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ESOPHAGUS
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69
AB
FIG. 4 (A) Upper gastrointestinal (GI) series with water-soluble oral contrast medium demonstrating extraluminal extravasation of contrast medium from
the left side of the esophagus approximately 2 cm below the level of the carina, consistent with esophageal perforation. (B) Repeat upper GI series with
water-soluble oral contrast medium in the same patient as in (A) demonstrates a distal esophageal stent in good position. There is no evidence of contrast
medium extravasation to suggest a persistent leak.
A B
FIG. 5 Endoscopic view of deployed and expanded self-expanding metal stent (A) and self-expandable plastic stent (B).
prevent stent insertion. Particular attention should be paid to stent
size. The internal diameter of the stent should be slightly larger than
the lesion of interest, thus allowing for adequate radial force to be
applied. An inadequately small stent diameter may increase the risk
of migration, whereas an oversized stent may lead to perforation and
excessive pressure necrosis. The length of a stent should be at least
4 cm longer than that of the lesion, overlapping it both proximally
and distally by at least 2 cm. However, the location of an esophageal
obstruction may necessitate modification to the general technique
for stent deployment. Most notably, stent placement in the proximal
esophagus is known to be challenging. In patients with esophageal
strictures near the upper esophageal sphincter (UES), the placement
is adjusted so that the proximal margin of the stent is below the UES
(i.e., the proximal stent margin may be <2 cm). Stent placement in
the distal esophagus or across the GEJ may also be challenging. In
these instances, it is important to avoid an excessively long stent so
that the distal margin of the stent does not result in contact with the
contralateral gastric wall and lead to ulceration or perforation.
ES can be achieved using either fluoroscopic guidance, endoscopic guidance, or both. One technique is the Seldinger technique,
in which a guidewire is endoscopically advanced into the esophagus
2 to 3 cm past the distal end of the lesion, the endoscope is removed,
70 USE OF ESOPHAGEAL STENTS
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and the stent delivery system is advanced over the guidewire. The
endoscope is then reinserted, and the stent positioned and deployed
under direct visualization. Caution should be used to ensure that
the stent is not fully deployed until satisfactory positioning has been
achieved. Using fluoroscopy, the guidewire is inserted using a catheter. Once a satisfactory position has been secured, a small amount
of water-soluble contrast medium is injected through the catheter to
delineate the stricture. Radiopaque markers are then used to delineate the location and length of the stricture on the patient’s skin.
Next, after the catheter is removed, the delivery system is advanced
over the guidewire, and the stent is deployed under continuous fluoroscopic monitoring.
The development and increased availability of through-the-scope
(TTS) SEMS has allowed for this technique to be performed by
advancing the stent catheter under direct visualization through the
accessory channel of a therapeutic double channel upper endoscope.
After deployment, the stent expands against the stricture and
the mucosa at the margins of the stricture. This anchors the stent
in place and helps prevent stent migration. Repeat endoscopy or an
upper gastrointestinal series 24 to 36 hours postdeployment is often
performed before resumption of oral intake. The stent is expected
to completely expand within 48 to 72 hours. When oral intake is
resumed, patients are discharged with written diet instructions based
on results of stent placement and the expected gradual expansion of
the stent. Patients are typically advised to consume liquids only for
24 to 48 hours and then to advance to a soft solid diet as tolerated, as
well as to adhere to long-term avoidance of fibrous foods such as raw
vegetables and large pieces of meat.
COMPLICATIONS
Close to 30% of patients undergoing an esophageal stent placement
experience complications (Table 3). These events are often classified
as early or late (Table 4). Events of mild to moderate severity such
as retrosternal pain or reflux symptoms typically resolve within 1
or 2 weeks postprocedure. Persistence of retrosternal pain beyond
2 weeks may indicate the need for endoscopic removal of the stent.
Recent studies have shown improvement of reflux symptoms with
TABLE 3 Overview of Adverse Events Related
to Esophageal Stent Placement for Different
Indications
Malignant
Dysphagia
Complications
(n = 1017)
SERIOUS ADVERSE EVENT (%)
Major bleeding 8.0 3.0 1.3
Aspiration pneumonia 5.0 1.3 0.7
Perforation 2.0 1.3 1.0
ADVERSE EVENTS (%)
Retrosternal pain 30.0 4.3 0.5
Reflux symptoms 7.0 2.6 0.5
Recurrent dysphagia 31.0 29.0 20.0
Stent migration 11.0 24.5 16.5
Tissue ingrowth/overgrowth 14.0 2.2 2.7
Food obstruction 7.0 2.2 1.1
Modified from Vermeulen BD, Siersema PD. Esophageal stenting in clinical
practice: an overview. Curr Treat Options Gastroenterol. 2018;16:260–273.
Benign
Dysphagia
(n = 232)
Esophageal
Leakage
(n = 599)
TABLE 4 Common Early and Late Complications
After Esophageal Stent Placement
Early Complications
(<2 weeks), 10%–20%
Retrosternal pain
Minor hemorrhage
Aspiration
Gastroesophageal reflux
disease
Migration
Occlusion
Airway erosion/compression
Vascular erosion
Modified from Vermeulen BD, Siersema PD. Esophageal stenting in clinical
practice: an overview. Curr Treat Options Gastroenterol. 2018;16:260–273.
the use of stents equipped with a distal reflux valve, especially in
patients with GEJ lesions. Other measures to prevent acid reflux and
aspiration of gastric contents include maintaining an upright (or
semi-upright) position at all times and a daily proton pump inhibitor.
Stent occlusion secondary to tumor in-growth is most commonly
seen with uncovered or partially covered stents but can now be
successfully managed with a stent-in-stent technique (Fig. 6). This
chapter focuses on the major complications of stent migration and
vascular and aerodigestive erosions.
Late Complications
(>2weeks), 15%–37%
Migration
Stent fracture
Obstruction/tumor ingrowth
Erosion
Airway erosion/compression
Vascular erosion
Tissue Erosion
Stent erosion into neighboring mediastinal structures such as the
big vessels and airway is rare but highly lethal when it occurs. Tissue
necrosis resulting from high radial pressure exerted on the esophageal wall is often compounded by poor tissue perfusion and impaired
wound healing secondary to malnutrition or radiation exposure.
Some studies have shown that a history of radiation to the chest or
mediastinum increases the risk of tissue erosion from ES. Similarly,
dual stenting of the esophagus and trachea is also associated with an
increased risk of tissue erosion.
Vascular Erosion
Vascular erosion is rare but highly lethal. Although aortoesophageal
fistula is perhaps the most common, vascular erosion involving the
retroesophageal subclavian and common carotid arteries have been
reported. One must always have a high degree of suspicion as to its
possibility. For example, an abrupt sentinel hematemesis associated
with retrosternal chest pain in a patient with a history of esophageal
stent placement should prompt immediate evaluation and intervention before a potential catastrophic exsanguination. Emergent management of an aortoesophageal fistula involves prompt control of
the potentially fatal hemorrhage, followed by timely vascular repair
(Fig. 7). Concurrent activation of the massive transfusion protocol
and airway protection may be necessary. In such an emergent setting,
endoscopic balloons can often be used to control the bleed, and some
surgeons have even successfully used Sengstaken-Blakemore tubes
for this purpose. Temporary intravascular occlusion and emergent
surgery are also options. Once control is obtained, it can be followed
with endovascular repair of the aortic defect. After the patient is
stabilized, attention can then be turned to the esophageal defect.
After removal of the offending stent, a small defect may be primarily repaired with muscle interposition. An esophagectomy may be
necessary for larger defects. Alternatively, in moribund patients, a
conservative approach involving diversion of esophageal contents
and palliative care may be more appropriate.
ESOPHAGUS
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71
A
C
B
FIG. 6 (A) Endoscopic view of a fractured self-expanding metal stent
(SEMS) with associated ingrowth of esophageal mucosa. (B) Interval
placement of an SEMS within the lumen of the preexisting, fractured
SEMS to facilitate removal. (C) Successful extraction of both fractured
SEMS (top) and intact SEMS (bottom).
FIG. 7 Thoracic endovascular aortic repair of aortic defect after an aortoesophageal fistula. (A) Circled area shows contrast medium leaking from the
aortic defect. (B) Arch aortogram showing the endovascular stent graft. (From Liang H, Chen C, Liu W, Yu F. Definitive treatment for aortoesophageal fistula by
endovascular stent graft. Indian J Surg. 2016;78:151–154.)
72 USE OF ESOPHAGEAL STENTS
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Aerodigestive Erosion
Tracheoesophageal erosions have been reported in 4% to 8% of
patients after ES (see Fig. 4). Unlike the dramatic presentation seen
with vascular erosion, patients often present with nonspecific symptoms such as dyspnea and frequent pulmonary infections. Although a
chest CT scan may help identify the lesion of interest, bronchoscopic
and endoscopic evaluations are often necessary to characterize the
extent and size of the defect. The management of tracheoesophageal
fistulas depends on the patient’s hemodynamic status and on the
underlying pathology that led to esophageal stricture. In a patient
who presents in extremis, securing the airway must be the priority.
One should maintain spontaneous ventilation if possible, but the
patient should be promptly intubated if there is an inability to ventilate. A variety of intubation methods can be used if ventilation is
difficult including contralateral mainstem intubation, use of a double
FIG. 8 Endoscopic view of an esophageal clip that stabilizes the proximal
aspect of an esophageal stent.
FIG. 9 Endoscopic view of the Apollo Overstitch device used for suture
fixation of the proximal aspect of an esophageal stent to the esophageal
mucosa.
FIG. 10 Comparison of the Apollo Overstitch device appearance at the distal end of the dual channel endoscope (left) and the Apollo Overstitch Sx device
appearance at the distal end of the single channel endoscope (right).
ESOPHAGUS
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73
lumen tube, employing a bronchial blocker, or sedating the patient to
ventilate. In some cases, tracheal stenting and esophageal diversion
may be needed, and definitive management may be delayed. Stable
patients with good functional status and with good esophageal tissue
integrity can undergo either a primary repair with muscle interposition or an esophagectomy. Otherwise, tracheal stenting, esophageal
diversion, and palliative care should be considered.
Stent Migration
Stent migration is perhaps the most common complication of esophageal stricture, occurring in 11% to 33% of cases. Over the past 2
decades, various interventions aimed at reducing the frequency of
migrations, such as anchoring the stent to the esophageal wall, have
Axios
(Boston Scientific,
Natick, MA, United
States)
Spaxus
(Taewoong
Medical, Gimposi,
South Korea)
Nagi
(Taewoong
Medical, Gimposi,
South Korea)
been introduced. Endoclips are used to secure the proximal stent
end to the esophageal wall, but a high migration rate persists (Fig. 8).
Endoscopic suturing using Apollo OverStitch and Apollo OverStitch
Sx devices (Figs. 9 and 10) has also shown some benefit in small studies; however, high-quality evidence is not available. More recently,
a specialized over-the-scope clip (OTSC) has become available for
stent fixation with promising results. Small studies indicate reduced
migration rates that, however, still exceed 15%. Additionally, off-label use of lumen-apposing metal stent (LAMS) has been studied for
management of short-segment benign gastrointestinal strictures.
Their unique dumbbell-shaped design helps to fix the stent in place
(Fig. 11). LAMS is an alternative to traditional options; however, data
are limited and future studies are needed to measure their efficacy.
The best treatment of migration is probably prevention. A study
Aixstent
(Leufen Medical,
Berlin, Germany)
Hanarostent Plumber
(M.I Tech, Pyeongtaek-si,
South Korea)
Stents
Availability in
United States
Flange diameter
(mm)
Length (mm)
Lumen diameter
(mm)
Delivery catheter
(Fr)
Material
Deployment
through-the-scope
Delivery in single
step
FIG. 11 List of currently available LAMS with representative images. From Sharma P, McCarty TR, Chhoda A, et al. Alternative uses of lumen apposing metal stents.
World J Gastroenterol. 2020;26(21):2715–2728.
Yes
21, 24, 29
10
10, 15, 20
10.8
Silicone-covered
Nitinol-braided stent
Yes
Yes
No
23, 25, 31
20
8, 10, 16
10
Silicone-covered
Nitinol-stent
Yes
No
No
20, 25, 31
10, 20, 30
10, 12, 14, 16
9, 10
Silicone-covered
Nitinol-stent
Yes
No
No
25
30
10, 15
10
Silicone-covered
Nitinol-stent
Yes
No
No
22 to 28
10, 30
10, 12, 14, 16
10.5
Silicone-covered
Nitinol-stent
Yes
No
74 MANAGEMENT OF ESOPHAGEAL PERFORATION
S u g g e S t e d R e a d i n g S
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TABLE 5 Rates of Complication Based on Stent Indwelling Time in the Management of Esophageal Leaks
and Perforations
Anastomotic Leak Perforation
<2 Weeks >2 Weeks P Value <4 Weeks >4 Weeks P Value
Number 29 16 96 21
Migration 4 (14%) 7 (44%) 0.04 9 (9%) 9 (43%) 0.0007
Dysphagia 5 (17%) 8 (50%) 0.04 4 (4%) 6 (29%) 0.0022
Hemorrhage 0 1 (6%) 0.4 0 2 (10%) 0.03
Stent fracture 3 (10%) 6 (38%) 0.05 5 (5%) 7 (33%) 0.001
Airway
compromise
Data from Freeman RK, Ascioti AJ, Dake M, Mahidhara RS. An assessment of the optimal time for removal of esophageal stents used in the treatment of an
esophageal anastomotic leak or perforation. Ann Thorac Surg. 2015;100:422–428.
1 (3%) 2 (13%) 0.3 3 (3%) 2 (10%) 0.2
by Freeman et al. evaluating the impact of stent indwelling time
in 162 patients treated with ES showed a significant reduction in
stent-related complications in patients who had a shorter indwelling
time (Table 5). In patients with anastomotic leaks, a 30% (P
reduction in stent migration rates was noted with a stent duration
of fewer than 14 days. Patients with acute perforation experienced
a 34% reduction in stent migration when the indwelling time was
fewer than 28 days.
= 0.04)
CONCLUSION
ES remains a mainstay in the palliation of advanced malignant
strictures. Although its indications have greatly expanded to include
various benign esophageal diseases, complications associated with
this procedure mandate thorough preprocedural evaluation of the
patients as well as an individualized therapeutic approach.
Management of
Esophageal Perforation
Juan A. Muñoz-Largacha, MD, and James M. Donahue, MD
INTRODUCTION
Despite advances in diagnostic imaging and early recognition,
esophageal perforation continues to be a life-threatening condition
with high morbidity and mortality rates. Reported mortality ranges
between 10% and 25% when diagnosis and treatment are initiated
within 24 hours and can be as high as 40% to 60% when diagnosis
and treatment are delayed. Other patient-related factors such as
comorbidities, functional condition, presence of sepsis and multiorgan failure, and location and cause of perforation can also influence
mortality in this group of patients.
Anderson M, Sippey M. Endoscopic stent placement: indications and success
rates. Annals of Laparoscopic and Endoscopic Surgery. 2019;4:55.
Jacobson BC, Hirota W, Baron TH, Leighton JA, Faigel DO. The role of
endoscopy in the assessment and treatment of esophageal cancer.
Standards of Practice Committee. American Society for Gastrointestinal
Endoscopy. Gastrointest Endosc. 2003;57(7):817.
Kim KY, Tsauo J, Song H-Y, Kim PH, Park J-H. Self-expandable metallic
stent placement for the palliation of esophageal cancer. J Korean Med Sci.
2017;32:1062–1071.
Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. A controlled trial of
an expansile metal stent for palliation of esophageal obstruction due to
inoperable cancer. N Engl J Med. 1993;329:1302–1307.
Sharma P, Kozarek R. Role of esophageal stents in benign and malig-
nant diseases. Practice Parameters Committee of American College of
Gastroenterology. Am J Gastroenterol. 2010;105(2):258.
Vermeulen BD, Siersema PD. Esophageal stenting in clinical practice: an
overview. Curr Treat Options Gastroenterol. 2018;16:260–273.
Iatrogenic injuries resulting from endoscopic procedures (diagnostic, biopsy, dilation, sclerotherapy, laser therapy, photodynamic
therapy, stent placement, transesophageal echocardiogram, esophageal ultrasound) are the most common cause of esophageal perforation, accounting for 60% to 70% of cases. Spontaneous rupture, or
Boerhaave’s esophagus, is the second most common cause of esophageal perforation (15%–30%). Other, less frequent causes include
trauma (penetrating or blunt), foreign body or caustic ingestion, cervical, nonesophageal surgery (thyroidectomy, mediastinoscopy, spine
surgery), and malignancy of the esophagus, lung, or other mediastinal
structures. Esophageal perforation has also been described in association with infectious processes in immunocompromised patients
(candida, herpes, syphilis, and tuberculosis), in the setting of severe
gastroesophageal reflux, and following Mallory-Weiss tears (Table 1).
DIAGNOSIS
A prompt diagnosis of esophageal perforation is crucial to improve
outcomes and survival, and a high level of suspicion should be
TABLE 1 Causes of Esophageal Perforation
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Iatrogenic Endoscopic procedures (diagnostic, biopsy,
dilation, stent placement)
Transesophageal echocardiography
Esophageal ultrasonography
Spontaneous Barogenic-Boerhaave syndrome
Traumatic Blunt
Penetrating
Surgical intervention: cervical intervention or
mediastinal surgery (i.e., thyroidectomy)
Ingestion Caustic
Foreign body
Neoplastic Primary esophageal malignancy
Mediastinal malignancy with esophageal
involvement and erosion
Infectious Candida, herpes, syphilis, tuberculosis
ESOPHAGUS
FIG. 1 Esophagram with water-soluble contrast. Evidence of esophageal
perforation and contrast extravasation in the right posterolateral aspect of
the mid-esophagus (red arrows).
75
maintained to achieve this goal. A detailed history and physical
examination are of utmost importance and will help determine the
most likely cause of perforation. Commonly, patients will report
recent esophageal instrumentation or forceful vomiting. Initial complaints often involve a vague description of pain localized to the neck,
chest, shoulder, or epigastrium. As the process progresses, patients
may experience dyspnea, dysphagia, or odynophagia. On physical
examination, patients may remain hemodynamically stable or present with signs of septic shock or mediastinitis such as tachycardia
or hypotension. Laboratory values generally reveal a leukocytosis.
Commonly, a chest x-ray is performed as part of the initial assessment of these patients, which may reveal presence of pneumomediastinum, pleural effusion, pneumothorax, subcutaneous emphysema,
or an abnormal cardiomediastinal contour. When esophageal perforation is on the differential diagnosis, further imaging studies such as
contrast esophagram and computed tomography (CT) are performed
for better evaluation of the extent of the injury, location, and degree
of mediastinal and pleural contamination.
Esophagram
An esophagram is a noninvasive diagnostic tool that can help determine the presence and location of a perforation. Either water-soluble
contrast (Gastrografin) or diluted barium can be used. Gastrografin
is generally preferred over barium because of the lower risk of mediastinitis. However, the sensitivity of Gastrografin has been reported
between 60% and 70%, so negative results do not completely exclude
perforation, especially in the cervical esophagus, because of the rapid
transit of the contrast. In addition, barium has been shown to have
better resolution for differentiating between contained and noncontained perforations. In practice, a Gastrografin esophagram is often
obtained first, and if inconclusive, repeat images with diluted barium
can be obtained as necessary for improved sensitivity and specificity.
If Gastrografin demonstrates free perforation into the pleural space
or abdominal cavity, the procedure is terminated. Figure 1 shows
evidence of esophageal perforation on a Gastrografin esophagram.
Computed Tomography
CT is readily available and provides important supportive information
related to an esophageal perforation, such as differentiating between a
contained versus noncontained perforation. A contained perforation
is characterized by no or minimal extravasation of contrast at the site
of perforation without evidence of pleural or peritoneal contamination, or by contrast drainage back into the esophagus. In addition, CT
allows for evaluation of the location of injury as well as the severity of
mediastinal, pleural, or peritoneal contamination if present. Figure 2
shows evidence of esophageal perforation on chest CT.
Computed Tomography Esophagography
CT esophagography is a more recently available option with the
potential to improve workflow and expedite the diagnosis of esophageal perforations by reducing the need for two radiologic examinations. Multiple reports over the past decade have shown its utility for
the evaluation of postoperative leaks after esophagectomy; however,
its use in the setting of acute esophageal perforations must be clarified. This technique is generally readily available, is less cumbersome
for the patient, and does not require a fluoroscopy suite, an additional technician, and a supervising radiologist. One of the main limitations of a fluoroscopic esophagram is that critically ill patients may
not be able to swallow the contrast or stand and change positions,
which are requisite parts of the examination. In CT esophagography,
noncontrast images are obtained first. For patients who cannot swallow, this allows for repositioning of a nasogastric tube (NGT) into
the proximal esophagus to allow for contrast administration. These
precontrast images are also useful to identify any radiopaque structures (i.e., staples, calcifications) that could be confounded with the
contrast in subsequent images. Then, oral contrast is either ingested
or administered via the NGT, and supine images are obtained. The
reported sensitivity and specificity of this technique are comparable to those for fluoroscopic esophagography, with an equal, if not
superior, accuracy for the diagnosis of acute esophageal perforations.
In practice, a fluoroscopic esophagram is often obtained following a
negative CT esophagram before enteral nutrition is implemented.
Endoscopy
Endoscopy is another helpful diagnostic and potentially therapeutic
tool for management of esophageal perforations. Its use should be
considered in patients with high suspicion for perforation who could
not undergo a swallow examination or underwent a nondiagnostic
study. It allows for direct visualization and careful inspection of
mucosal integrity and viability as well as characterization of the
76 MANAGEMENT OF ESOPHAGEAL PERFORATION
AB
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FIG. 2 Chest CT with contrast. (A) Patient with spontaneous distal esophageal perforation with pneumomediastinum and periesophageal fluid with con-
trast extravasation (red arrow) and bilateral small pleural effusions (asterisks). (B) Large periesophageal fluid collection (red arrow) with associated pneumo-
mediastinum and small right pleural effusion (asterisk).
anatomic location of the injury and identification of other pathologic
changes or underlying diseases of the esophagus such as strictures or
neoplasms. Careful inspection with minimal air insufflation should
be performed because this could potentially increase the size of the
perforation or cause a tension pneumothorax through a free perforation into the pleural space. As discussed later, endoscopy can also be
used for therapeutic purposes, as a stent may be placed in the same
setting as the diagnostic procedure.
Assessing Severity of Illness and Prognosis
Several illness severity scoring systems, such as the APACHE system, have been applied to patients with esophageal perforation with
various degrees of accuracy. The Pittsburgh Severity Score (PSS)
is a scoring system specially devised for esophageal perforation
patients that was first described by Abbas et al. in 2009. The authors
attempted to identify clinical factors that could predict survival and
potentially identify those patients amenable to nonoperative management. The score includes 10 clinical variables that were considered by the authors to be potentially important indicators of injury
severity and patient outcomes, which are assigned a value from 1 to 3
(Table 2). In their report, all survivors had PSS ≤3.3, and all patients
who died had a PSS ≥6.5. Lower PSS scores were also associated
with successful nonoperative management, shorter length of stay,
and decreased morbidity. Similar findings have been found in other,
independent cohorts. The PSS is a useful tool in terms of estimating
prognosis for patients with esophageal perforation, but its validation
with the use of prospective studies and potential improvement with
more rigorous analysis of clinical data are still needed to definitively
guide management.
MANAGEMENT
after appropriate diagnostic workup can be determined by clinical
and imaging characteristics. In a select group of patients with contained perforations, a nonoperative approach may be appropriate.
For patients with free perforations, operative management with open
primary repair of the perforation has been the traditionally preferred
approach, particularly when the repair can be undertaken within 24
hours of the perforation. Recent evidence has shown that a less invasive approach consisting of endoscopic stenting and thoracoscopic
mediastinal and pleural drainage produces encouraging results. In
TABLE 2 Pittsburgh Severity Score
Variables Points Assigned
• Age>75years
1
• Tachycardia(>100bpm)
• Leukocytosis(>10.000WBC/mL)
• Pleuraleffusiononimaging*
• Fever(>38.5°C)
• Noncontainedperforation
†
2
• Respiratorydistress(>O2 require-
ments, RR >30, need for mechanical
ventilation)
• Timetodiagnosis>24hours
• Hypotension
3
• Malignancy
*Chest x-ray, esophagram, or chest CT.
†
Esophagram or chest CT.
bpm, Beats per minute; RR, respiratory rate; WBC, white blood cells.
the most dire situations, esophageal resection and exclusion may
be necessary. Regardless of the therapeutic approach chosen, initial
management of patients with esophageal perforation should include
close monitoring in a surgical critical care unit. Patients should be
maintained nil per os (NPO), appropriately resuscitated with intravenous fluid, and started on broad-spectrum antibiotics to include
fungal coverage. Adequate intravenous analgesia and a proton pump
inhibitor (PPI) should be started, and early total parenteral nutritional support can be considered if a prolonged course is expected.
Nonoperative Management
Criteria for nonoperative management were initially described by
Cameron et al. in 1979 and further modified by Altorjay. These
included early diagnosis, contained perforations or perforations
draining back into the esophagus, no significant mediastinal contamination, absence of sepsis or multiorgan failure, and perforation
not associated with malignancy or obstruction of the esophagus. If
ESOPHAGUS
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77
hemodynamically stable without signs of sepsis or multiorgan failure, the patient is admitted to the surgical critical care unit for 48 to
72 hours of observation. Patients should be maintained NPO with
the head of the bed elevated, started on 72 hours of broad-spectrum
antibiotics and a PPI, and, dependent on premorbid nutritional status, considered for parenteral nutritional support. Repeat imaging is
obtained in 72 to 96 hours. If this demonstrates no evidence of free
perforation, a liquid diet may be initiated. It is important to remember that these patients require close observation to ensure that they
continue to meet nonoperative criteria. Should the patient’s clinical
condition deteriorate as evidenced by the development of fever, leukocytosis, tachypnea, tachycardia, or mental status changes, repeat
imaging and possible endoscopy are indicated.
Endoscopic Stenting with Thoracoscopic Mediastinal
and Pleural Drainage
For patients with evidence of free contrast extravasation into the
mediastinum, endoscopic covered stent placement or endoluminal
clipping to attempt to seal the perforation can be performed as an
alternative to open surgical repair. It is vital to remember that this
approach does not address the associated mediastinal and possible
pleural contamination. For this reason, early video-assisted thoracoscopic surgery (VATS), performed either immediately after stent
placement or within 1 to 2 days following the procedure, is generally
required for debridement and drainage of the mediastinum and
pleural cavity. At the conclusion of the VATS procedure, depending
on the degree of contamination, at least one chest tube is left in the
pleural space, and another (often a Blake drain) is left adjacent to the
esophagus. Typically, a contrast esophagram is performed 48 hours
after stent placement to determine if sealing of the esophageal perforation has occurred. If there is no evidence of extravasation, a clear
liquid diet can be started and advanced to full liquids. It is advisable
to leave the tube in place adjacent to the esophagus while the liquid
diet is being initiated to monitor the character of the output as well as
the patient’s clinical condition. On the other hand, if the esophagram
shows extravasation of contrast around the stent into the mediastinum or the drainage character changes after liquids are begun, the
patient should be returned to NPO status and will require placement
of a jejunostomy tube.
In their study, Ben-David et al. showed encouraging results in 76
patients with esophageal perforation (majority iatrogenic or spontaneous) managed with endoscopically placed metallic covered stents
in addition to laparoscopic or VATS drainage and enteral feeding
access placement. All patients were treated within 24 hours of initial
presentation, and perforation occlusion was confirmed within 48
hours after stent placement in 68 patients (89.5%). Additionally, no
need for an open esophageal procedure was required, avoiding the
morbidity of a more invasive operation. However, stent placement
was not without complications, with an almost 40% migration rate
requiring additional intervention within the first week of placement.
The ideal time for esophageal stent removal remains controversial
and may depend on the size of the perforation. Some studies have
shown adequate healing within 10 days for small perforations, while
this process may take up to 8 weeks for larger defects. Ben-David et
al. showed a mean length of 36 days from initial placement to final
stent removal. In practice, waiting between 4 and 6 weeks, depending
on the size of the perforation, is reasonable. Imaging confirmation of
perforation healing with an esophagram should be obtained following stent removal before a liquid diet is initiated. If the perforation
has not healed at the time of stent removal, the stent can be replaced
for another 4 to 6 weeks.
Endoscopic Techniques
The use of endoluminal stents for the management of esophageal
perforations is not a new concept, and in fact the most used self-expanding metal stents (SEMS) have been available since the 1990s.
Technology improvement with better deployment mechanisms have
also increased their use. The development of covered stents with different polymers has increased the technical and clinical success of the
management of esophageal perforations and, at the same time, has
decreased the rate of stent-related complications. Esophagogastroduodenoscopy (EGD) is performed to localize the defect, determine
the extent of the perforation, and identify anatomic landmarks and
other esophageal abnormalities. Under direct vision and with the
concomitant use of fluoroscopy, a careful assessment of the landing
zones and the desired diameter and length of the stent is conducted.
Once this assessment is completed, the landmarks for the proximal
and distal extent of the stent are marked with radio-opaque markers
under fluoroscopy. A guidewire is then introduced under fluoroscopy. Figure 3 shows an endoscopic view of a perforation and subse-
quent stent placement. Ideally, the stent deployment will successfully
cover the perforation on the first attempt, however the stent can be
endoscopically repositioned to achieve complete coverage of perforation if needed. If there is evidence of incomplete radial deployment,
a balloon dilation may be performed to attain complete contact
between the stent and esophageal mucosa. An NGT can be placed
under direct vision for gastric decompression in the acute setting. An
anteroposterior and lateral chest x-ray should be obtained after stent
placement to have a baseline for its location and facilitate further
assessment of adequate positioning. As noted, a contrast esophagram
should be obtained 48 hours after stent placement before liquids are
begun. Figure 4 shows a SEMS in adequate position without evidence
of contrast extravasation.
Stent complications include migration, bleeding, erosion, and tissue overgrowth, among others. Migration is the most common complication reported in about 8% to 40% of cases, with less migration
rates reported with the use of metallic stents compared with plastic
stents. Some studies have reported endoscopic suturing or clipping to
secure the stent and prevent migration with favorable results.
Endoscopic suturing or clip placement may also be used to
attempt to primarily repair small, early perforations. Previous reports
demonstrate higher rates of closure, with an average defect size of 8
mm and higher failure rates when the lesion is greater than 13 mm.
EGD is performed, and the esophageal defect is identified to confirm
healthy mucosal edges for adequate clip placement. Through-thescope clips can be used for defects less than 1 cm, and an over-thescope clip system can be used for larger lesions. Suction can be used
to help approximate the lesion edges and aid with better clip deployment. Even though acceptable results have been reported in the
literature, this technique is not commonly used given that patients
usually present with a more advanced disease process requiring more
aggressive interventions.
Open Repair
Currently, little data exist to guide surgeons as to whether to proceed with an open repair or choose stent placement with pleural/
mediastinal drainage. Elderly patients and those with multiple
medical comorbidities are likely better served with the endoscopic/
thoracoscopic approach. Although the likelihood of success of an
open repair diminishes over 24 hours from the perforation event,
several reports describe successful repairs being performed for
perforations beyond the 24-hour mark. Following initial resuscitation efforts, patients who remain hemodynamically labile may
still undergo successful repair, although a less invasive approach
has obvious advantages in these patients. Ultimately, the decision
is left to surgeon judgment and experience of the surgeon and his
or her team with each approach. If open repair is chosen, it is critical to identify the location of the perforation to guide the surgical
approach. This may require performance of endoscopy in the operating room before incision. Whenever feasible, two-layer closure
should be performed and reinforced with a pedicled buttress. In
cases of delayed perforation, single-layer closure may be all that is
possible.
78 MANAGEMENT OF ESOPHAGEAL PERFORATION
AB
https://t.me/medicina_free
A B
FIG. 3 Endoscopic treatment of esophageal perforation. (A) Endoscopic view of a perforation in the middle third of the esophagus (arrow). (B) Endoscopic
view of the stent in place. (From Chirica M, Champault A, Dray X, etal. Esophageal perforations. J Visc Surg. 2010;147[3]:e117–e128.)
FIG. 4 Esophagram. (A) Esophageal stent in adequate position covering a
prior perforation. (B) Stent in place without evidence of contrast extravasation.
Thoracic Perforations
Perforations of the upper and middle thirds of the esophagus are
best approached through a right posterolateral thoracotomy via
the fourth or fifth intercostal space. The intercostal muscle (ICM)
within the interspace is harvested at this time using electrocautery
to ultimately buttress the repair. The cautery tip is positioned near
parallel with the surface of the superior rib to avoid injury to the
neurovascular bundle. The ICM is freed from the rib to the level of
the lumbar-dorsal fascia. Care must be taken to identify this landmark because further dissection risks injury to the intercostal vessels.
The ICM flap is transected anteriorly after ligating or clipping the
anterior aspect of the muscle to prevent bleeding. Next, the pleura is
opened in the area of the perforation, and the esophagus is dissected
enough to obtain clear visualization of the perforation. The edges of
the perforation should be debrided to determine the full extent of
the injury. Of note, the mucosal injury may extend a greater distance
than the visualized muscular injury. The esophageal mucosa is closed
with running or interrupted absorbable suture (4-0 Vicryl or PDS),
and the muscularis is closed with interrupted 3-0 silk sutures. The
pleural side of the ICM flap is then placed in contact with the repair
and secured to the muscle layer of the esophagus with multiple interrupted silk sutures. Pleural and mediastinal drainage tubes are placed
at the conclusion of the operation.
Perforations of the lower third of the esophagus should be
approached through a left posterolateral thoracotomy in the seventh
or eighth intercostal space. Although an ICM flap is generally used as
a buttress, a diaphragmatic flap is also an option. A posteriorly based
full-thickness diaphragmatic flap of adequate length and width can
be mobilized to reach the area of primary repair. The flap is secured
to the esophageal muscle with interrupted silk sutures to cover the
repair. The diaphragm then is closed primarily with nonabsorbable
suture. Advantages of diaphragmatic flap use include its, thickness,
ease, and extent of mobility.
Cervical Perforations
The preferred method of exposure for cervical esophageal perforation is a left-sided neck incision along the anterior border of the
sternocleidomastoid muscle (SCM). It may be necessary to ligate the
middle thyroid vein for improved exposure. The trachea and thyroid
gland are retracted medially for exposure of the esophagus (Fig. 5).
The retroesophageal space is entered bluntly along the prevertebral
fascia, with care taken to preserve the recurrent laryngeal nerve.
Blunt dissection should be continued down to the posterior mediastinum to drain all fluid collections. If the perforation is identified, the
defect is repaired primarily as described earlier. A strap muscle can
be used to buttress the repair. If the defect is not clearly identified,
closed drainage of the area is performed.
Abdominal Perforations
Patients with abdominal esophageal perforation and uncontained
leak should be taken to the operating room for primary repair.
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