Esophageal Perforation: A Therapeutic Challenge Safuh Attar, MD, John R. Hankins, MD, Charles M. Suter, PhD, Thomas R. Coughlin, MD, Alex Sequeira, MD, and Joseph S. McLaughlin, MD Division of Thoracic and Cardiovascular Surgery, - . Department of Surgery, University of Maryland Medical School and Hospital, Baltimore, Maryland
The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%)were due to injury from intraluminal causes. Twenty (31%)resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%)were spontaneous perforations, and two (3%)were caused by perforation of an esophageal malignancy. Ten (91%)of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%)of 8 patients treated more than 24 hours after injury; hence 16 (84%)of the 19 patients in the cervical
E
sophageal perforations continue to carry a serious prognosis because of the associated high rate of morbidity and mortality [l].The unique anatomical configuration of the esophagus, that is, lacking a serosal layer and being surrounded by loose areolar tissue, allows bacteria and digestive enzymes easy access to the mediastinum, and this leads to the development of severe mediastinitis, empyema, sepsis, and ultimately multipleorgan failure. The treatment of esophageal perforations has evolved over the past 30 years, and substantial improvements in the results are due to the use of hyperalimentation, antibiotics, and better postoperative care (21.Nevertheless, the management of delayed or missed perforations remains controversial. We review here our experience with esophageal perforation since 1958.
Material and Methods Clussificution Esophageal perforations constitute such a heterogeneous group of injuries that some form of unifying -classification is indicated. Perforations of the esophagus are classified in Table 1 according to cause, as the latter affects the clinical symptomatology, therapy, and prognosis. This is a modification of the classification of Seiler and Brooks [ 3 ] . Injuries from intraluminal agents are by far the most common and are listed first. Spontaneous perforations and perforations occurring on the basis of preexisting Presented at the Thirty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdele, AZ, Nov 9-11, 1989. Address reprint requests to Dr Attar, University of Maryland Hospital, 22 S Greene St, Baltimore, MD 21201.
0 1990 by The Society of Thoracic Surgeons
group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%);hence 28 (64%)of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%)lived. Total esophagectomy was performed in 9 patients, 7 (78%)of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%)survived. (Ann Tliorac Surg 1990;50:45-51)
disease are listed separately because of the complex problems they present in diagnosis and treatment.
Patient Population The hospital records of 64 patients treated for esophageal perforation at the University of Maryland Hospital between 1958 and mid-1989 were reviewed. There were 42 men and 22 women with a median age of 47.5 years. The cause of the perforations is shown in Table 1. The largest number of patients, 31 patients or 48%, had perforations due to intraluminal causes (group A). The instrumentation-associated injuries resulted from endoscopy in 13 patients, dilation of strictures in 9, and attempted tracheal intubation in 2. Two perforations were caused by foreign bodies; 2, balloon dilation for achalasia; and 3, ingestion of caustic material. The second largest group, 20 patients or 31%, had injury due to extraluminal causes (group B). Most of these patients (11) had penetrating wounds (ten gunshot wounds and one stab wound). In 3, the perforation resulted from blunt trauma (after a fall in 2 and a motorcycle accident in 1) and in 6, after a thoracic surgical procedure (hiatus hernia repair, 4; Zenker’s diverticulum, 1; and ligation of esophageal varices, 1). Group C comprised 11 patients (17%) with perforation due to Boerhaave’s syndrome and group D, 2 patients (3%)with perforation caused by squamous cell carcinoma of the middle third of the esophagus. Nineteen perforations involved the cervical esophagus, 44 the thoracic esophagus, and one the abdominal esophagus. The last was caused by a fall from a bicycle. Underlying esophageal disease was documented in 28 patients (44%).Underlying esophageal diseases that were associated with but did not cause the perforation included 0003-4975/90/$3.50
46
ATTARETAL ESOPHAGEAL PERFORATION
A n n Thorac Surg 1990;50:4551
Table 1. Classification According to Cause of Perforation
Cause Injury from intraluminal causes Instrumentation Endoscopy Dilation Intubation Sclerotherapy Foreign body Pneumatic injury Caustic ingestion B. Injury from extraluminal causes Penetrating wound Blunt trauma Operative injury C. Spontaneous perforation D. Perforations associated with preexisting esophageal disease Tumor Esophagitis
A.
No. of Patients (n = 64)
% ’
31
48
24
13 9 2
0 2 2 3 20 11
31
3
6 11 2
17 3
2 0
malignancy (5 patients), esophageal stricture (12), hiatus hernia (4), motility disorders ( 5 ) , esophageal varices (1 patient), and compression by lymph nodes involved with Hodgkin’s disease (1). The clinical diagnosis of perforation was confirmed by contrast study with Gastrografin (diatrizoate meglumine and diatrizoate sodium) initially. When extravasation of contrast medium was not demonstrated by Gastrografin swallow, in the presence of a clinical situation highly suggestive of perforation, diluted barium was used. The perforation was missed in 5 patients (8%) in this series using Gastrografin alone. Esophagoscopy was performed mostly in patients with perforation due to traumatic injury and in patients who were suspected of having a perforation but in whom one could not be demonstrated by contrast study.
Treatment The selection of the operative procedure is dependent on the clinical condition of the patient after the esophageal perforation. This in turn is dependent on the time interval elapsed between the onset of the perforation and therapy, and on the underlying disease. The longer the interval after the perforation, the sicker the patient and the less extensive the procedure used. Based on this presumption, patients who were diagnosed early underwent primary repair of the perforation, whereas patients with a delayed diagnosis underwent a drainage procedure, or a modification thereof, with a less favorable prognosis. Patients whose perforation was caused by an underlying disease, such as malignancy, underwent a more radical surgical procedure. Sixty-two patients (97%)were treated surgically. Twen-
ty-eight (45%) of the surgical patients, including all of those with perforation due to extraluminal injury (penetrating, blunt, and associated with thoracic surgical procedure), underwent primary suture closure when the diagnosis was made less than 24 hours after perforation. In 2 patients with achalasia in whom the diagnosis was made soon after balloon dilation, a Heller esophagocardiomyotomy was performed concomitantly with primary closure of the Perforation. Total esophagectomy was performed in 9 patients because of the presence of underlying disease of the esophagus: three perforations were associated with dilation of peptic strictures, three were due to necrosis of the esophagus from caustic ingestion, and three were due to malignancy of the esophagus. Two of the malignancies perforated without manipulation, whereas one perforated during gastroscopy and biopsy of an adenocarcinoma of the cardia of the stomach. Six of the esophagectomies were transthoracic and three, transhiatal. Two total gastrectomies were performed simultaneously with esophagectomy for caustic necrosis of the stomach. Colon interposition was performed in 3 patients 7 weeks to 6 months after esophageal resection. There were five exclusion-diversion operations with a feeding jejunostomy, four in patients with perforations who were treated more than 24 hours after perforation and one in a patient whose perforation was treated within 24 hours because of the friability of the tissues. Three exclusion-diversion operations were performed for spontaneous perforations, one for delayed perforation due to a gunshot wound, and one for accidental perforation of the esophagus during mediastinoscopy for Hodgkin’s disease. Seventeen patients with late perforations underwent drainage procedures: eight cervical and nine thoracicmediastinal. One Thal procedure was performed 2 days after a spontaneous perforation. Two patients were treated nonoperatively because the perforations were contained, and they did not show any signs of sepsis. One was a cervical perforation that was due to a foreign body (a piece of glass) and was diagnosed late, and the other was diagnosed immediately after rigid esophagoscopy with biopsy of a peptic stricture.
Results Because the cervical and thoracic perforations constitute the largest groups of perforations, the characteristics of each group are summarized in Table 2. The two groups appear to be homogeneous with no significant difference in age, sex, cause of perforation, time elapsed between the onset of perforation and therapy, types of operative procedures, and years of therapy. The only significant difference between the two groups is underlying disease, which is more predominant in the thoracic group ( p = 0.049). The survival rate in the cervical perforation group was 16 (84%)of 19 and in the thoracic perforation group, 28 (64%)of 44 patients. No significant difference could be demonstrated between the two groups, presumably because of the small sample size (Table 3; Fig 1).
A'ITARETAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 1990;50:4551
The various risk factors affecting survival are summarized in Table 3 and Figure 1. Statistical analysis was performed using the 2, rank sum, and Fisher's exact test ( t tail) from the Statistical Analysis System. Three factors were found to affect survival: age, cause of perforation, and time interval between perforation and therapy.
Age
The median age of the survivors was 36 years compared with 56 years for the nonsurvivors (p = 0.0127).
Cause of Perforation There was a significant difference in survival between group A (injury from intraluminal causes) and group C (spontaneous perforations) ( p = 0.001) (see Fig 1). This difference is attributed partly to age differences, as the median age of group A was 46 years compared with 59 years in group C ( p = 0.033), and partly to the underlying disease, as group A had 22 patients with underlying disease compared with none in group C ( p = 0.0001). A
Table 2. Characteristics of Cervical and Thoracic Perforation Groups Variable
Cervical (n = 19)
Thoracic (n = 44)
pValue
Rank sum test Age (yr) Mean Median ,$ Test Sex Male Female Etiology group A B C D Time interval 24 h Operation Primary suture Drainage Esophagectomy Exclusion-diversion Thal Nonoperative Underlying disease Present Absent Years of therapy 195f3-1974 19751989
NS 41.5 36
45.6 50
14 5
27 17
NS NS
9 10 0 0
22 9 11 2
NS NS NS NS
11 8
19 25
NS NS
12 6 0 0 0 1
17 11 9 5 1 1
NS NS NA NA NA NS 0.026
5 14
25 19
12 7
16 28
0.049
~
NA = not applicable;
~~
NS = not significant.
47
Table 3. Factors Affecting Survival in Patients With Esophageal Perforation",' Nonsurvivors
Variable
Survivors
Median age (yr) Location Cervical Thoracic Cause Group A Group B Group C Group D A versus C B versus C Time interval 24 h Operation Primary suture Drainage Esophagectomy Exclusion-diversion Underlying disease Present Absent Years of therapy 1958-1974 19751989
36
56
16 (84) 28 (64)
3 16
26 (84) 15 (75)
5 5 8 1
3 (27) 1 (50)
p Value 0.0127 NS
0.001 0.014 0.004 27 (87) 18 (55)
4 15
25 (83) 10 (59)
5 7 2 4
NS
7 (78) 1(20)
NS 24 21
6 13
19 (68) 7
9 28
NS
Data for location and a Numbers in parentheses are percentages. years of therapy exclude patient with abdominal perforation. NS
=
not significant.
significant difference in survival was also noted between group B (injury from extraluminal causes) and group C (spontaneous perforations) ( p = 0.014). This was partly due to age differences, the median age of group B being 27.5 years compared with 59 years in group C, and partly due to the time interval between the diagnosis of the perforation and therapy. In group B, 13 of 20 patients were treated less than 24 hours after the perforation compared with 8 of 11 patients in group C treated more than 24 hours after perforation ( p = 0.044).
Time Interval Elapsed Between Esophageal Perforation and Therapy There were 31 patients with esophageal perforations treated within 24 hours, with 27 survivors (87%), compared with 33 patients treated more than 24 hours after perforation, with 18 survivors (55%).Statisticalanalysis of the two groups demonstrated a highly significant effect of the time interval elapsed between perforation and therapy ( p = 0.004). Survival in the group treated more than 24 hours after perforation was significantly worse.
48
ATTARETAL ESOPHAGEAL PERFORATION
Fig I. Si
The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%)were due to injury from intraluminal causes. Twenty (31%)resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%)were spontaneous perforations, and two (3%)were caused by perforation of an esophageal malignancy. Ten (91%)of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%)of 8 patients treated more than 24 hours after injury; hence 16 (84%)of the 19 patients in the cervical
E
sophageal perforations continue to carry a serious prognosis because of the associated high rate of morbidity and mortality [l].The unique anatomical configuration of the esophagus, that is, lacking a serosal layer and being surrounded by loose areolar tissue, allows bacteria and digestive enzymes easy access to the mediastinum, and this leads to the development of severe mediastinitis, empyema, sepsis, and ultimately multipleorgan failure. The treatment of esophageal perforations has evolved over the past 30 years, and substantial improvements in the results are due to the use of hyperalimentation, antibiotics, and better postoperative care (21.Nevertheless, the management of delayed or missed perforations remains controversial. We review here our experience with esophageal perforation since 1958.
Material and Methods Clussificution Esophageal perforations constitute such a heterogeneous group of injuries that some form of unifying -classification is indicated. Perforations of the esophagus are classified in Table 1 according to cause, as the latter affects the clinical symptomatology, therapy, and prognosis. This is a modification of the classification of Seiler and Brooks [ 3 ] . Injuries from intraluminal agents are by far the most common and are listed first. Spontaneous perforations and perforations occurring on the basis of preexisting Presented at the Thirty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdele, AZ, Nov 9-11, 1989. Address reprint requests to Dr Attar, University of Maryland Hospital, 22 S Greene St, Baltimore, MD 21201.
0 1990 by The Society of Thoracic Surgeons
group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%);hence 28 (64%)of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%)lived. Total esophagectomy was performed in 9 patients, 7 (78%)of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%)survived. (Ann Tliorac Surg 1990;50:45-51)
disease are listed separately because of the complex problems they present in diagnosis and treatment.
Patient Population The hospital records of 64 patients treated for esophageal perforation at the University of Maryland Hospital between 1958 and mid-1989 were reviewed. There were 42 men and 22 women with a median age of 47.5 years. The cause of the perforations is shown in Table 1. The largest number of patients, 31 patients or 48%, had perforations due to intraluminal causes (group A). The instrumentation-associated injuries resulted from endoscopy in 13 patients, dilation of strictures in 9, and attempted tracheal intubation in 2. Two perforations were caused by foreign bodies; 2, balloon dilation for achalasia; and 3, ingestion of caustic material. The second largest group, 20 patients or 31%, had injury due to extraluminal causes (group B). Most of these patients (11) had penetrating wounds (ten gunshot wounds and one stab wound). In 3, the perforation resulted from blunt trauma (after a fall in 2 and a motorcycle accident in 1) and in 6, after a thoracic surgical procedure (hiatus hernia repair, 4; Zenker’s diverticulum, 1; and ligation of esophageal varices, 1). Group C comprised 11 patients (17%) with perforation due to Boerhaave’s syndrome and group D, 2 patients (3%)with perforation caused by squamous cell carcinoma of the middle third of the esophagus. Nineteen perforations involved the cervical esophagus, 44 the thoracic esophagus, and one the abdominal esophagus. The last was caused by a fall from a bicycle. Underlying esophageal disease was documented in 28 patients (44%).Underlying esophageal diseases that were associated with but did not cause the perforation included 0003-4975/90/$3.50
46
ATTARETAL ESOPHAGEAL PERFORATION
A n n Thorac Surg 1990;50:4551
Table 1. Classification According to Cause of Perforation
Cause Injury from intraluminal causes Instrumentation Endoscopy Dilation Intubation Sclerotherapy Foreign body Pneumatic injury Caustic ingestion B. Injury from extraluminal causes Penetrating wound Blunt trauma Operative injury C. Spontaneous perforation D. Perforations associated with preexisting esophageal disease Tumor Esophagitis
A.
No. of Patients (n = 64)
% ’
31
48
24
13 9 2
0 2 2 3 20 11
31
3
6 11 2
17 3
2 0
malignancy (5 patients), esophageal stricture (12), hiatus hernia (4), motility disorders ( 5 ) , esophageal varices (1 patient), and compression by lymph nodes involved with Hodgkin’s disease (1). The clinical diagnosis of perforation was confirmed by contrast study with Gastrografin (diatrizoate meglumine and diatrizoate sodium) initially. When extravasation of contrast medium was not demonstrated by Gastrografin swallow, in the presence of a clinical situation highly suggestive of perforation, diluted barium was used. The perforation was missed in 5 patients (8%) in this series using Gastrografin alone. Esophagoscopy was performed mostly in patients with perforation due to traumatic injury and in patients who were suspected of having a perforation but in whom one could not be demonstrated by contrast study.
Treatment The selection of the operative procedure is dependent on the clinical condition of the patient after the esophageal perforation. This in turn is dependent on the time interval elapsed between the onset of the perforation and therapy, and on the underlying disease. The longer the interval after the perforation, the sicker the patient and the less extensive the procedure used. Based on this presumption, patients who were diagnosed early underwent primary repair of the perforation, whereas patients with a delayed diagnosis underwent a drainage procedure, or a modification thereof, with a less favorable prognosis. Patients whose perforation was caused by an underlying disease, such as malignancy, underwent a more radical surgical procedure. Sixty-two patients (97%)were treated surgically. Twen-
ty-eight (45%) of the surgical patients, including all of those with perforation due to extraluminal injury (penetrating, blunt, and associated with thoracic surgical procedure), underwent primary suture closure when the diagnosis was made less than 24 hours after perforation. In 2 patients with achalasia in whom the diagnosis was made soon after balloon dilation, a Heller esophagocardiomyotomy was performed concomitantly with primary closure of the Perforation. Total esophagectomy was performed in 9 patients because of the presence of underlying disease of the esophagus: three perforations were associated with dilation of peptic strictures, three were due to necrosis of the esophagus from caustic ingestion, and three were due to malignancy of the esophagus. Two of the malignancies perforated without manipulation, whereas one perforated during gastroscopy and biopsy of an adenocarcinoma of the cardia of the stomach. Six of the esophagectomies were transthoracic and three, transhiatal. Two total gastrectomies were performed simultaneously with esophagectomy for caustic necrosis of the stomach. Colon interposition was performed in 3 patients 7 weeks to 6 months after esophageal resection. There were five exclusion-diversion operations with a feeding jejunostomy, four in patients with perforations who were treated more than 24 hours after perforation and one in a patient whose perforation was treated within 24 hours because of the friability of the tissues. Three exclusion-diversion operations were performed for spontaneous perforations, one for delayed perforation due to a gunshot wound, and one for accidental perforation of the esophagus during mediastinoscopy for Hodgkin’s disease. Seventeen patients with late perforations underwent drainage procedures: eight cervical and nine thoracicmediastinal. One Thal procedure was performed 2 days after a spontaneous perforation. Two patients were treated nonoperatively because the perforations were contained, and they did not show any signs of sepsis. One was a cervical perforation that was due to a foreign body (a piece of glass) and was diagnosed late, and the other was diagnosed immediately after rigid esophagoscopy with biopsy of a peptic stricture.
Results Because the cervical and thoracic perforations constitute the largest groups of perforations, the characteristics of each group are summarized in Table 2. The two groups appear to be homogeneous with no significant difference in age, sex, cause of perforation, time elapsed between the onset of perforation and therapy, types of operative procedures, and years of therapy. The only significant difference between the two groups is underlying disease, which is more predominant in the thoracic group ( p = 0.049). The survival rate in the cervical perforation group was 16 (84%)of 19 and in the thoracic perforation group, 28 (64%)of 44 patients. No significant difference could be demonstrated between the two groups, presumably because of the small sample size (Table 3; Fig 1).
A'ITARETAL ESOPHAGEAL PERFORATION
Ann Thorac Surg 1990;50:4551
The various risk factors affecting survival are summarized in Table 3 and Figure 1. Statistical analysis was performed using the 2, rank sum, and Fisher's exact test ( t tail) from the Statistical Analysis System. Three factors were found to affect survival: age, cause of perforation, and time interval between perforation and therapy.
Age
The median age of the survivors was 36 years compared with 56 years for the nonsurvivors (p = 0.0127).
Cause of Perforation There was a significant difference in survival between group A (injury from intraluminal causes) and group C (spontaneous perforations) ( p = 0.001) (see Fig 1). This difference is attributed partly to age differences, as the median age of group A was 46 years compared with 59 years in group C ( p = 0.033), and partly to the underlying disease, as group A had 22 patients with underlying disease compared with none in group C ( p = 0.0001). A
Table 2. Characteristics of Cervical and Thoracic Perforation Groups Variable
Cervical (n = 19)
Thoracic (n = 44)
pValue
Rank sum test Age (yr) Mean Median ,$ Test Sex Male Female Etiology group A B C D Time interval 24 h Operation Primary suture Drainage Esophagectomy Exclusion-diversion Thal Nonoperative Underlying disease Present Absent Years of therapy 195f3-1974 19751989
NS 41.5 36
45.6 50
14 5
27 17
NS NS
9 10 0 0
22 9 11 2
NS NS NS NS
11 8
19 25
NS NS
12 6 0 0 0 1
17 11 9 5 1 1
NS NS NA NA NA NS 0.026
5 14
25 19
12 7
16 28
0.049
~
NA = not applicable;
~~
NS = not significant.
47
Table 3. Factors Affecting Survival in Patients With Esophageal Perforation",' Nonsurvivors
Variable
Survivors
Median age (yr) Location Cervical Thoracic Cause Group A Group B Group C Group D A versus C B versus C Time interval 24 h Operation Primary suture Drainage Esophagectomy Exclusion-diversion Underlying disease Present Absent Years of therapy 1958-1974 19751989
36
56
16 (84) 28 (64)
3 16
26 (84) 15 (75)
5 5 8 1
3 (27) 1 (50)
p Value 0.0127 NS
0.001 0.014 0.004 27 (87) 18 (55)
4 15
25 (83) 10 (59)
5 7 2 4
NS
7 (78) 1(20)
NS 24 21
6 13
19 (68) 7
9 28
NS
Data for location and a Numbers in parentheses are percentages. years of therapy exclude patient with abdominal perforation. NS
=
not significant.
significant difference in survival was also noted between group B (injury from extraluminal causes) and group C (spontaneous perforations) ( p = 0.014). This was partly due to age differences, the median age of group B being 27.5 years compared with 59 years in group C, and partly due to the time interval between the diagnosis of the perforation and therapy. In group B, 13 of 20 patients were treated less than 24 hours after the perforation compared with 8 of 11 patients in group C treated more than 24 hours after perforation ( p = 0.044).
Time Interval Elapsed Between Esophageal Perforation and Therapy There were 31 patients with esophageal perforations treated within 24 hours, with 27 survivors (87%), compared with 33 patients treated more than 24 hours after perforation, with 18 survivors (55%).Statisticalanalysis of the two groups demonstrated a highly significant effect of the time interval elapsed between perforation and therapy ( p = 0.004). Survival in the group treated more than 24 hours after perforation was significantly worse.
48
ATTARETAL ESOPHAGEAL PERFORATION
Fig I. Si
