Eur J Cardio-thorac

Surg (1992) 6:565-567

surgery G Springer-Verlag 1992

Foreign body perforation of the normal oesophagus S.A. M. Nashef, C. Klein, C. Martigne, J.-F. Velly, and L. Couraud Department

of Thoracic Surgery, Xavier Arnozan

Hospital. Pessac. France

Abstract. Over an 1l-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (>48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesphagoscopy. A third of the perforations were cervical, the remainder intrathoracic. AU patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment. [Eur J Cardio-thorat Surg (1992) 6:565-5671 Key words: Oesophageal perforation

~ Foreign body - Surgical repair

When not spontaneous [l], oesophageal perforation is most commonly due to instrumentation either during diagnostic endoscopy or therapeutic dilation of a stricture [13, 14, 171. Perforation due to swallowed foreign bodies is rare, representing only 12% - 25% of the total of three large series [2, 8, 151. We report an 1l-year experience in the management of foreign body oesophageal perforation in 12 patients with no preexisting oesophageal disease.

severity was present in 3 patients: mild mental retardation, vagrancy, and schizophrenia. Surgical treatment was used in all patients: the type of operation depended on the site, extent and duration of the perforation. All patients received enteral or parenteral feeding in the postoperative period. Follow-up endoscopy or contrast oesophagography was performed in all patients at I- 3 months after discharge from hospital.

Patients and methods

Presentation

From 1980 to 1991, 59 perforations of the oesophagus were treated at our institution of which 12 were due to foreign bodies (20%). Patients in whom instrumentation was clearly and directly responsible for the perforation, even in the presence of a foreign body, were excluded from the study. The mean age was 60 years (range 42-73) with equal sex distribution. Impaired psychosocial ability ofvarying

Received for publication: Accepted for publication:

December 10, 1991 March 12, 1992

Table 1. Incidence of presenting features phageal perforation by site in 12 patients

Fever Pain Dysphagia Dyspnoea Haematemesis Loss of denture Shock Cervical abscess

of foreign

body oeso-

Number of patients Cervical

Thoracic

Overall

3 3 4 3

5 5 3

8 8 7 3 1 1 4 3

1 1 4 3

566

Fig. 1. Chest radiograph of a patient presenting late with foreign body perforation of the oesophagus. Note the foreign body (dental plate), pneumomediastinum, right-sided pleural effusion and atelectasis

Fig. 2. Contrast

oesophagography of a patient with a history of painful deglutition: the foreign body had passed into the stomach, but there is extravasation of contrast at two different locations

Results Presentation

The presenting symptoms and signs are summarised in Table 1. Five patients presented within 48 h of foreign body ingestion. The remaining 7 presented late between 4 and 16 days after ingestion (Fig. 1). Perforation was cervical in 4 patients, 3 of whom presented late with a neck abscess. The remaining 8 patients had a perforation of the intrathoracic oesophagus (upper third: 3, middle third: 3, lower third: 2). Three perforations were multifocal (Fig. 2). The causative foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species involved were pigeon, rabbit, veal, pork and fish (1 each). The remaining 2 perforations were due to swallowed dentures. A history of ingestion of the foreign body was given by all but the institutionalised schizophrenic patient in whom the recent disappearance of a dental plate was noted by nursing staff and raised the possibility of foreign body ingestion. The foreign body had passed into the stomach at the time of presentation in 4 patients, was extracted endoscopically in 5 and surgically in 3 patients.

Outcome

There were no operative deaths. At contrast oesophagography 7 days postoperatively, oesophageal integrity had been restored in 7 patients. Four patients (3 with intrathoracic and 1 with cervical perforation) had evidence of a minor residual leak at the suture line which resolved after a further period of enteral or parenteral alimentation. One patient with a cervical perforation (late presentation at 16 days) had a significant leak with recurrent abscess formation requiring reoperation for further drainage. At follow-up esophagoscopy or contrast oesophagography wihin 3 months of hospital discharge, all patients had normal oesophageal luminal and mucosal appearances confirming the absence of chronic oesophageal disease at the time of perforation. Discussion

Operation

Surgical drainage with primary suture repair of the perforation was carried out in 8 patients. In the remaining 4 (3 of whom were late presenters) there was evidence of a partly healed perforation with no residual total breach of the oesophageal wall: they were treated without primary suture by surgical drainage of the resultant abscess which was cervical in 2 patients and mediastinal in 2 patients. Diversion of secretions was achieved by continuous nasooesophageal aspiration in all patients and concomitant gastrostomy in those with an intrathoracic perforation. Postoperative alimentation was by feeding jejunostomy in patients with thoracic perforation and parenteral intravenous nutrition in patients with cervical perforation. All patients received perioperative antibiotic therapy.

None of our patients had pre-existing oesophageal disease and only 3 had psychosocial dysfunction of any type, indicating that foreign body oesophageal perforation remains a hazard, albeit small, of hasty or careless deglutition in healthy adults. In perforation due to foreign bodies, it is difficult to know with certainty the exact time of perforation: this may occur at ingestion or may develop gradually with erosion of an impacted foreign body through the oesophageal wall [IO]. Oesophageal perforation in general is a major lifethreatening surgical emergency requiring immediate treatment. The prognosis of instrumental perforation is generally better than spontaneous perforation [2,6]. This may in part be due to the immediate recognition and, therefore, treatment of the former whereas spontaneous

perforation may present late and evade diagnosis leading to higher mortality [2]. The late presentation in more than half of our patients and the absence of previous oesophageal disease would suggest that foreign body perforation should resemble spontaneous rather than instrumental perforation in its sequelae. It differs, however, in that the site is almost universally the lower third in spontaneous perforation but was roughly equally distributed throughout the oesophagus in our series and was multifocal in a quarter of the patients. That our patients have fared better than is expected in spontaneous perforation may be due to the gradual nature of the perforation: leaks due to slow erosion are more likely to be contained by the local inflammatory reaction which thus limits the spread of sepsis. This is in stark contrast with spontaneous perforation in which the instantaneous transmural breach of the oesophagus in its lower third leads to a corrosive leak of gastric contents and therefore rapidly spreading diffuse mediastinitis. The treatment of oesophageal perforation remains controversial. Good results are claimed both for medical [8, 91 and surgical [ll, 141 management. Medical treatment of perforation is an attractive option in that it avoids major surgical intervention in patients who may be critically ill. Medical therapy is often employed in selected cases of “clean” perforation with early presentation or restricted to perforation of the cervical oesophagus [8, 11, 171. We find it difficult to justify medical management in foreign body perforation for a number of reasons. Firstly, surgical removal of the foreign body may be required if endoscopic extirpation fails (3 cases in this series). Secondly, our procedure of surgical drainage with primary suture where appropriate is a relatively conservative surgical intervention which was well tolerated by all patients. Thirdly, late presentation, which occurred in nearly half of our patients, often indicates well-established infection with abscess formation which is unlikely to respond to simple antibiotic therapy. The presence of frank infection can also compromise the results of surgery leading to a postoperative leak from the suture line in 5 of 13 patients, a higher proportion than would be expected after a clean procedure. Fortunately, the leaks were of a minor nature and healed spontaneously in all but 1 patient. This emphasises, in our view, the importance of well-placed drains in the management of these patients. Patients with intrathoracic perforation are at risk of corrosive mediastinitis if gastric contents leak into the chest. For this reason, we routinely divert gastric secretions by gastrostomy in these patients and take the opportunity to introduce a concomitant feeding jejunostomy. Those with cervical perforation do not run such a risk, are not routinely subjected to laparotomy and therefore receive parenteral alimentation. All types of foreign bodies may impact in the oesophagus but bones, because of their presence in food, are particularly common, representing 19% of all oesophageal foreign bodies [7]. The frequency of chicken bones in this series is harder to explain. We have no data on the scale of chicken consumption in our region but have no reason to believe that chicken is disproportion-

ately represented on the menus of southwestern France. It is possible that chicken bones are particularly liable to cause perforation and should be treated with caution. Foreign body perforation is a rare but important subentity in oesophageal perforation. It can occur in all parts of a previously healthy oesophagus. The perforations are often multiple and late presentation is typical. The results of immediate surgical treatment by primary repair, drainage and diversion of secretions are excellent. References 1. Abbott OA, Mansour KA, Logan WD, Hamner CR, Symbas PN (1970) Atraumatic so-called “spontaneous” rupture of the esophagus. A review of 47 personal cases with comments on a new method of surgical therapy. J Thorac Cardiovasc Surg 59:67-83 2. Bladergroen MR, Lowe JE, Postlethwait RW (1986) Diagnosis and recommended management of oesophageal perforation and rupture. Ann Thorac Surg 42~235-239 3. Brewer LA, Carter R, Mulder GA, Stiles QR (1986) Options in the management of perforation of the esophagus. Am J Surg 152:62-69 4. Brichon PY, Couraud L, Velly J-F, Martigne C, Clerc F (1990) Les perforations et ruptures de l’oesophage. A propos de 35 cas. Ann Chir 441464-470 5. Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker R (1979) Selective non-operative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 27:404408 6. Flynn AE, Verrier ED, Way LW, Thomas AN, Pellegrini CA (1989) Esophageal perforation. Arch Surg 124: 1211-1215 7. Jackson C, Jackson C (1936) Diseases of the air and food passages of foreign body origin. Philadelphia, Saunders 8. Kezler P. Buzna E (1981) Surgical and conservative management of esophageal perforations. Chest 80: 158 -- 162 9. Lyons WS. Sermetis MG, de Guzman VC, Peabody JW Jr (1978) Ruptures and perforations of the esophagus: the case for conservative supportive management. Ann Thorac Surg 25:346-350 10. McLaughlin RT, Morris JD. Haight C (1968) The morbid nature of the migrating foreign body in the esophagus. J Thorac Cardiovasc Surg 55: 188 11. Michel L. Grill0 HC, Malt RA (1982) Esophageal perforation. Ann Thorac Surg 33:203-210 12. Moghissi K, Pender D (1988) Instrumental perforations of the oesophagus and their management. Thorax 43:642-646 13. Nashef SAM, Pagliero KM (1987) Instrumental perforation of the esophagus in benign disease. Ann Thorac Surg 44: 360-362 14. Sarr MG, Pemberton JH, Payne WS (1982) Management of instrumental perforation of the esophagus. J Thorac Cardiovast Surg 211-218 15. Tilanus HW, Bossuyt P, Schattenkerk ME, Obertop H (1991) Treatment of oesophageal perforation: a multivariate analysis. Br J Surg 78:582-585 16. Walker WS, Cameron EWJ. Walbaum PR (1985) Diagnosis and management of spontaneous transmural rupture of the oesophagus (Boerhaave’s syndrome). Br J Surg 72:204-207 17. Wesdorf ICE, Barelsman JFWM. Huibregtse K, Den Hartog Jager FCA, Tytgat GN (1984) Treatment of instrumental esophageal perforation. Gut 25:398-404 Samer A.M. Nashef, FRCS Service de Chirurgie Thoracique Hopital Xavier Arnozan Avenue du Haut-Leveque F-33604 Pessac France

Foreign body perforation of the normal oesophagus.

Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodie...
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