Spontaneous Perforation of the Cervical Esophagus R.
Randolph Bradham, MD; Charlton deSaussure, MD;
A. Lawrence
\s=b\ A rare case of spontaneous rupture of the cervical esophagus occurred during vomiting after eating. The plain x-ray film showed air in the neck, but barium swallow did not reveal the perforation. Operation performed two days later because of bleeding consisted of suturing two rents in the anterior wall of the cervical esophagus distal to the cricopharyngeus muscle, and the patient did well. The mechanism causing such a perforation is not well understood. With the absence of bleeding, treatment would ordinarily consist of drainage without suture.
(Arch Surg 111:284-285, 1976)
of "spontaneous" rupture of the cervical esophagus. It is an unusual case, and on reviewing many articles on perforation of the esoph¬ agus, only one other case was found,1 which was referred to in a collective review of Tesler and Eisenberg.2 Other extensive reviews did not mention such a case.36
This
report
concerns a case
Lemel, MD
The
patient
was
observed and remained afebrile. The chest
roentgenogram remained normal. The crepitus disappeared. The
reading dropped from 37% to 32%. Two units of blood given on Oct 9, but by the next morning the hematocrit read¬
hematocrit were
was 25%. There was still no evidence of infection. Because of the evidence that bleeding was continuing, operation was performed on the morning of Oct 10. The cervical esophagus was exposed through a right vertical oblique incision conforming to the anterior border of the sternocleidomastoid muscle. The esophagus was mobilized but the perforation was not found. The
ing
Lateral roentgenogram of neck showing air in soft tissue rior to esophagus and anterior to neck.
REPORT OF A CASE Our patient was a 50-year-old woman who vomited after eating chicken on the evening of Oct 8, 1970. She complained of a severe pain in her neck and was seen soon thereafter by one of us (CD.) in the emergency room. She emphatically denied swallowing any bone. The pharynx was mildly edematous. While in the emergency room, she vomited 1,000 ml of bright blood. A plain x-ray film of the neck revealed air between the cervical spine and posterior esophageal wall (Figure). Barium swallow did not confirm perfo¬ ration of the esophagus. There was no evidence of pneumomediastinum. The patient had been in good health and denied having had dysphagia. She was pale and there was crepitation in the neck. The hemoglobin level was 13.3 gm/100 ml and the hemato¬ crit reading was 40%.
Accepted for publication Oct 28, 1975. From the departments of surgery (Dr Bradham), medicine (Dr deSaussure), and otolaryngology (Dr Lemel), Roper Hospital, Charleston, SC. Reprint requests to Suite 2-J, The Ashley House, Charleston, SC 29401 (Dr Bradham).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/15/2015
poste¬
esophagus was
then
opened through
a
lateral wall incision. There
two rents in the anterior wall of the cervical esophagus just distal to the cricopharyngeus muscle, measuring 1 and 4 cm in were
extended through the wall. There was no bleeding. The remainder of the esophagus was visualized with an esophagoscope and no other abnormalities were found. A biopsy study was done of the edge of the larger perforation and this specimen was reported as necrotic and inflamed tissue. The rents were su¬ tured from the interior of the esophagus. The esophagotomy was closed in two layers, and the neck was drained adequately. Oral nourishment was withheld for five days and appropriate antibiotic therapy was administered. On the fifth postoperative day, an esophagogram with a water-soluble contrast medium revealed no extravasation. Healing progressed satisfactorily and the patient was discharged on the tenth postoperative day. There has been no subsequent dysphagia during the four years since this occurred.
length, which
COMMENT
The mechanism that caused this perforation is not un¬ derstood. There was no evidence of a cervical diverticulum, nor did the patient have any antecedent symp¬ toms suggesting abnormal neuromuscular function of the esophagus. It is conceivable that the patient had an acute episode of lower esophageal spasm and a closed crico¬ pharyngeus muscle above that created a closed segment with increased intraluminal pressure. The plain x-ray film showed air in the neck, but none was seen in the mediastinum, which indicated that the perforation was probably in the cervical esophagus. A bar¬ ium swallow was done, but evidently the rents were stuck together sufficiently so that none of the barium pene¬ trated through these defects. In this situation or in instru¬ mental perforation, it is important to try to locate the level of the perforation, as those in the neck and chest might be managed differently. Both a swallow with a
weak barium solution or water-soluble contrast medium and esophagoscopy might be helpful. The perforations in the thorax, unlike those in the neck, are subject to a negative pressure, and the esophagus is not surrounded by supporting structures in the thorax as it is in the neck. Therefore, perforations in the neck will usually heal if adequately drained, whereas those in the thorax should have an attempt at closure as well as ex¬ tremely good drainage of the mediastinum and pleural
cavity.
The indication for closure of the perforation in our case the continued bleeding. Confronted with a cervical perforation again, immediate drainage will be done and not delayed as in this case. It is fortunate that this patient did not develop an infection. The operative approach was very satisfactory, as it al¬ lowed good exposure of the cervical esophagus with an excellent opportunity to inspect the remainder of the esophagus with an esophagoscope. The technique of this operative approach is described well by Pearse.7
was
References 1. Russell JY:
Spontaneous perforation
of the
esophagus.
Br J
Surg
40:312-318, 1953. 2. Tesler MA, Eisenberg MM: Spontaneous esophageal rupture: Collective review. Int Abstracts Surg 117:1-10, 1963. 3. Loop FD, Groves LK: Esophageal perforations: Collective review. Ann Thorac Surg 10:571-587, 1970. 4. Miller AC Jr, Hirschowitz BI: Twenty-three patients with Mallory\x=req-\ Weiss syndrome. South Med J 63:441-444, 1970. 5. Postlethwait RW, Sealy WC: Surgery of the Esophagus. Springfield, Ill, Charles C Thomas Publisher, 1961. 6. Wichern WA: Perforation of the esophagus. Am J Surg 119:534-536, 1970. 7. Pearse HE Jr: The
operation for perforation of the cervical esophagus. Surg Gynecol Obstet 56:192-196, 1933.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/15/2015
Randolph Bradham, MD; Charlton deSaussure, MD;
A. Lawrence
\s=b\ A rare case of spontaneous rupture of the cervical esophagus occurred during vomiting after eating. The plain x-ray film showed air in the neck, but barium swallow did not reveal the perforation. Operation performed two days later because of bleeding consisted of suturing two rents in the anterior wall of the cervical esophagus distal to the cricopharyngeus muscle, and the patient did well. The mechanism causing such a perforation is not well understood. With the absence of bleeding, treatment would ordinarily consist of drainage without suture.
(Arch Surg 111:284-285, 1976)
of "spontaneous" rupture of the cervical esophagus. It is an unusual case, and on reviewing many articles on perforation of the esoph¬ agus, only one other case was found,1 which was referred to in a collective review of Tesler and Eisenberg.2 Other extensive reviews did not mention such a case.36
This
report
concerns a case
Lemel, MD
The
patient
was
observed and remained afebrile. The chest
roentgenogram remained normal. The crepitus disappeared. The
reading dropped from 37% to 32%. Two units of blood given on Oct 9, but by the next morning the hematocrit read¬
hematocrit were
was 25%. There was still no evidence of infection. Because of the evidence that bleeding was continuing, operation was performed on the morning of Oct 10. The cervical esophagus was exposed through a right vertical oblique incision conforming to the anterior border of the sternocleidomastoid muscle. The esophagus was mobilized but the perforation was not found. The
ing
Lateral roentgenogram of neck showing air in soft tissue rior to esophagus and anterior to neck.
REPORT OF A CASE Our patient was a 50-year-old woman who vomited after eating chicken on the evening of Oct 8, 1970. She complained of a severe pain in her neck and was seen soon thereafter by one of us (CD.) in the emergency room. She emphatically denied swallowing any bone. The pharynx was mildly edematous. While in the emergency room, she vomited 1,000 ml of bright blood. A plain x-ray film of the neck revealed air between the cervical spine and posterior esophageal wall (Figure). Barium swallow did not confirm perfo¬ ration of the esophagus. There was no evidence of pneumomediastinum. The patient had been in good health and denied having had dysphagia. She was pale and there was crepitation in the neck. The hemoglobin level was 13.3 gm/100 ml and the hemato¬ crit reading was 40%.
Accepted for publication Oct 28, 1975. From the departments of surgery (Dr Bradham), medicine (Dr deSaussure), and otolaryngology (Dr Lemel), Roper Hospital, Charleston, SC. Reprint requests to Suite 2-J, The Ashley House, Charleston, SC 29401 (Dr Bradham).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/15/2015
poste¬
esophagus was
then
opened through
a
lateral wall incision. There
two rents in the anterior wall of the cervical esophagus just distal to the cricopharyngeus muscle, measuring 1 and 4 cm in were
extended through the wall. There was no bleeding. The remainder of the esophagus was visualized with an esophagoscope and no other abnormalities were found. A biopsy study was done of the edge of the larger perforation and this specimen was reported as necrotic and inflamed tissue. The rents were su¬ tured from the interior of the esophagus. The esophagotomy was closed in two layers, and the neck was drained adequately. Oral nourishment was withheld for five days and appropriate antibiotic therapy was administered. On the fifth postoperative day, an esophagogram with a water-soluble contrast medium revealed no extravasation. Healing progressed satisfactorily and the patient was discharged on the tenth postoperative day. There has been no subsequent dysphagia during the four years since this occurred.
length, which
COMMENT
The mechanism that caused this perforation is not un¬ derstood. There was no evidence of a cervical diverticulum, nor did the patient have any antecedent symp¬ toms suggesting abnormal neuromuscular function of the esophagus. It is conceivable that the patient had an acute episode of lower esophageal spasm and a closed crico¬ pharyngeus muscle above that created a closed segment with increased intraluminal pressure. The plain x-ray film showed air in the neck, but none was seen in the mediastinum, which indicated that the perforation was probably in the cervical esophagus. A bar¬ ium swallow was done, but evidently the rents were stuck together sufficiently so that none of the barium pene¬ trated through these defects. In this situation or in instru¬ mental perforation, it is important to try to locate the level of the perforation, as those in the neck and chest might be managed differently. Both a swallow with a
weak barium solution or water-soluble contrast medium and esophagoscopy might be helpful. The perforations in the thorax, unlike those in the neck, are subject to a negative pressure, and the esophagus is not surrounded by supporting structures in the thorax as it is in the neck. Therefore, perforations in the neck will usually heal if adequately drained, whereas those in the thorax should have an attempt at closure as well as ex¬ tremely good drainage of the mediastinum and pleural
cavity.
The indication for closure of the perforation in our case the continued bleeding. Confronted with a cervical perforation again, immediate drainage will be done and not delayed as in this case. It is fortunate that this patient did not develop an infection. The operative approach was very satisfactory, as it al¬ lowed good exposure of the cervical esophagus with an excellent opportunity to inspect the remainder of the esophagus with an esophagoscope. The technique of this operative approach is described well by Pearse.7
was
References 1. Russell JY:
Spontaneous perforation
of the
esophagus.
Br J
Surg
40:312-318, 1953. 2. Tesler MA, Eisenberg MM: Spontaneous esophageal rupture: Collective review. Int Abstracts Surg 117:1-10, 1963. 3. Loop FD, Groves LK: Esophageal perforations: Collective review. Ann Thorac Surg 10:571-587, 1970. 4. Miller AC Jr, Hirschowitz BI: Twenty-three patients with Mallory\x=req-\ Weiss syndrome. South Med J 63:441-444, 1970. 5. Postlethwait RW, Sealy WC: Surgery of the Esophagus. Springfield, Ill, Charles C Thomas Publisher, 1961. 6. Wichern WA: Perforation of the esophagus. Am J Surg 119:534-536, 1970. 7. Pearse HE Jr: The
operation for perforation of the cervical esophagus. Surg Gynecol Obstet 56:192-196, 1933.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/15/2015
