Iatrogenic Esophageal Perforation

Author: Stephanie Worrell, MD
Institution: University of Arizona
Date Reviewed: 2023
Original Case: David Greenhouse, MD / Massachusetts General Hospital
Learning Domain: Cardiothoracic Trauma
Learning Objective: Management of iatrogenic esophageal perforation
PowerPoint File: File 2023 Iatrogenic Esophageal Perforation.pptx

 

Background

50-year-old male presents to the ED with chest pain. The day prior had an endoscopy done for symptoms of dysphagia.  The endoscopy was significant for a mid esophageal stricture which was easily dilated to 20mm per the report. Biopsies were also don’t at the time of endoscopy and were negative for cancer. 

  • PMH: HTN, CAD, GERD
  • PSH: none
  • Meds: Aspirin, Atorvastatin, Metoprolol, Omeprazole 
  • Former smoker, occasional alcohol 
  • Physical Exam:
    • HR 97 BP 165/86 RR 20 O2 sat 96% on RA
    • Heart RRR, Lungs CTA bilaterally
    • Abdomen soft NTND
    • Crepitus in the anterior chest and neck

 

 

Discussion Points

  • What are the risks of iatrogenic perforation?
  • How commonly does it occur?

 

Iatrogenic Esophageal Perforation

  • Perforation rate for benign strictures: ~0.1%
  • Perforation rate for achalasia dilation: 4-5%
  • Risk Factors:
    • A malignant stricture
    • Severe esophagitis
    • Prior radiation therapy
    • A history of caustic ingestion
    • Complex (tortuous) or long strictures
    • Presence of esophageal diverticula
    • Inexperienced operator
    • A large hiatal hernia
    • Use of high inflation pressures with balloon dilation (achalasia balloons 30-40mm)
    • A history of previous esophageal perforation
    • A history of prior esophageal surgery
    • Prior Botox injection

 

Etiology of Esophageal Perforation

  • More than half of esophageal perforations in adults are iatrogenic, most commonly from complex upper endoscopy 
  • Following iatrogenic etiology: 
    • Boerhave’s syndrome (15%)
    • foreign body obstruction (12%)
    • trauma (9%), intraoperative injury (2%)
    • malignancy (1%)
    • Other less common etiologies include caustic ingestion, pneumatic injury, peptic ulceration, Crohn’s disease, and eosinophilic esophagitis 

 

Discussion Points

  • What additional evaluation is indicated?
  • What is the role of esophagography?  
  • What are the advantages/disadvantages of water-soluble contrast vs. thin barium?
  • What are the advantages/disadvantages of CT?
  • What are the risks and benefits of esophagoscopy?

 

CT Scan

 

Management of contained esophageal perforations

  • NPO/IVF
  • Broad-spectrum antibiotics
  • +/- enteral access
  • Start diet slowly
    • Liquids x2 wks
    • Soft diet, slowly advance to regular

 

Management of uncontained esophageal perforations

  • Drain the mediastinum
    • VATs vs thoracotomy
  • Close the hole versus divert the esophagus
    • 2 layer closure with muscle flap
    • Stent
    • Endovac
  • Feeding access

 

Case

  • Patient made NPO and obtained esophagram
  • Esophagram negative for leak
  • Started on clears and sent him with oral antibiotics

 

Clinical Care Points

  • Esophageal perforation is a rare but severe disease process that requires prompt diagnosis and treatment.
  • Initial management includes resuscitation, broad spectrum antibiotics, consideration of antifungal therapy, controlling the perforation, restoring luminal integrity, and debriding all extraluminal contamination.
  • Surgical intervention has historically been the mainstay of treatment, however a shift towards endoscopic treatment exists, despite no randomized clinical trials comparing patient outcomes.
  • Self-expanding metal stents and endoscopic vacuum therapy have been widely described across a diverse patient population and appear to be safe and effective as a treatment strategy, in the proper clinical setting.