ESOPHAGEAL PERFORATION:

Perforation of esophagus in the adult is a very morbid condition with high morbidity and mortality. Most common causes of esophageal perforation include

• Medical instrumentation (65%)

• Post emetic (16%) is also called Boerhaav's syndrome.

• Trauma

• Post-operative

• Penetrating chest injury

• Blunt chest trauma

•  Less common causes

• Neoplasm

•  Ingestion of caustic materials

Clinical features:

• Retrosternal chest pain

• Dyspnea

• Cough

• Subcutaneous emphysema

• Sepsis (fever, leukocytosis,shock)

• Peritonitis in case of distal esophageal perforation

Investigations:

1. Posteroanterior and lateral chest and upright abdominal radiographs (diagnostic in 90% of cases). 

Following findings may be noted in case of esophageal perforation

• Hydrothorax (usually on the left)

• Hydropneumothorax

• Pneumothorax

• Pneumomediastinum

• Subcutaneous emphysema

• Subdiaphragmatic air (in case of perforation of intra-abdominal portion of esophagus)

2. Gastrografin or barium contrast study:

Treatment:

The reported mortality from treated esophageal perforation is 10% to 25%, when therapy is

may be initiated within 24 hours of perforation, but it could rise up to 40% to 60% when the treatment  is delayed beyond 48 hours. After making the diagnosis of esophageal perforation following steps should taken

• Admission to medical/surgical ICU

• Nil by mouth/NPO

• Broad spectrum antibiotics

• Intravenous fluids

• Narcotic analgesics

Definitive treatment may be conservative or Surgical

Criteria for nonoperative treatment include the following:

• Recent iatrogenic perforation or late iatrogenic

• Absence of sepsis 

• No malignancy, obstruction, or stricture in the region of the perforation

• Minimal symptoms

• Perforation confined to the mediastinum

• Perforation of cervical esophagus

Criteria for operative treatment include:

• Clinical instability with sepsis

• Recent post emetic perforation

• Intra-abdominal perforation

• Leak outside the mediastinum (ie,extravasation of contrast into adjacent body cavities)

• Malignancy, obstruction, or stricture in the region of the perforation

What operation?

• If the perforation is recognized early (4-6 hours) direct primary repair is sufficient.

 If a patient presents after 24 hours, tissues become edematous and friable and direct suturing may not be appropriate. In this case the perforation should be isolated by bringing the proximal end of the esophagus out through the neck and closing the distal end. Feeding jejunostomy should be carried out for nutritional support. Later the esophagostomy is taken down and colon or jejunum is interposed to bridge the gap at the site of resection. Sometimes esophagectomy has to be performed when there is extensive necrosis of esophagus as in case of chemical ingestion. Perforation of abdominal esophagus leads to peritonitis and should be repaired by upper midline laparotomy. Perforation which is caused by malignancy is best dealt by placement of covered self expanding metal stent.