Overview
Definition:
Thoracic esophageal injury refers to damage to the esophagus occurring within the thoracic cavity, most commonly resulting from spontaneous rupture (Boerhaave syndrome), iatrogenic causes (e.g., during endoscopy), trauma, or foreign body ingestion
Repair aims to restore esophageal continuity, prevent mediastinitis, and preserve organ function.
Epidemiology:
Spontaneous esophageal rupture (Boerhaave syndrome) is rare, with an incidence of approximately 3-7 per 100,000 person-years
Iatrogenic injuries are more common, particularly following endoscopic procedures like dilation or stent placement
Trauma-related injuries are less frequent but can be severe.
Clinical Significance:
Esophageal injuries in the thorax are surgical emergencies due to the high risk of mediastinitis, sepsis, and mortality
Prompt and appropriate surgical intervention is crucial for patient survival and to minimize long-term morbidity, including stricture formation and dysphagia
Understanding repair techniques is vital for surgical residents preparing for DNB and NEET SS.
Clinical Presentation
Symptoms:
Severe retrosternal or epigastric pain, often sudden in onset
Vomiting or retching preceding pain
Dyspnea or shortness of breath
Chest pain radiating to the back or shoulder
Hemoptysis or hematemesis
Subcutaneous emphysema (crepitus) in the neck or chest
Fever and tachycardia may develop later.
Signs:
Vomiting and retching
Subcutaneous emphysema on palpation of the neck or chest wall
Hypotension, tachycardia, and tachypnea indicating shock or sepsis
Hamman’s sign (mediastinal crunch) may be present but is rare
Signs of peritoneal irritation if the injury extends distally.
Diagnostic Criteria:
No single definitive diagnostic criteria exist for esophageal injury
Diagnosis is primarily based on clinical suspicion, confirmed by imaging and endoscopy
Classic presentation of forceful retching followed by chest pain (Mackler triad) is highly suggestive of Boerhaave syndrome.
Diagnostic Approach
History Taking:
Detailed history of any recent vomiting, retching, or preceding events
History of instrumentation (endoscopy, dilation, stent placement)
History of trauma (blunt or penetrating)
Ingestion of foreign bodies or caustic substances
Pre-existing medical conditions like peptic ulcer disease or esophageal motility disorders.
Physical Examination:
Careful assessment for signs of shock (hypotension, tachycardia)
Palpation for subcutaneous emphysema in the neck, supraclavicular fossae, and chest wall
Auscultation for Hamman’s sign
Thorough abdominal examination to rule out associated intra-abdominal injuries.
Investigations:
Chest X-ray: May show mediastinal widening, pleural effusion (often left-sided), pneumomediastinum, or pneumothorax
CT scan of the chest and abdomen with oral contrast (water-soluble contrast like Gastrografin is preferred): Highly sensitive for detecting esophageal perforation and mediastinitis, delineating the extent of injury and associated fluid collections
Esophagography with contrast: Can confirm the site and extent of perforation, but may be delayed if oral contrast CT is definitive
Endoscopy: Can visualize the injury directly but carries a risk of exacerbating the perforation and is often deferred until the patient is stable and CT findings are available
Complete blood count (CBC): Leukocytosis may indicate infection
Electrolytes and renal function: To assess for dehydration and sepsis.
Differential Diagnosis:
Myocardial infarction
Aortic dissection
Pulmonary embolism
Pericarditis
Pneumonia
Acute pancreatitis
Esophageal spasm
Esophageal rupture from other causes (e.g., malignancy, webs, diverticula).
Management
Initial Management:
Immediate resuscitation with intravenous fluids and broad-spectrum antibiotics to cover oral flora (e.g., ampicillin-sulbactam, clindamycin plus a fluoroquinolone)
Pain control with intravenous analgesics
Nasogastric tube insertion to decompress the stomach and prevent further spillage
Hemodynamic monitoring and management of shock.
Surgical Management:
Indications for surgery include significant perforation, hemodynamic instability, widespread mediastinitis, inability to control leakage with endoscopic methods, and large defects
Surgical options depend on the location, size, and timing of the injury: Thoracic esophagectomy (e.g., transhiatal or transthoracic) with cervical esophagostomy and gastrostomy tube for diversion and feeding
Esophageal resection with primary repair (if feasible, usually for distal injuries <24-48 hours old and small defects) with pleural flap or intercostal muscle reinforcement
Esophageal diversion and drainage of mediastinal abscess
In some cases, minimally invasive approaches (thoracoscopic or laparoscopic) may be considered for smaller, selected perforations.
Supportive Care:
Nutritional support via jejunostomy tube or parenteral nutrition
Chest tube insertion for drainage of pleural effusion or empyema
Intensive care unit (ICU) monitoring for sepsis and respiratory failure
Monitoring for signs of recurrent infection or anastomotic leak.
Complications
Early Complications:
Mediastinitis
Sepsis
Empyema
Pneumothorax
Acute respiratory distress syndrome (ARDS)
Mediastinal abscess
Anastomotic leak
Recurrent perforation.
Late Complications:
Esophageal stricture formation leading to dysphagia
Gastroesophageal reflux disease (GERD)
Chronic pain
Esophageal fistulas
Nutritional deficiencies.
Prevention Strategies:
Careful technique during endoscopic procedures
Timely recognition and management of symptoms post-endoscopy
Prompt surgical intervention for significant injuries
Adequate antibiotic prophylaxis
Thorough drainage of infected cavities.
Prognosis
Factors Affecting Prognosis:
Time to diagnosis and treatment is the most critical factor
The presence and extent of mediastinitis
Patient’s overall health status and comorbidities
Etiology of the injury (iatrogenic vs
Boerhaave vs
trauma)
Location and size of the perforation
Effectiveness of surgical repair and postoperative care.
Outcomes:
With prompt treatment, mortality rates for esophageal perforation can be reduced significantly
Early diagnosis and repair (<24 hours) are associated with better outcomes
Delayed treatment, especially in the presence of sepsis, leads to higher mortality
Long-term complications like strictures require ongoing management.
Follow Up:
Regular outpatient follow-up is essential
Esophagography may be performed at 2-3 weeks post-repair to assess for strictures or leaks
Nutritional assessment
Management of GERD if present
Speech therapy for any vocal cord dysfunction related to mediastinal involvement
Dilations may be required for symptomatic strictures.
Key Points
Exam Focus:
Boerhaave syndrome: forceful retching, midthoracic or distal esophagus, often transmural
Iatrogenic injuries: common post-endoscopy, typically anterior wall
Management is time-sensitive
CT with oral contrast is the gold standard for diagnosis
Surgical intervention is often required for significant thoracic injuries.
Clinical Pearls:
Always consider esophageal injury in patients with sudden, severe chest pain following vomiting or retching
Use water-soluble contrast for CT if perforation is suspected
Early antibiotics are crucial
The choice of repair depends on the injury characteristics and patient factors.
Common Mistakes:
Delaying diagnosis due to low suspicion or misinterpreting symptoms as cardiac pain
Using barium contrast in suspected perforation, which can worsen mediastinitis
Inadequate antibiotic coverage for oral flora
Inappropriate timing or extent of surgical intervention.