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Esophageal Injury Reinold J. Jones, M.D., and Paul C. Samson, M.D. ABSTRACT This review considers all possible modes of esophageal injury, based on a schema originally published in 1954 and more recently modified in 1970. For each category of injury there are detailed discussions of diagnosis and treatment. The best available knowledge of present-day modalities has been based on a survey of the literature for the past decade. When diverse methods of treatment were encountered, we have made comments consistent with our personal experience, when appropriate. The medicolegal literature contains a number of references to esophageal injury. Certain excerpts dealing with several types of potential actions are extracted: (1) suits to recover damages for esophageal perforation in which negligent endoscopy was claimed; (2) suits following endoscopic accidents in which lack of informed consent was claimed; and (3) suits for professional liability based on misdiagnosis, delayed diagnosis, or wrong treatment of esophageal perforation.
T
rauma to the esophagus has long been a diagnostic and therapeutic problem for both internist and surgeon. In 1954 a new schema for the classification of esophageal injury was suggested [83],and it was republished in modified form in 1970 [85]. The present review endeavors to classify the modalities of injury according to this outline and presents what we consider to be major developments leading to the current standards of therapy. During the past ten years several excellent collective and current reviews covering various aspects of esophageal injury have appeared: Tesler and Eisenberg (1963) [95], Hughes (1965) [48], Bolsted (1966) [13], Wesselhoeft and Keshishian (1968) [loo], Loop and Groves (1970) [57], and Feldman and associates (1973) [33]. From the Division of Cardiothoracic Surgery, Mary’s Help and St. Mary’s Hospitals, the University of California, San Francisco, School of Medicine, San Francisco, and the Division of Thoracic and Cardiac Surgery, Highland General Hospital, Oakland, Calif. Address reprint requests to Dr. Jones, 2645 Ocean Ave., San F’rancisco, Calif. 94132.
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Classification of Esophageal I n j u r y T h e most recent classification of esophageal injury 1831 is given in outline form below. I. Extraluminal causes of injury. Includes wounding, blunt external trauma, and operative accidents, either to esophagus or to adjacent organs 11. Intraluminal causes of injury A. Intrinsic (pressure from within body): complete and incomplete rupture B. Extrinsic (pressure mechanisms from outside body) 1. Foreign body sojourn with or without perforation 2. Perforation-instrumental or other 3. Ingestion-caustics, acids 111. Complications of injury. Includes abscess, fistula, stricture EXTRALUMINAL CAUSES OF IN JURY
Penetrating and perforating wounds of the esophagus are uncommon due to the anatomical position of this structure. If external wounds are incurred sufficient to penetrate the esophagus, there is frequently severe associated injury to surrounding vital structures [go]. T h e cervical esophagus is the most common segment perforated by gunshot and knife wounds [2, 691. Treatment of the perforation is standardized, but the greatest error is overlooking esophageal trauma when there is associated cardiac, great vessel, or pulmonary injury. Blunt trauma per se causes far fewer esophageal injuries but must be considered if severe crushing has occurred [78, 1041. Tracheoesophageal fistula has been reported following a steering wheel injury in the cervical area [64]. Operative injury is also classified as extraluminal or external trauma. Vagotomy and pyloroplasty have become two of the standard surgical modalities for peptic ulcer disease. Postlethwait and associates [75] report an incidence of 0.54% of perforated esophagus in 4,414 operations reviewed. Others report a similar occurrence of this complication [42, 761. Hiatal hernia repair in which sutures through the esophageal muscularis are utilized as part of the repair can cause a tear of the esophageal wall if placed too deeply or with undue tension [89]. T h e same problem of esophageal fistula or abscess can occur with the transabdominal repair of hiatal hernia either when the arcuate ligament is employed as an anchor or when using fundoplication [43,681. INTRALUMINAL CAUSES OF IN JURY
Intrinsic. T h e most common intrinsic rupture is on the basis of increased pressure from forceful or prolonged emesis. T h e entity was first described by Boerhaave in 1724 [12].
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Most cases of postemetic esophageal rupture follow excessive alcoho or food intake [27, 581. The tear is usually in the lower third of the posterolateral wall. The majority of “spontaneous” or postemetic ruptures occur in normal esophagi and not in patients with esophagitis or ulcer, as would be expected [44]. Spontaneous rupture unrelated to alcohol intakc [97] and also in the newborn has been reported [102]. Likewise, there a n reports of “spontaneous” rupture which occurred without emesis bui following blunt trauma, forceful childbirth, heavy lifting, and seizures. Ir these situations some authors have postulated that there was a preexisting esophageal abnormality, usually esophagitis [55]. Even forceful swallowing in the absence of regurgitation has been reported as sufficient to cause rupture of the distal esophagus [25]. Esophagomalacia predisposes tc esophageal injury and is associated particularly with hypothalamic disorder! resulting in muscle incoordination [57]. Incomplete rupture with resultant hemorrhage is frequently related tc forceful emesis. The most common manifestation of this injury is a mucosal tear in the gastric fundus, the Mallory-Weiss syndrome [32, 1081. The teal may extend through the esophagogastric junction and involve the mucosa 01 the distal esophagus. Extrinsic Pressure (Mechanism from Outside Body). Foreign Bod) Sojourn. Most ingested objects pass through the intestinal tract causing nc injury. Due to size or configuration, however, many become lodged in the esophagus. Foreign body retention is increased by the presence of stricture or tumor of the esophagus. The majority of foreign bodies are found in the esophagi of children because of their propensity to put objects in their mouth [49]. Other common causes for foreign body retention combine an overintake of alcohol with complete dentures. This has resulted in obstruction from a bone, incompletely masticated food, and even cocktail toothpicks. The steak house syndrome [70] and cafe coronary [41] could be listed in this category. Patients with dentures have a greater incidence 01 hard foreign bodies in the esophageal lumen since they are unable to sense the object with a denture in place [57]. The foreign body may penetrate or perforate the esophageal wall. More severe is the perforation caused by attempted instrumental removal, either by a poorly trained endoscopist or by one who is trying to push the foreign body ahead of the endoscope and into the stomach. Although most perforations due to a foreign body are caused by a sharp edge penetrating the esophagus, pressure necrosis with breakdown of the esophageal wall may also occur. In children this has been associated with migration of the object into the pleural cavity or the major vessels [61]. Instrumental or Other Perforations. Iatrogenic injury is one of the common causes of esophageal perforation. The reported incidence from esophagoscopy varies from 0.2 to 2yo [106]. The majority of rigid tube esophagoscopies are now performed under general anesthesia, and this has
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apparently decreased the incidence of perforation. Esophagogastroscopy using the fiberoptic instrument seems to carry a lesser incidence of perforation [72, 1061. The most common area of perforation from an endoscopic examination with a rigid tube is in the region of the cricopharyngeus muscle [88]. There are numerous reasons for this: (1) anatomical configuration due to the posterior muscular band; (2) inadequate anesthesia; (3) failure of the anesthesiologist to deflate the endotracheal balloon; and (4) fused or spurred cervical vertebrae. Dilating the esophagus likewise carries a risk of perforation. Most dilations are performed for stricture, and this means forcing a bougie through diseased tissue. Poor visibility and bougienage ahead of the endoscope can cause perforation without the operator’s knowledge. Early dilation in burns may predispose to perforation when there is mucosal edema and injured esophageal wall [39]. Biopsy of the esophageal mucosa, particularly when using the rigid instrument, has been a fairly frequent cause of perforation [85, 1061. This seldom occurs in grossly apparent malignancy but rather in patients with esophagitis or normal mucosa. Perforation is more likely if the biopsy is done blind with the forceps placed beyond the operator’s visual field. Apparently biopsy is much safer when small forceps are used with the more immediate visualization offered by the fiberscope. Other tubes in the esophagus have caused injury. Endotracheal tubes have been inadvertently passed and caused either laceration or perforation [103]. The Sengstaken-Blakemore tube has led to perforation of the esophagus from a variety of causes [9, 24, 871. Patients have pulled the inflated gastric balloon out of the stomach with resultant rupture of the esophagus [191. Prolonged inflation and traction, particularly of the gastric balloon, can cause pressure necrosis of the stomach and distal esophagus [19]. The hydrostatic balloon, formerly used as part of the standard treatment of achalasia, can split the mucosa of the esophagus as well as the muscularis [30, 3 11. Palliation of carcinoma of the esophagus has been accomplished by the use of various semirigid tubes [1, 201. Such devices have occasionally perforated a tumor during introduction. The tube may also erode through the esophagus, especially at its flanged edge [106]. Finally, there have been isolated reports of rupture by air blast [7, 56, 781 and self-catheterization [15] and by sword swallowing, among other esoteric occupations. Esophageal Burns. The ingestion of caustic agents or acids may result in minimal mucosal damage, may severely burn the gullet with eventual stricture, or may perforate the esophagus, causing mediastinitis or an esophageal-airway fistula [ 1001. Unfortunately, children are frequently the victims of carelessness, while adults ingest injurious solutions either inadvertently or with suicidal intent [85].
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Diagnosis Perforating wounds of the neck and thorax, depending on their location and direction, should lead the surgeon to consider possible esophageal injury [94].If esophageal penetration is suspected and the patient’s condition is stable, an esophagogram done preoperatively will confirm and localize the site of injury [57]. T h e symptoms of intraluminal esophageal perforation-whether by instrument, foreign body, or emesis-vary according to the location and size of the perforation, the rapidity with which the perforation develops, and whether or not an esophagotracheobronchial fistula occurs. All perforations, however, are accompanied by fever, rapid pulse, general malaise, and leukocytosis. In the cervical esophagus the clinical combination of pain, swelling, point tenderness or crepitation, and sternocleidomastoid irritation have been well documented [84]. Perforation of the thoracic esophagus may or may not be dramatic [85]. Shoulder pain and a nasal twang to the voice are frequently noted [82].Air in the mediastinum is a common finding and can be considered diagnostic [ 161. Swallowing, deep breathing, and motion greatly increase the patient’s pain. As time passes in an untreated patient, the progressive mediastinal contamination usually results in clinical shock. Perforation of the abdominal esophagus brings on the whole train of symptoms and signs associated with any perforation of a hollow viscus in the abdomen: pain, tenderness, splinting, rigidity, and shock [35]. T h e diagnosis of esophagotracheobronchial fistula is suspected by the additional symptoms of shortness of breath, hemoptysis, dysphagia, and cough [IOO]. The symptoms may come on shortly after injury or they may be delayed. Perforation of the esophagus due to endoscopy is usually recognized at the time by the endoscopist. If perforation is not immediately suspected, the signs and symptoms rapidly appear shortly after the procedure. A high index of suspicion after a difficult endoscopic examination should alert the surgeon to an early recognition of perforation. Definitive diagnosis is made by having the patient swallow contrast material. There is controversy over the use of barium in suspected perforation since many believe it will cause a more severe mediastinitis [73], and iodinated contrast material is advocated instead [ZI]. Many foreign bodies are radiopaque, and a routine chest film will disclose the object and the level of the esophagus at which it is lodged. For nonopaque foreign bodies it is necessary to have the patient swallow contrast material to confirm the presence of the object and its location. Some small spicules of bones are best localized by having the patient swallow a pledget of cotton that has been saturated with a contrast medium. Burns of the esophagus are usually diagnosed by history alone. T h e type
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of ingested material, whether caustic or acid, is frequently known. Burns or even ulceration of the lips and oropharynx are seen. T h e patient has severe pain which is aggravated by attempts at swallowing. Esophagoscopy is often considered to delineate the extent of the burn and to grade its severity [Z]. As endoscopy is only diagnostic, no attempt should be made to advance the scope once ulceration, edema, or bleeding is observed [26]. T h e extent of the mucosal injury can then be evaluated by an esophagogram [65].
Treatment When external penetrating or perforating wounds of the esophagus become manifest, there frequently are associated injuries to adjacent major structures [SO]. Exploration is mandatory in these patients, often for the control of severe hemorrhage. One must be always on the alert for an esophageal rent which could later lead to life-threatening complications [66]. T h e esophageal injury is exposed and debrided if nonviable edges are seen. A primary two-layered closure is then effected, if possible. Adequate drainage is essential. T h e morbidity and mortality are far less with cervical perforation than with intrathoracic esophageal injury [ 101. In the case of thoracic injury, wide opening of the pleura and copious lavage are done to ensure drainage and prevent mediastinal contamination. T h e prognosis not only depends on the immediacy of treatment but is further predicated on the size and site of perforation [54]. Foreign bodies are usually extracted by endoscopy, but if this is not feasible, a cervical or thoracic esophagotomy may be necessary for their removal [57]. The belief has grown over the years that esophageal rupture (spontaneous, postemetic, or from any other cause) must be recognized early and definitive therapy immediately instituted [8, 58, 83, 1061. Early operation, repair, and drainage are essential for survival [7 11. Correction of shock, appropriate antibiotic coverage, and a two-layered closure are carried out. T h e blood supply of the esophagus is tenuous and segmental, and the lack of serosa is a hindrance to adequate anastomosis. There must be care in technique and avoidance of tension on suture lines or else the sutures may tear, resulting in fistula and abscess formation. Hyperalimentation has proved valuable in the postoperative recovery period, affording a period of rest for the repaired esophagus with the patient remaining in positive nitrogen balance [29]. Opinion is far from unanimous on how instrumental or foreign body perforations should be handled. T h e choice between surgical and nonsurgical treatment is still frequently discussed. Together with Groves [37] and Ravitch [79], we object to equating nonoperative therapy with “conservative’’ management. One may well question the use of the word conservative in this connection since it implies that surgical intervention is therefore radical. There is considerable argument to suggest that the reverse may be
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true: that operative treatment is conservative and nonoperative treatment radical. T h e majority of writers hold that virtually all perforations of the esophagus are dangerous, if not potentially lethal. They tend to bring all modalities to bear on treatment, including-it is hoped-early diagnosis, massive antibiotic therapy, and prompt exposure of the esophageal rent, usually followed by suture repair and adequate drainage [lo, 30, 67, 73, 77, 85, 93, 101, 1061. There are those who concede that large tears require prompt operative intervention but that nonoperative (conservative?) treatment will suffice in the remainder [28, 40, 59, 62, 911. In general they argue-with some validity-that the size, location, and rapidity with which the laceration develops and the condition of the esophageal wall are important in determining the deadliness of the perforation. At one extreme is the classic postemetic rupture, a sudden large tear in the normal esophagus with overwhelming intrathoracic contamination. Should the patient not have definitive operation, or should drainage be inadequate, death is inevitable. At the other extreme is the slowly developing, tiny perforation from a sharp foreign body, particularly in the cervical region or proximal to an old inflammatory stricture, which carries little likelihood of serious consequence. Between these two examples lie all gradations of damage and danger. Apparently there are only a few proponents of primary nonoperative management for esophageal perforation, and the numbers of patients treated this way are small [6, 621. T h e essentials of nonoperative treatment are these: all feedings are discontinued, nasogastric suction is instituted, and closed intercostal drainage is used if there is pleural fluid or air. Massive antibiotic coverage is employed, consisting of 10 million units of penicillin and 1 gm of streptomycin a day. At least part of this is given intravenously [621* Since those physicians who put primary dependence on a nonoperative regimen are apparently in the minority, they must be prepared to defend their choice of treatment [45]. If this routine does not cause progressive clinical and roentgenographic improvement within six to twelve hours, one may seriously question any decision to persist with a conservative attitude. T h e fallacy of depending upon a strictly medical regimen lies in the possible misinterpretation of signs and symptoms. One cannot always be sure that the rent is indeed a small one [34]. T h e physician may be lulled into a false sense of security because the patient seems to be doing reasonably well. It is not a rarity under these circumstances for the practitioner to realize belatedly that a fully established abscess or mediastinitis has severely reduced the patient’s chances for uncomplicated recovery [57, 67,851. Perforations associated with distal abnormalities such as stricture or malignancy present a different therapeutic problem. There have been reports of successful one-stage management with removal of the lesion, drainage, and an appropriate reconstructive procedure [11, 521. Reconstruc~~
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tion of the esophagus has been accomplished using the stomach, colon, or small bowel; some rents have been closed using the gastric fundus as a patch [ l l , 63, 86, 961. In some patients a significant period has elapsed before a diagnosis is made and operative intervention instituted. If these patients survive, primary resection or closure is not judicious, and there is still a place for an esophageal exclusion procedure [51]. After the acute infection has been cleared by drainage and antibiotics, the blind loop of the esophagus is removed and the esophagus reconstituted, usually by colon interposition [531The modern treatment for traumatic esophagotracheobronchial fistula is direct operative intervention with isolation, division, and closure of the fistula [5, 74, 100, 1051. If possible, pleural or other soft tissue should be interposed between the suture lines in the esophagus and airway. If the fistula is in the neck, a cervical incision may be employed, perhaps combined with either mediastinotomy or resection of the medial end of the clavicle or both [23]. Most intrathoracic fistulas can be exposed through a right thoracotomy. It is to be hoped that the diagnosis will not be too long delayed since there is danger of extensive pulmonary damage, although longstanding fistulas have been successfully divided [22].
Treatment of Caustic Injuries There are two schools of thought in the management of injuries caused by caustic substances: (1) use of early and continued dilation [39]; and (2) use of systemic steroids and antibiotics without dilation, with the hope of precluding damage to the inflamed mucosa [38]. In either type of management, the extent and degree of injury is verified if possible. This is commonly accomplished by esophagoscopy and esophagograms [ 1071. It is most important that the esophagoscope reaches only to the top of the burn [26]. In the experience of some, esophagoscopy in children carries too great a complication rate and should not be performed [14]. In spite of one experimental model to the contrary [19], nearly all authors are convinced that the early massive use of corticosteroids has an inhibitory effect on fibroblastic proliferation and the formation of granulation and scar tissue [33, 81, 921. Steroids must be administered within the first forty-eight hours to have a maximal effect [99]. I n addition the concomitant use of antibiotics has been widely accepted, and many authors believe this combination of therapies to be adequate r47, 981. Others, however, believe strongly that there should be a repeat esophagoscopy two to three weeks following injury with dilation being performed as needed until healing is complete [14]. Repeat esophagograms should be obtained at intervals to allow early detection of a delayed stricture. In spite of adequate initial care and good follow-up management, in
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some patients strictures will occur which necessitate careful, sometimes prolonged bougienage and occasionally esophageal replacement. This is particularly true in patients with third-degree burns. Or the physician may see a patient who was inadequately treated at the onset and is now beyond the point of being helped by less radical modes of therapy. When extensive second- and third-degree burns are encountered, attempts to have the patient swallow a string are commenced as soon as a liquid diet can be tolerated. If the patient is seen more than forty-eight hours after the accident, antibiotics should be administered but no steroids. Bougienage can then be started early but should not be used during or immediately following a course of steroid therapy [46]. One may use either mercury-filled Hurst or tapered Maloney bougies or the Tucker or Plummer type of olive-tipped bougie, using the previously swallowed string as a guide. If a gastrostomy has been necessary for feeding purposes, retrograde esophageal dilation is possible. A relatively normal esophageal lumen may be established after the discovery of a tight stricture or even atresia. Rarely what appears to be an atretic lumen may turn out to be a long, relatively normal esophageal segment between two tight, weblike strictures. Recannulation and dilation are then rapidly successful [47]. When all attempts at dilation fail, the surgeon must resort to excision and replacement of the diseased segment of esophagus [17]. If the stricture extends to the oropharynx and the anastomosis must be made in the cervical region, the stomach is usually too bulky as a replacement, especially in children. A reverse gastric tube is technically possible for a pullthrough to the neck, but arterial incompetence or venous stasis may doom the procedure. In a recent report, however, good results were reported when a reverse gastric tube was used for esophageal replacement in children [4]. Excision of a midthoracic stricture or the rare lower thoracic stricture may be easily accomplished by using the stomach as a replacement. The small intestine is an attractive replacement [63]; reflux esophagitis is usually precluded by this technique, although an adequate vascular supply may be a problem if a long length of the small bowel is necessary. The most satisfactory replacement is probably the colon. Both right and left colon have been favored [36, 601. Proponents of the right colon point out the desirability of anastomosing the distal ileum to the esophagus because of their close approximation in size. The left colon is easily mobilized, and the blood supply is adequate for establishing a cervical anastomosis without fear of necrosis. The segment of bowel considered for interposition may be brought up alongside the esophagus (less desirable), anterior to the sternum in a subcutaneous tunnel, or retrosternally. Since the procedure is done for benign disease and frequently in young patients, the retrosternal position is usually considered preferable [60]. Removal of the strictured segment of esophagus has been considered.
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Usually this will have to be performed as a second-stage procedure. Since there is at least some evidence of a long-delayed but increased incidence of carcinoma in the battered esophagus, many authors believe that it should be removed sooner or later [50], From time to time the ingestion of solid granules of a caustic substance or of certain acids may cause little or no esophageal injury. Close observation is necessary, however, because the noxious material may rapidly erode and perforate the gastric wall. This requires immediate laparotomy, peritoneal lavage, and closure of the perforation or resection.
Medicolegal Aspects of Esophageal Perforation and Rupture .
A general survey of the implications of liability in esophageal perforation has been assembled by Angela R. Holder [45]. This review plus a few other legal references form the basis for the following discussion. It is not surprising that esophageal disruption leads to medicolegal involvements from time to time. Potential actions may be reviewed under the following headings: 1. Suits to recover damages for esophageal perforation in which negligent endoscopy is claimed. Statistics quoted previously indicate that perforation is a known hazard of endoscopy even in the best of hands [106]. The courts therefore generally have held that the fact of esophageal perforation does not in and of itself imply negligence. When normal procedures are conducted in accordance with approved practice, negligence will not be inferred just because there has been an inadvertent perforation. Negligence in such cases is held to occur only when the physician has not met the required standard of due care which he owes his patient. A Colorado general practitioner was sued for causing an esophageal perforation while attempting to “wipe out” a bone lodged in the esophagus. Expert medical testimony indicated that the method used was not in conformity with good Fedical practice. When a decision was made that “due care” had not been used, the appeals court upheld the jury’s award of damage to the plaintiff. Expert medical testimony generally is necessary because the causes of esophageal perforation are outside the competence of a lay jury to understand, and the doctrine of res ipsa loquitur is usually held inapplicable. In an Illinois decision, however, expert testimony was not required since the endoscopist had lifted the patient up to show an intern the proper position of the tube. The court held it was obvious that the physician’s action indicated improper use of the procedure (gastroscopy) and thus was sufficient to establish a prima facie case of negligence. 2. Suits following endoscopic accidents in which lack of informed consent was claimed. It has been held on a number of occasions that “informed consent” does not necessarily include a specific discussion of the possibility of esophageal perforation. For example, when esophageal
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perforation resulted in a suit against a Washington physician, the court held that the low incidence of perforation eliminated it as a “reasonably foreseeable risk” and that there was no cause for action against the physician for his failure to mention perforation specifically as a risk in endoscopic procedures. Considered strictly from a legal standpoint, however, it is probably sounder nowadays to indicate beforehand that esophageal perforation occasionally occurs during endoscopy despite precautions, particularly if the surrounding circumstances are such that the consent of a reasonable person who is not a physician might be affected materially. In addition, the recent decision handed down by the California Supreme Court (Cobb vs. Grant, 8 California 3d 229) eventually may have a tremendous impact upon the physician’s responsibility to obtain a patient’s “informed consent” before providing any medical or surgical treatment. 3. Suits for professional liability based on misdiagnosis, delayed diagnosis, or wrong treatment of esophageal perforation or rupture. A Michigan physician died in Florida as the result of postemetic rupture of the esophagus, and a malpractice suit was filed on behalf of the widow. T h e failure of the radiologist to diagnose free air in the mediastinum when the patient was first admitted to the hospital resulted in a delay in diagnosis of some thirty hours, which was believed to have greatly lessened the patient’s chances for recovery; liability was imposed. A Louisiana doctor admitted puncturing the patient’s esophagus while performing an esophagoscopy. He did not operate after discovering the perforation and tried other methods of dealing with the problem. T h e plaintiff presented expert testimony that the defendant wrongly prescribed an unsterile diet for the patient. The subsequent infection sustained by the patient required at least three major operations for its control. T h e jury found for the plaintiff patient.
References The complications of endoesophageal tube. J Thorac Cardiovasc Surg 51:685, 1966. Alford, B. R., and Harris, H. H. Chemical burns of the mouth, pharynx and esophagus. Ann Otol68: 122, 1959. Alford, B. R., Johnson, R. L., and Harris, H. H. Penetrating and perforating injuries of the esophagus. A n n Otol 72:995, 1963. Anderson, K. D., and Randolph, J. G. The gastric tube for esophageal replacement in children. J Thorac Cardiovasc Surg 66:333, 1973. Anderson, R. P., and Sabiston, D. C., Jr. Acquired bronchoesophageal fistula of benign origin. Surg Gynecol Obstet 121:261, 1965. Aniansson, G., and Hallen, 0. Perforations of the esophagus. Acta Otolaryngol (Stockh.) 59:554, 1965. Badruddoja, M., and .Macgregor, J. K. Rupture of the intrathoracic esophagus by compressed air blast. Arch Surg 103:417, 1971. Barrett, N. R. Spontaneous perforation of esophagus: Review of literature and report of 3 new cases. Thorax 1:48, 1946. Bennett, H. D., Baker, L., and Baker, L. A. Complications in use of
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esophageal compression balloons (Sengstaken tube). Arch Intern Med 90: 196, 1952. Berry, B. E., and Ochsner, J. L. Perforation of the esophagus. J Thorac Cardiovasc Surg 65: 1, 1973. Blalock, J. Primary esophagogastrectomy for instrumental perforation of the esophagus. A m J Surg 94:393, 1957. Boerhaave, H. Atrocis nec descripti pruis. In Morbi Hislorica Secundum Medicae Artis Leges Conscripta. Ludg. Bontesteniana, 1724. Translated in Bull Med Libr Assoc 43:217, 1955. Bolstad, D. S. The management of stricture of the esophagus. Ann Otol Rhino1 Laryngol75: 1019, 1966. Borja, A. R., Ransdell, H. T., Thomas, T. V., and Johnson, W. Lye injuries of the esophagus. J Thorac Cardiovasc Surg 57:533, 1969. Brewster, E. S. Traumatic perforation of the esophagus caused by self catheterization with heavy electric wire. A m J Surg 93: 1021, 1957. Briggs, J. N., and Germann, T. D. Traumatic perforation of the esophagus. Surg Clin North A m 48: 1297, 1968. Burford, T. H., Webb, W. R., and Ackerman, L. Caustic burns of the esophagus and their surgical management: A clinical experimental correlation. Ann Surg 138:453, 1953. Byrne, W. D., Samson, P. C., and Dugan, D. . Complications associated with the use of esophageal compression bal oons. A m J Surg 104:250, 1962. Byrne, W. D., Samson, P. C., Dugan, D. J., Noel, S. M., and May, I. A. Experimental lye burns of the esophagus in dogs. Surg Forum 13:254, 1962. Celestin, L. R. Permanent intubation in inoperable cancer of the esophagus and cardia. Ann R Coll Surg Engl 25:165, 1959. Christoforidis, A., and Nelson, S. W. Spontaneous rupture of esophagus with emphasis on the roentgenologic diagnosis. A m J Roentgen01 Radium Ther Nucl'?!fed 78:574, 1957. Clagett, 0. T., and Schmidt, H. W. Surgical management of acquired stricture of esophagus with esophagobronchial fistula and bronchiectasis of entire right lung. Surgery 23:221, 1948. Coleman, F. P. Acquired non-malignant esophagorespiratory fistula. A m J Surg 93:321, 1957. Conn, H. 0. Hazards attending the use of esophageal tamponade. N Engl J Med 259:701, 1958. Conte, B. A. Esophageal rupture in absence of vomiting. J Thorac Cardiovasc Surg 5 1:137, 1966. Daly, J. F. Corrosive esophagitis. Otolayngol Clin North A m 1:119, 1968. Derrick, J. R., Harrison, W. H., and Howard, J. M. Factors predisposing to spontaneous perforation of the esophagus. Surgery 43:486, 1958. Doig, V. F. Perforated esophagus: An acute emergency. A m Surg 26:361, 1960. Dudrick, S. J., and Rhoads, J. E. New horizons for intravenous feeding. JAMA 215:939, 1971. Dugan, D. J. The management of esophageal perforations. Dis Chest 22:556, 1952. Ellis, F. H., Jr., and Olsen, A. M. Achalasia of the Esophagus. In Major Problems in Clinical Surgery. Philadelphia: Saunders, 1969. Vol IX. Etheredge, S. M. The Mallory-Weiss syndrome. A m J Surg 100:200, 1960. Feldman, M., Iben, A. B., and Hurley, E. J. Corrosive injury to oropharynx and esophagus. Calif Med 118:6, 1973. Foster, J. H., Jolly, P. C., Sawyers, J. L., and Daniel, R. A. Esophageal perforation: Diagnosis and treatment. Ann Surg 161:701, 1965.
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JONES AND SAMSON 35. Graham, J., Barnes, N., and Rubenstein, A. S. Rupture of esophagus stimulating rupture of stomach. Arch Surg 83:306, 1961. 36. Gross, R. E., and Firestone, F. N. Colonic reconstruction of the esophagus in infants and children. Surgery 61:955, 1967. 37. Groves, L. K. Instrumental perforation of the esophagus: What is conservative management? J Thorac Cardiovasc Surg 52: 1, 1966. 38. Haller, J. A., Andrews, H. G., White, J. J., Tamer, M. A., and Cleveland, W. A. Pathophysiology and management of acute corrosive burns of the esophagus: Results of treatment in 285 children. J Pediatr Surg 6:578, 1971. 39. Haller, J. A., and Bachman, K. The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics 34:236, 1964. 40. Hardin, W. J., Hardy, J. D., and Conn, J. H. Esophageal perforations. Surg Gynecol Obstet 124:325, 1967. 41. Haugen, R. K. The cafk coronary. JAMA 186:142, 1963. 42. Hauser, J. B., and Lucas, R. J. Esophageal perforation during vagotomy. Arch Surg 101:466, 1970. 43. Hill, L. D. An effective operation for hiatal hernia: An eight year appraisal. Ann Surg 166:681, 1967. 44. Hochberg, L. A., and Parlamis, H. Spontaneous perforation and rupture of the esophagus with a report of five cases. A m J Surg 102:428, 1961. 45. Holder, A. R. Liability for esophageal perforation. JAMA 216:1399, 1971. 46. Holinger, P. H. Management of esophageal lesions caused by chemical burns. Ann Otol Rhino1 Laryngol77:819, 1968. 47. Holinger, P. H., Johnston, K. C., Potts, W. J., and DaCunha, F. The conservative and surgical management of benign strictures of the esophagus. J Thorac Surg 28:345, 1954. 48. Hughes, R. K. Thoracic trauma. Ann Thorac Surg 1:778, 1965. 49. Jackson, C. L. Foreign bodies in the esophagus. A m J Surg 93:308, 1957. The role of benign esophageal 50. Jaske, R. A., and Benedict, E. B. obstruction in the development of carcinoma of the esophagus. Gastroenterology 36:749, 1959. 51. Johnson, J., Schwegman, C. W., and Kirby, C. K. Esophageal exclusion for persistent fistula following spontaneous rupture of the esophagus. J Thorac Surg 32:827, 1956. 52. Johnson, J,, Schwegman, C. W., and MacVaugh, H. Early esophagogastrostomy in the treatment of iatrogenic perforation of the distal esophagus. J Thorac Cardiouasc Surg 55:24, 1968. 53. Keen, G. The surgical management of old esophageal perforations. J Thorac Cardiovasc Surg 56:603, 1968. 54. Keighley, M. R., Girdwood, R. W., Wooler, G. H., and Ionescu, M. I. Morbidity and mortality of esophageal perforation. Thorax 27:353, 1972. 55. Kinsella, T. J., Morse, R. W., and Hertzog, A. J. Spontaneous rupture of esophagus. J Thorac Surg 17:613, 1948. 56. Levy, S. J., and Thomas, G. Partial rupture of the esophagus due to compressed air. Pvoc Mine Med O f Assoc 46:59, 1966. Esophageal perforations (collective 57. Loop, F. S., and Groves, L. K. review). Ann Thorac Surg 10:571, 1970. 58. Mackler, S. A. Spontaneous rupture of the esophagus: An experimental and clinical study. Surg Gynecol Obstet 95:345, 1952. 59. Mathewson, C. F., Dozier, W. E., Hamill, J. P., and Smith, M. Clinical experiences with perforation of the esophagus. A m J Surg 104:257, 1962. 60. May, I. A., Byrne, W. D., Yee, J., Hardy, K. L., and Samson, P. C. Left colon total bypass for benign and malignant disease of the esophagus. A m J Surg 108:204, 1964. 61. McLaughlin, R. T., Morris, J . D., and Haight, C. The morbid nature of
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62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83.
84. 85.
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the migrating foreign body in the esophagus. J Thorac Cardiovasc Surg 55: 188, 1968. Mengoli, L. R., and Klassen, K. P. Conservative management of esophageal perforation. Arch Surg 91:238, 1965. Merendino, K. A., and Dillard, D. H. The concept of sphincter substitution by an interposed jejunal segment for anatomic and physiologic abnormalities at the esophagogastric junction. Ann Surg 142486, 1955. Michelson, E., and Roque, A. H. Cervical tracheoesophageal fistula due to steering wheel injury. Ann Thorac Surg 5: 178, 1968. Middelkamp, J. N., Ferguson, T. B., Roper, C. L., and Hoffman, F. D. The management and problems of caustic burns in children. J Thorac Cardiouasc Surg 57:341, 1969. Naclerio, E. A. Chest Injuries. New York: Grune & Stratton, 1971. Nealon, T. F., Templeton, J. Y., HI, Cuddy, V. D., and Gibbon, J. H., Jr. Instrumental perforation of the esophagus. J Thorac Cardiovasc Surg 41:75, 1961. Nissen, R. Transthorakale Fundusraffung zur beeinflussung besonder Formen in Refluxoesophagitis. Langenbecks Arch Klin Chir 293:365, 1960. Noon, G. P., Beall, A. C., and DeBakey, M. E. Surgical management of penetrating esophageal injuries. J Trauma 8:458, 1968. Norton, R. A., and King, G. D. “Steakhouse syndrome”: The symptomatic lower esophageal ring. Lahey Clin Bull 13:55, 1963. Overstreet, J. W., and Ochsner, A. Traumatic rupture of the esophagus. J Thorac Surg 30: 164, 1955, Palmer, E. D., and Wirts, C. W. Survey of gastroscopic and esophagoscopic accidents. JAMA 164:2012, 1957. Paulson, D. L., Shaw, R. R., and Kee, J. L. Recognition and treatment of esophageal perforations. Ann Surg 152:13, 1960. Petrovsky, B. V., Perelman, M. I., Vantsian, E. N., and Bagirov, D. M. Palliative and radical operations for acquired esophagotracheal and esophagobronchial fistulas. Surgery 66:463, 1969. Postlethwait, R. W., Kim, S. K., and Dillon, M. L. Esophageal complications of vagotomy. Surg Gynecol Obstet 128:481, 1969. Price, J. J., Powis, S. J. A., and Morrissey, D. M. Oesophageal perforation during abdominal truncal vagotomy for duodenal ulcer. Br J Surg 59:936, 1972. Quintana, R., Bartley, T. D., and Wheat, M. W., Jr. Esophageal perforation: Analysis of 10 cases. Ann Thorac Surg 1045, 1970. Randolph, H., Melick, D. W., and Grant, A. R. Perforation of the esophagus from external trauma or blast injuries. Dis Chest 51:121, 1967. Ravitch, M. M. Conservative, radical, palliate, mitigate (editorial). Ann Thorac Surg 6:96, 1968. Reul, G. J., Jr., Mattox, K. L., Beall, A. C., Jr., and Jordan, G. L., Jr. Recent advances in the operative management of massive chest trauma. Ann Thorac Surg 16:52, 1973. Rosenberg, N., Kunderman, P. J., Vroman, L., and Moolten, S. E. Prevention of experimental lye strictures of the esophagus by cortisone. A M A Arch Surg 63:147, 1951. Samson, P. C. Postemetic rupture of esophagus. Surg Gynecol Obstet 93:221, 1951. Samson, P. C. Injuries and wounds of the esophagus: A classification. Calif Med 80:363, 1954. Samson, P. C., and Dugan, D. J. Unusual causes of dysphagia. Ann Otol Rhino1 Laryngol60:738, 1951. Samson, P. C., and Jones, R. J. Esophageal Injuries. In G. F. Madding and P. A. Kennedy (Eds), Surgical Techniques: Medical Atlas for Attorneys. San Francisco: Bancroft-Whitney, 1970. P 224.
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JONES AND SAMSON 86. Satinsky, V. P., and Kron, S. D. One-stage esophagectomy in presence of mediastinitis. A M A Arch Surg 64: 124, 1952. 87. Sengstaken, R. W., and Blakemore, A. H. Balloon tamponage for control of hemorrhage from esophageal varices. Ann Surg 131:781, 1950. 88. Seybold, W. D., Johnson, M. A., 111, and Learly, W. V. Perforation of the esophagus. Surg Clin North A m 30: 1155, 1950. 89. Skinner, D. B., and Belsey, R. H. Surgical management of esophageal reflux and hiatus hernia: Long term results with 1,030 patients. J Thorac Cardiovasc Surg 53:33, 1967. 90. Sommer, G. N., Jr., Trenton, N. J., and O’Brien, C. E. War wounds of the esophagus. J Thorac Surg 17:393, 1948. 91. Sorensen, K., and Welin, F. Foreign bodies in the esophagus: Complications of diagnostic esophagoscopy and their treatment. Acta Otolaryngol (Stockh) 54:308, 1962. 92. Spain, D. M., Molomut, N., and Haber, A. The effect of cortisone on the formation of granulation tissue in mice (abstract). A m J Pathol 26:710, 1950. 93. Storey, C. F. Acquired Surgical Lesions of the Esophagus. (Publication No. 4, The John Alexander Monograph Series on various phases of thoracic surgery.) Springfield, Ill.: Thomas, 1962. 94. Symbas, P. N., Tyras, D. H., Hatcher, C. R., Jr., and Perry, B. Penetrating wounds of the esophagus. Ann Thorac Surg 13:552, 1972. 95. Tesler, M. A., and Eisenberg, M. M. Spontaneous esophageal rupture (collective review, Znt Abstr Surg). Surg Gynecol Obstet 117:1, 1963. 96. Thal, A. P., and Hatafuku, T. Improved operation for esophageal rupture. JAMA 108:826, 1964. 97. Ware, G. W., Shnider, B. I., and Davis, E. W. Spontaneous rupture of esophagus. A M A Arch Surg 65:723, 1952. 98. Webb, W. R., Koutras, P., Ecker, R. R., and Sugg, W. L. An evaluation of steroids and antibiotics in caustic burns of the esophagus. Ann Thorac Surg 9:95, 1970. 99. Weisskopf, A. Effects of cortisone on experimental lye burns of esophagus. Ann Otol Rhinol Laryngol 61:681, 1952. 100. Wesselhoeft, C. D., and Keshishian, J. M. Acquired nonmalignant esophagotracheal and esophagobronchial fistulas (collective review). Ann Thorac Surg 6: 187, 1968. 101. Wichern, W. A. Perforation of the esophagus. A m J Surg 119:534, 1970. 102. Wiseman, H. J., Celano, E. R., and Hester, F. C., 111. Spontaneous rupture of the esophagus in a newborn infant. J Pediatr 55:207, 1959. 103. Wolff, A. P., Kuh, F. A., and Agura, J. H. Pharyngeal-esophageal perforations associated with rapid oral endotracheal intubation. Ann Otol Rhinol Laryngol81:258, 1972. 104. Worman, L. W., Hhrley, J. D., Pemberton, A. E., and Narodick, B. G. Rupture of the esophagus from external blunt trauma. Arch Surg 85:333, 1962. 105. Wychulis, A. R., Ellis, F. H., Jr., and Andersen, H. A. Acquired nonmalignant esophagotracheobronchial fistula. JAMA 196: 117, 1966. 106. Wychulis, A. R., Fontana, R. S., and Payne, W. S. Instrumental perforations of the esophagus. Dis Chest 55: 184, 1969. 107. Yarington, C. T., Jr., Bales, G. A., and Frazer, J. P. A study of the management of caustic esophageal trauma. Ann Otol Rhinol Laryngol 73: 1130, 1964. 108. Zikria, B. A., Rosenthal, A. D., and Potter, R. T. Mallory-Weiss syndrome and emetogenic spontaneous rupture of the esophagus. Ann Surg 162:151, 1965.
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Esophageal Injury Reinold J. Jones, M.D., and Paul C. Samson, M.D. ABSTRACT This review considers all possible modes of esophageal injury, based on a schema originally published in 1954 and more recently modified in 1970. For each category of injury there are detailed discussions of diagnosis and treatment. The best available knowledge of present-day modalities has been based on a survey of the literature for the past decade. When diverse methods of treatment were encountered, we have made comments consistent with our personal experience, when appropriate. The medicolegal literature contains a number of references to esophageal injury. Certain excerpts dealing with several types of potential actions are extracted: (1) suits to recover damages for esophageal perforation in which negligent endoscopy was claimed; (2) suits following endoscopic accidents in which lack of informed consent was claimed; and (3) suits for professional liability based on misdiagnosis, delayed diagnosis, or wrong treatment of esophageal perforation.
T
rauma to the esophagus has long been a diagnostic and therapeutic problem for both internist and surgeon. In 1954 a new schema for the classification of esophageal injury was suggested [83],and it was republished in modified form in 1970 [85]. The present review endeavors to classify the modalities of injury according to this outline and presents what we consider to be major developments leading to the current standards of therapy. During the past ten years several excellent collective and current reviews covering various aspects of esophageal injury have appeared: Tesler and Eisenberg (1963) [95], Hughes (1965) [48], Bolsted (1966) [13], Wesselhoeft and Keshishian (1968) [loo], Loop and Groves (1970) [57], and Feldman and associates (1973) [33]. From the Division of Cardiothoracic Surgery, Mary’s Help and St. Mary’s Hospitals, the University of California, San Francisco, School of Medicine, San Francisco, and the Division of Thoracic and Cardiac Surgery, Highland General Hospital, Oakland, Calif. Address reprint requests to Dr. Jones, 2645 Ocean Ave., San F’rancisco, Calif. 94132.
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Classification of Esophageal I n j u r y T h e most recent classification of esophageal injury 1831 is given in outline form below. I. Extraluminal causes of injury. Includes wounding, blunt external trauma, and operative accidents, either to esophagus or to adjacent organs 11. Intraluminal causes of injury A. Intrinsic (pressure from within body): complete and incomplete rupture B. Extrinsic (pressure mechanisms from outside body) 1. Foreign body sojourn with or without perforation 2. Perforation-instrumental or other 3. Ingestion-caustics, acids 111. Complications of injury. Includes abscess, fistula, stricture EXTRALUMINAL CAUSES OF IN JURY
Penetrating and perforating wounds of the esophagus are uncommon due to the anatomical position of this structure. If external wounds are incurred sufficient to penetrate the esophagus, there is frequently severe associated injury to surrounding vital structures [go]. T h e cervical esophagus is the most common segment perforated by gunshot and knife wounds [2, 691. Treatment of the perforation is standardized, but the greatest error is overlooking esophageal trauma when there is associated cardiac, great vessel, or pulmonary injury. Blunt trauma per se causes far fewer esophageal injuries but must be considered if severe crushing has occurred [78, 1041. Tracheoesophageal fistula has been reported following a steering wheel injury in the cervical area [64]. Operative injury is also classified as extraluminal or external trauma. Vagotomy and pyloroplasty have become two of the standard surgical modalities for peptic ulcer disease. Postlethwait and associates [75] report an incidence of 0.54% of perforated esophagus in 4,414 operations reviewed. Others report a similar occurrence of this complication [42, 761. Hiatal hernia repair in which sutures through the esophageal muscularis are utilized as part of the repair can cause a tear of the esophageal wall if placed too deeply or with undue tension [89]. T h e same problem of esophageal fistula or abscess can occur with the transabdominal repair of hiatal hernia either when the arcuate ligament is employed as an anchor or when using fundoplication [43,681. INTRALUMINAL CAUSES OF IN JURY
Intrinsic. T h e most common intrinsic rupture is on the basis of increased pressure from forceful or prolonged emesis. T h e entity was first described by Boerhaave in 1724 [12].
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Most cases of postemetic esophageal rupture follow excessive alcoho or food intake [27, 581. The tear is usually in the lower third of the posterolateral wall. The majority of “spontaneous” or postemetic ruptures occur in normal esophagi and not in patients with esophagitis or ulcer, as would be expected [44]. Spontaneous rupture unrelated to alcohol intakc [97] and also in the newborn has been reported [102]. Likewise, there a n reports of “spontaneous” rupture which occurred without emesis bui following blunt trauma, forceful childbirth, heavy lifting, and seizures. Ir these situations some authors have postulated that there was a preexisting esophageal abnormality, usually esophagitis [55]. Even forceful swallowing in the absence of regurgitation has been reported as sufficient to cause rupture of the distal esophagus [25]. Esophagomalacia predisposes tc esophageal injury and is associated particularly with hypothalamic disorder! resulting in muscle incoordination [57]. Incomplete rupture with resultant hemorrhage is frequently related tc forceful emesis. The most common manifestation of this injury is a mucosal tear in the gastric fundus, the Mallory-Weiss syndrome [32, 1081. The teal may extend through the esophagogastric junction and involve the mucosa 01 the distal esophagus. Extrinsic Pressure (Mechanism from Outside Body). Foreign Bod) Sojourn. Most ingested objects pass through the intestinal tract causing nc injury. Due to size or configuration, however, many become lodged in the esophagus. Foreign body retention is increased by the presence of stricture or tumor of the esophagus. The majority of foreign bodies are found in the esophagi of children because of their propensity to put objects in their mouth [49]. Other common causes for foreign body retention combine an overintake of alcohol with complete dentures. This has resulted in obstruction from a bone, incompletely masticated food, and even cocktail toothpicks. The steak house syndrome [70] and cafe coronary [41] could be listed in this category. Patients with dentures have a greater incidence 01 hard foreign bodies in the esophageal lumen since they are unable to sense the object with a denture in place [57]. The foreign body may penetrate or perforate the esophageal wall. More severe is the perforation caused by attempted instrumental removal, either by a poorly trained endoscopist or by one who is trying to push the foreign body ahead of the endoscope and into the stomach. Although most perforations due to a foreign body are caused by a sharp edge penetrating the esophagus, pressure necrosis with breakdown of the esophageal wall may also occur. In children this has been associated with migration of the object into the pleural cavity or the major vessels [61]. Instrumental or Other Perforations. Iatrogenic injury is one of the common causes of esophageal perforation. The reported incidence from esophagoscopy varies from 0.2 to 2yo [106]. The majority of rigid tube esophagoscopies are now performed under general anesthesia, and this has
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apparently decreased the incidence of perforation. Esophagogastroscopy using the fiberoptic instrument seems to carry a lesser incidence of perforation [72, 1061. The most common area of perforation from an endoscopic examination with a rigid tube is in the region of the cricopharyngeus muscle [88]. There are numerous reasons for this: (1) anatomical configuration due to the posterior muscular band; (2) inadequate anesthesia; (3) failure of the anesthesiologist to deflate the endotracheal balloon; and (4) fused or spurred cervical vertebrae. Dilating the esophagus likewise carries a risk of perforation. Most dilations are performed for stricture, and this means forcing a bougie through diseased tissue. Poor visibility and bougienage ahead of the endoscope can cause perforation without the operator’s knowledge. Early dilation in burns may predispose to perforation when there is mucosal edema and injured esophageal wall [39]. Biopsy of the esophageal mucosa, particularly when using the rigid instrument, has been a fairly frequent cause of perforation [85, 1061. This seldom occurs in grossly apparent malignancy but rather in patients with esophagitis or normal mucosa. Perforation is more likely if the biopsy is done blind with the forceps placed beyond the operator’s visual field. Apparently biopsy is much safer when small forceps are used with the more immediate visualization offered by the fiberscope. Other tubes in the esophagus have caused injury. Endotracheal tubes have been inadvertently passed and caused either laceration or perforation [103]. The Sengstaken-Blakemore tube has led to perforation of the esophagus from a variety of causes [9, 24, 871. Patients have pulled the inflated gastric balloon out of the stomach with resultant rupture of the esophagus [191. Prolonged inflation and traction, particularly of the gastric balloon, can cause pressure necrosis of the stomach and distal esophagus [19]. The hydrostatic balloon, formerly used as part of the standard treatment of achalasia, can split the mucosa of the esophagus as well as the muscularis [30, 3 11. Palliation of carcinoma of the esophagus has been accomplished by the use of various semirigid tubes [1, 201. Such devices have occasionally perforated a tumor during introduction. The tube may also erode through the esophagus, especially at its flanged edge [106]. Finally, there have been isolated reports of rupture by air blast [7, 56, 781 and self-catheterization [15] and by sword swallowing, among other esoteric occupations. Esophageal Burns. The ingestion of caustic agents or acids may result in minimal mucosal damage, may severely burn the gullet with eventual stricture, or may perforate the esophagus, causing mediastinitis or an esophageal-airway fistula [ 1001. Unfortunately, children are frequently the victims of carelessness, while adults ingest injurious solutions either inadvertently or with suicidal intent [85].
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Diagnosis Perforating wounds of the neck and thorax, depending on their location and direction, should lead the surgeon to consider possible esophageal injury [94].If esophageal penetration is suspected and the patient’s condition is stable, an esophagogram done preoperatively will confirm and localize the site of injury [57]. T h e symptoms of intraluminal esophageal perforation-whether by instrument, foreign body, or emesis-vary according to the location and size of the perforation, the rapidity with which the perforation develops, and whether or not an esophagotracheobronchial fistula occurs. All perforations, however, are accompanied by fever, rapid pulse, general malaise, and leukocytosis. In the cervical esophagus the clinical combination of pain, swelling, point tenderness or crepitation, and sternocleidomastoid irritation have been well documented [84]. Perforation of the thoracic esophagus may or may not be dramatic [85]. Shoulder pain and a nasal twang to the voice are frequently noted [82].Air in the mediastinum is a common finding and can be considered diagnostic [ 161. Swallowing, deep breathing, and motion greatly increase the patient’s pain. As time passes in an untreated patient, the progressive mediastinal contamination usually results in clinical shock. Perforation of the abdominal esophagus brings on the whole train of symptoms and signs associated with any perforation of a hollow viscus in the abdomen: pain, tenderness, splinting, rigidity, and shock [35]. T h e diagnosis of esophagotracheobronchial fistula is suspected by the additional symptoms of shortness of breath, hemoptysis, dysphagia, and cough [IOO]. The symptoms may come on shortly after injury or they may be delayed. Perforation of the esophagus due to endoscopy is usually recognized at the time by the endoscopist. If perforation is not immediately suspected, the signs and symptoms rapidly appear shortly after the procedure. A high index of suspicion after a difficult endoscopic examination should alert the surgeon to an early recognition of perforation. Definitive diagnosis is made by having the patient swallow contrast material. There is controversy over the use of barium in suspected perforation since many believe it will cause a more severe mediastinitis [73], and iodinated contrast material is advocated instead [ZI]. Many foreign bodies are radiopaque, and a routine chest film will disclose the object and the level of the esophagus at which it is lodged. For nonopaque foreign bodies it is necessary to have the patient swallow contrast material to confirm the presence of the object and its location. Some small spicules of bones are best localized by having the patient swallow a pledget of cotton that has been saturated with a contrast medium. Burns of the esophagus are usually diagnosed by history alone. T h e type
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of ingested material, whether caustic or acid, is frequently known. Burns or even ulceration of the lips and oropharynx are seen. T h e patient has severe pain which is aggravated by attempts at swallowing. Esophagoscopy is often considered to delineate the extent of the burn and to grade its severity [Z]. As endoscopy is only diagnostic, no attempt should be made to advance the scope once ulceration, edema, or bleeding is observed [26]. T h e extent of the mucosal injury can then be evaluated by an esophagogram [65].
Treatment When external penetrating or perforating wounds of the esophagus become manifest, there frequently are associated injuries to adjacent major structures [SO]. Exploration is mandatory in these patients, often for the control of severe hemorrhage. One must be always on the alert for an esophageal rent which could later lead to life-threatening complications [66]. T h e esophageal injury is exposed and debrided if nonviable edges are seen. A primary two-layered closure is then effected, if possible. Adequate drainage is essential. T h e morbidity and mortality are far less with cervical perforation than with intrathoracic esophageal injury [ 101. In the case of thoracic injury, wide opening of the pleura and copious lavage are done to ensure drainage and prevent mediastinal contamination. T h e prognosis not only depends on the immediacy of treatment but is further predicated on the size and site of perforation [54]. Foreign bodies are usually extracted by endoscopy, but if this is not feasible, a cervical or thoracic esophagotomy may be necessary for their removal [57]. The belief has grown over the years that esophageal rupture (spontaneous, postemetic, or from any other cause) must be recognized early and definitive therapy immediately instituted [8, 58, 83, 1061. Early operation, repair, and drainage are essential for survival [7 11. Correction of shock, appropriate antibiotic coverage, and a two-layered closure are carried out. T h e blood supply of the esophagus is tenuous and segmental, and the lack of serosa is a hindrance to adequate anastomosis. There must be care in technique and avoidance of tension on suture lines or else the sutures may tear, resulting in fistula and abscess formation. Hyperalimentation has proved valuable in the postoperative recovery period, affording a period of rest for the repaired esophagus with the patient remaining in positive nitrogen balance [29]. Opinion is far from unanimous on how instrumental or foreign body perforations should be handled. T h e choice between surgical and nonsurgical treatment is still frequently discussed. Together with Groves [37] and Ravitch [79], we object to equating nonoperative therapy with “conservative’’ management. One may well question the use of the word conservative in this connection since it implies that surgical intervention is therefore radical. There is considerable argument to suggest that the reverse may be
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true: that operative treatment is conservative and nonoperative treatment radical. T h e majority of writers hold that virtually all perforations of the esophagus are dangerous, if not potentially lethal. They tend to bring all modalities to bear on treatment, including-it is hoped-early diagnosis, massive antibiotic therapy, and prompt exposure of the esophageal rent, usually followed by suture repair and adequate drainage [lo, 30, 67, 73, 77, 85, 93, 101, 1061. There are those who concede that large tears require prompt operative intervention but that nonoperative (conservative?) treatment will suffice in the remainder [28, 40, 59, 62, 911. In general they argue-with some validity-that the size, location, and rapidity with which the laceration develops and the condition of the esophageal wall are important in determining the deadliness of the perforation. At one extreme is the classic postemetic rupture, a sudden large tear in the normal esophagus with overwhelming intrathoracic contamination. Should the patient not have definitive operation, or should drainage be inadequate, death is inevitable. At the other extreme is the slowly developing, tiny perforation from a sharp foreign body, particularly in the cervical region or proximal to an old inflammatory stricture, which carries little likelihood of serious consequence. Between these two examples lie all gradations of damage and danger. Apparently there are only a few proponents of primary nonoperative management for esophageal perforation, and the numbers of patients treated this way are small [6, 621. T h e essentials of nonoperative treatment are these: all feedings are discontinued, nasogastric suction is instituted, and closed intercostal drainage is used if there is pleural fluid or air. Massive antibiotic coverage is employed, consisting of 10 million units of penicillin and 1 gm of streptomycin a day. At least part of this is given intravenously [621* Since those physicians who put primary dependence on a nonoperative regimen are apparently in the minority, they must be prepared to defend their choice of treatment [45]. If this routine does not cause progressive clinical and roentgenographic improvement within six to twelve hours, one may seriously question any decision to persist with a conservative attitude. T h e fallacy of depending upon a strictly medical regimen lies in the possible misinterpretation of signs and symptoms. One cannot always be sure that the rent is indeed a small one [34]. T h e physician may be lulled into a false sense of security because the patient seems to be doing reasonably well. It is not a rarity under these circumstances for the practitioner to realize belatedly that a fully established abscess or mediastinitis has severely reduced the patient’s chances for uncomplicated recovery [57, 67,851. Perforations associated with distal abnormalities such as stricture or malignancy present a different therapeutic problem. There have been reports of successful one-stage management with removal of the lesion, drainage, and an appropriate reconstructive procedure [11, 521. Reconstruc~~
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tion of the esophagus has been accomplished using the stomach, colon, or small bowel; some rents have been closed using the gastric fundus as a patch [ l l , 63, 86, 961. In some patients a significant period has elapsed before a diagnosis is made and operative intervention instituted. If these patients survive, primary resection or closure is not judicious, and there is still a place for an esophageal exclusion procedure [51]. After the acute infection has been cleared by drainage and antibiotics, the blind loop of the esophagus is removed and the esophagus reconstituted, usually by colon interposition [531The modern treatment for traumatic esophagotracheobronchial fistula is direct operative intervention with isolation, division, and closure of the fistula [5, 74, 100, 1051. If possible, pleural or other soft tissue should be interposed between the suture lines in the esophagus and airway. If the fistula is in the neck, a cervical incision may be employed, perhaps combined with either mediastinotomy or resection of the medial end of the clavicle or both [23]. Most intrathoracic fistulas can be exposed through a right thoracotomy. It is to be hoped that the diagnosis will not be too long delayed since there is danger of extensive pulmonary damage, although longstanding fistulas have been successfully divided [22].
Treatment of Caustic Injuries There are two schools of thought in the management of injuries caused by caustic substances: (1) use of early and continued dilation [39]; and (2) use of systemic steroids and antibiotics without dilation, with the hope of precluding damage to the inflamed mucosa [38]. In either type of management, the extent and degree of injury is verified if possible. This is commonly accomplished by esophagoscopy and esophagograms [ 1071. It is most important that the esophagoscope reaches only to the top of the burn [26]. In the experience of some, esophagoscopy in children carries too great a complication rate and should not be performed [14]. In spite of one experimental model to the contrary [19], nearly all authors are convinced that the early massive use of corticosteroids has an inhibitory effect on fibroblastic proliferation and the formation of granulation and scar tissue [33, 81, 921. Steroids must be administered within the first forty-eight hours to have a maximal effect [99]. I n addition the concomitant use of antibiotics has been widely accepted, and many authors believe this combination of therapies to be adequate r47, 981. Others, however, believe strongly that there should be a repeat esophagoscopy two to three weeks following injury with dilation being performed as needed until healing is complete [14]. Repeat esophagograms should be obtained at intervals to allow early detection of a delayed stricture. In spite of adequate initial care and good follow-up management, in
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some patients strictures will occur which necessitate careful, sometimes prolonged bougienage and occasionally esophageal replacement. This is particularly true in patients with third-degree burns. Or the physician may see a patient who was inadequately treated at the onset and is now beyond the point of being helped by less radical modes of therapy. When extensive second- and third-degree burns are encountered, attempts to have the patient swallow a string are commenced as soon as a liquid diet can be tolerated. If the patient is seen more than forty-eight hours after the accident, antibiotics should be administered but no steroids. Bougienage can then be started early but should not be used during or immediately following a course of steroid therapy [46]. One may use either mercury-filled Hurst or tapered Maloney bougies or the Tucker or Plummer type of olive-tipped bougie, using the previously swallowed string as a guide. If a gastrostomy has been necessary for feeding purposes, retrograde esophageal dilation is possible. A relatively normal esophageal lumen may be established after the discovery of a tight stricture or even atresia. Rarely what appears to be an atretic lumen may turn out to be a long, relatively normal esophageal segment between two tight, weblike strictures. Recannulation and dilation are then rapidly successful [47]. When all attempts at dilation fail, the surgeon must resort to excision and replacement of the diseased segment of esophagus [17]. If the stricture extends to the oropharynx and the anastomosis must be made in the cervical region, the stomach is usually too bulky as a replacement, especially in children. A reverse gastric tube is technically possible for a pullthrough to the neck, but arterial incompetence or venous stasis may doom the procedure. In a recent report, however, good results were reported when a reverse gastric tube was used for esophageal replacement in children [4]. Excision of a midthoracic stricture or the rare lower thoracic stricture may be easily accomplished by using the stomach as a replacement. The small intestine is an attractive replacement [63]; reflux esophagitis is usually precluded by this technique, although an adequate vascular supply may be a problem if a long length of the small bowel is necessary. The most satisfactory replacement is probably the colon. Both right and left colon have been favored [36, 601. Proponents of the right colon point out the desirability of anastomosing the distal ileum to the esophagus because of their close approximation in size. The left colon is easily mobilized, and the blood supply is adequate for establishing a cervical anastomosis without fear of necrosis. The segment of bowel considered for interposition may be brought up alongside the esophagus (less desirable), anterior to the sternum in a subcutaneous tunnel, or retrosternally. Since the procedure is done for benign disease and frequently in young patients, the retrosternal position is usually considered preferable [60]. Removal of the strictured segment of esophagus has been considered.
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Usually this will have to be performed as a second-stage procedure. Since there is at least some evidence of a long-delayed but increased incidence of carcinoma in the battered esophagus, many authors believe that it should be removed sooner or later [50], From time to time the ingestion of solid granules of a caustic substance or of certain acids may cause little or no esophageal injury. Close observation is necessary, however, because the noxious material may rapidly erode and perforate the gastric wall. This requires immediate laparotomy, peritoneal lavage, and closure of the perforation or resection.
Medicolegal Aspects of Esophageal Perforation and Rupture .
A general survey of the implications of liability in esophageal perforation has been assembled by Angela R. Holder [45]. This review plus a few other legal references form the basis for the following discussion. It is not surprising that esophageal disruption leads to medicolegal involvements from time to time. Potential actions may be reviewed under the following headings: 1. Suits to recover damages for esophageal perforation in which negligent endoscopy is claimed. Statistics quoted previously indicate that perforation is a known hazard of endoscopy even in the best of hands [106]. The courts therefore generally have held that the fact of esophageal perforation does not in and of itself imply negligence. When normal procedures are conducted in accordance with approved practice, negligence will not be inferred just because there has been an inadvertent perforation. Negligence in such cases is held to occur only when the physician has not met the required standard of due care which he owes his patient. A Colorado general practitioner was sued for causing an esophageal perforation while attempting to “wipe out” a bone lodged in the esophagus. Expert medical testimony indicated that the method used was not in conformity with good Fedical practice. When a decision was made that “due care” had not been used, the appeals court upheld the jury’s award of damage to the plaintiff. Expert medical testimony generally is necessary because the causes of esophageal perforation are outside the competence of a lay jury to understand, and the doctrine of res ipsa loquitur is usually held inapplicable. In an Illinois decision, however, expert testimony was not required since the endoscopist had lifted the patient up to show an intern the proper position of the tube. The court held it was obvious that the physician’s action indicated improper use of the procedure (gastroscopy) and thus was sufficient to establish a prima facie case of negligence. 2. Suits following endoscopic accidents in which lack of informed consent was claimed. It has been held on a number of occasions that “informed consent” does not necessarily include a specific discussion of the possibility of esophageal perforation. For example, when esophageal
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perforation resulted in a suit against a Washington physician, the court held that the low incidence of perforation eliminated it as a “reasonably foreseeable risk” and that there was no cause for action against the physician for his failure to mention perforation specifically as a risk in endoscopic procedures. Considered strictly from a legal standpoint, however, it is probably sounder nowadays to indicate beforehand that esophageal perforation occasionally occurs during endoscopy despite precautions, particularly if the surrounding circumstances are such that the consent of a reasonable person who is not a physician might be affected materially. In addition, the recent decision handed down by the California Supreme Court (Cobb vs. Grant, 8 California 3d 229) eventually may have a tremendous impact upon the physician’s responsibility to obtain a patient’s “informed consent” before providing any medical or surgical treatment. 3. Suits for professional liability based on misdiagnosis, delayed diagnosis, or wrong treatment of esophageal perforation or rupture. A Michigan physician died in Florida as the result of postemetic rupture of the esophagus, and a malpractice suit was filed on behalf of the widow. T h e failure of the radiologist to diagnose free air in the mediastinum when the patient was first admitted to the hospital resulted in a delay in diagnosis of some thirty hours, which was believed to have greatly lessened the patient’s chances for recovery; liability was imposed. A Louisiana doctor admitted puncturing the patient’s esophagus while performing an esophagoscopy. He did not operate after discovering the perforation and tried other methods of dealing with the problem. T h e plaintiff presented expert testimony that the defendant wrongly prescribed an unsterile diet for the patient. The subsequent infection sustained by the patient required at least three major operations for its control. T h e jury found for the plaintiff patient.
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JONES AND SAMSON 35. Graham, J., Barnes, N., and Rubenstein, A. S. Rupture of esophagus stimulating rupture of stomach. Arch Surg 83:306, 1961. 36. Gross, R. E., and Firestone, F. N. Colonic reconstruction of the esophagus in infants and children. Surgery 61:955, 1967. 37. Groves, L. K. Instrumental perforation of the esophagus: What is conservative management? J Thorac Cardiovasc Surg 52: 1, 1966. 38. Haller, J. A., Andrews, H. G., White, J. J., Tamer, M. A., and Cleveland, W. A. Pathophysiology and management of acute corrosive burns of the esophagus: Results of treatment in 285 children. J Pediatr Surg 6:578, 1971. 39. Haller, J. A., and Bachman, K. The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics 34:236, 1964. 40. Hardin, W. J., Hardy, J. D., and Conn, J. H. Esophageal perforations. Surg Gynecol Obstet 124:325, 1967. 41. Haugen, R. K. The cafk coronary. JAMA 186:142, 1963. 42. Hauser, J. B., and Lucas, R. J. Esophageal perforation during vagotomy. Arch Surg 101:466, 1970. 43. Hill, L. D. An effective operation for hiatal hernia: An eight year appraisal. Ann Surg 166:681, 1967. 44. Hochberg, L. A., and Parlamis, H. Spontaneous perforation and rupture of the esophagus with a report of five cases. A m J Surg 102:428, 1961. 45. Holder, A. R. Liability for esophageal perforation. JAMA 216:1399, 1971. 46. Holinger, P. H. Management of esophageal lesions caused by chemical burns. Ann Otol Rhino1 Laryngol77:819, 1968. 47. Holinger, P. H., Johnston, K. C., Potts, W. J., and DaCunha, F. The conservative and surgical management of benign strictures of the esophagus. J Thorac Surg 28:345, 1954. 48. Hughes, R. K. Thoracic trauma. Ann Thorac Surg 1:778, 1965. 49. Jackson, C. L. Foreign bodies in the esophagus. A m J Surg 93:308, 1957. The role of benign esophageal 50. Jaske, R. A., and Benedict, E. B. obstruction in the development of carcinoma of the esophagus. Gastroenterology 36:749, 1959. 51. Johnson, J., Schwegman, C. W., and Kirby, C. K. Esophageal exclusion for persistent fistula following spontaneous rupture of the esophagus. J Thorac Surg 32:827, 1956. 52. Johnson, J,, Schwegman, C. W., and MacVaugh, H. Early esophagogastrostomy in the treatment of iatrogenic perforation of the distal esophagus. J Thorac Cardiouasc Surg 55:24, 1968. 53. Keen, G. The surgical management of old esophageal perforations. J Thorac Cardiovasc Surg 56:603, 1968. 54. Keighley, M. R., Girdwood, R. W., Wooler, G. H., and Ionescu, M. I. Morbidity and mortality of esophageal perforation. Thorax 27:353, 1972. 55. Kinsella, T. J., Morse, R. W., and Hertzog, A. J. Spontaneous rupture of esophagus. J Thorac Surg 17:613, 1948. 56. Levy, S. J., and Thomas, G. Partial rupture of the esophagus due to compressed air. Pvoc Mine Med O f Assoc 46:59, 1966. Esophageal perforations (collective 57. Loop, F. S., and Groves, L. K. review). Ann Thorac Surg 10:571, 1970. 58. Mackler, S. A. Spontaneous rupture of the esophagus: An experimental and clinical study. Surg Gynecol Obstet 95:345, 1952. 59. Mathewson, C. F., Dozier, W. E., Hamill, J. P., and Smith, M. Clinical experiences with perforation of the esophagus. A m J Surg 104:257, 1962. 60. May, I. A., Byrne, W. D., Yee, J., Hardy, K. L., and Samson, P. C. Left colon total bypass for benign and malignant disease of the esophagus. A m J Surg 108:204, 1964. 61. McLaughlin, R. T., Morris, J . D., and Haight, C. The morbid nature of
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