described by Boerhaave [24], refers to disruption of the full

5 Ann Thorac Surg 1989;48: REVIEW COHNETAL 313 thickness of the esophageal wall. It is often associated with prolonged or forceful vomiting. Acute upper abdominal and thoracic pain preceded by episodic or forceful vomiting associated with mediastinal or cervical subcutaneous emphysema, or both, suggest perforation. The diagnosis can be confirmed by contrast radiography. Nasogastric decompression, fluid resuscitation, and antibiotics are followed immediately by surgical intervention. Through a left thoracotomy, the mediastinal pleura is opened wide and the site of perforation is identified. The muscular rent should be lengthened to expose the entire mucosal tear, which is often much more extensive than the muscular tear. Failure to expose the entire rent could result in an incomplete closure of the mucosal tear, which would lead to suture line leakage [25]. The tissue edges are freshened when necessary, and a mucosato-mucosa and muscularis-to-muscularis two-layered closure is performed. The repair is always buttressed. The mediastinum and pleural space are thoroughly drained. When surgical intervention is late and the tissues will not hold sutures well, a variety of surgical options are available. Wide drainage of the area alone, partial closure of the perforation over a T tube with sump drainage of the area, and exclusion with a diverting cervical esophagostomy and ligation of the distal esophagus with an absorbable suture have all been used successfully. Each procedure is supplemented by a decompressing gastrostomy and feeding jejunostomy [l-3, 19, 26, 271. These surgical procedures are used not only for repair of spontaneous ruptures, but for repair of other esophageal injuries as well. Operative intervention is sometimes necessary to confirm a diagnosis of penetrating wound to the intrathoracic esophagus when the location of a foreign body or the course taken by a missile suggests an esophageal injury that cannot be detected by either contrast radiography or endoscopy. If associated injuries require an anterior approach through which the esophageal perforation cannot be repaired effectively, repairs to adjacent organs should be carried out and the patient turned over to approach the esophageal injury posterolaterally using the standard principles of esophageal repair (K. L. Matton, personal communication, May 1988). Nonoperative management may be appropriate in select cases of instrumental perforation of the thoracic esophagus that meet Cameron s criteria. However, one must keep in mind that delays in management are associated with an increase in mortality and greater technical difficulty in managing the offending pathology. Distinguishing between an early contained esophageal injury and one that will cause extensive mediastinal contamination is sometimes extremely difficult. Abdominal Esophagus The intraabdominal esophagus can rupture spontaneously, or it can be perforated by endoscopic manipulation or penetrating injuries; it can also be ruptured by paraesophageal operations such as vagotomy, antireflux procedures, or hiatal hernia repair. Epigastric pain with signs of peritoneal irritation signal perforation. Free air under the diaphragm may be evident on an erect chest radiogram, and perforation can be confirmed by contrast radi- ography. The previously stated principles of repair apply, and a successful outcome can be achieved by a twolayered closure buttressed by fundoplication or an omental wrap coupled with decompressing gastrostomy and feeding jejunostomy. Morbidity and mortality are greatly influenced by associated injuries to the liver, spleen, major vessels, or pancreas. Caustic injuries of the esophagus occur mostly in children and are caused by ingestion of strong acids or alkalis. Industrial strength alkalis usually affect the esophagus, whereas strong acids affect the stomach. Endoscopy within the first 24 hours is performed to assess the extent of the injury and to determine its severity. Industrial strength lye always causes severe injuries, usually circumferential and associated with white patchy eschar. Stricture formation and the need for esophageal replacement are determined by the depth of the burn. Steroids have been ineffectual in altering the course of these burns [28]. A baseline barium swallow should be obtained. The objective of therapy is to restore normal swallowing function. If the burn is severe, a gastrostomy should be performed, and the patient should be instructed to swallow a string as a guide for subsequent dilations. If the burn is mild, endoscopy is repeated after 3 weeks to reassess healing or stricture formation. If the burn is moderate, or if a stricture develops, antegrade dilations are necessary at periodic intervals for up to a year. If antegrade dilation fails, or if the burn or stricture is severe, retrograde dilation with Horst dilators should be attempted every ten days to 2 weeks. If this procedure is effective, antegrade dilation can be started in 3 to 6 months and the gastrostomy closed. If retrograde dilation proves ineffective, esophageal replacement with either colon, stomach, or a reversed gastric tube should be considered. Conclusions Certain caveats and principles related to esophageal injuries have evolved from our experience and from the wealth of information available in the surgical literature. Most penetrating esophageal wounds occur in the neck. Perforations in the cervical esophagus have low morbidity and mortality if treated within the first 24 hours [ll, 14, 291. Most instrumental and spontaneous perforations occur within the thoracic esophagus. Instrumental perforations result more often from therapeutic dilation than from diagnostic endoscopy [30]. When pain or fever develops, either with or without subcutaneous emphysema, after instrumentation, perforation should be suspected [31]. The diagnosis can often be confirmed by contrast radiography using Gastrografin or barium sulfate [29]. The associated morbidity and mortality arise from the overwhelming sepsis caused by the myriad aerobes and anaerobes that contaminate the periesophageal region. Spontaneous perforations result in higher mortality than do instrumental perforations [lo, 25, 27, 321. Prompt recognition of the esophageal injury followed by surgical repair is the preferred method of treatment and produces the most favorable outcome. Operative procedures vary with the location and type of injury.

6 314 REVIEW COHNETAL Ann Thorac Surg 1989;48: Drainage alone, primary repair and drainage, repair either with or without resection of the offending pathology with restoration of gastrointestinal continuity, and exclusion with or without resection are among the treatment options. Buttressing of the repaired perforation with viable tissue appears to improve the outcome. Delays in treatment are associated with an unacceptable mortality rate. Multiple operations needed to manage complications also increase mortality. Nonoperative management appears to be applicable to only a small, select group of patients who manifest no clinical signs of sepsis and have minimal, well-contained injuries. We gratefully acknowledge the cooperation of Robert G. Somers, MD, Albert Einstein Medical Center, Northern Division; Rudolph Camishon, MD, UMDNJ-Robert Wood Johnson Medical School at Camden; Clyde Barker, MD, Hospital of the University of Pennsylvania; and Wallace Ritchie, MD, Temple University Hospital, for assistance in accessing the data used in this article. References 1. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 1986;42: Michel L, Grillo HC, Malt RA. Esophageal perforation. Ann Thorac Surg 1982;33: Brewer LA, Carter R, Mulder GA, et al. Options in the management of perforations of the esophagus. Am J Surg 1986;152: Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 1979; Wesdorp ICE, Bartelsman JFWM, et al. Treatment of instrumental esophageal perforation. Gut 1984;25: Brown RA, Cohen PS. 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