Successful treatment for a delay-diagnosed esophageal perforation with deep neck infection, mediastinitis, empyema, and sepsis.

To the Editor: Perforation of the esophagus is a formidable challenge. Successful therapy for esophageal perforation depends on the length of the perforation itself, the time elapsed between rupture and diagnosis, and the underlying health of the patient. Location and size of the perforation, delayed diagnosis, and delay in initiating treatment are the main factors contributing to poor survival rates. (1) Here we describe our experience of successful treatment for a delayed esophageal perforation, due to an ingested fish bone, complicated with severe comorbidities.

A 74-year-old diabetic man presented to the emergency room with odynophagia and dysphagia with foreign body sensations over the lower neck, and subsequently developed fever, severe chest and abdominal pain. Physical examination revealed redness and swelling with subcutaneous emphysema and tenderness over the lower neck and anterior chest wall, as well as epigastric tenderness with rigidity. Laboratory testing disclosed leukocytosis (WBC 14,700) and an elevated C-reactive protein (CRP 50.81 mg/dL). Chest x-ray revealed subcutaneous emphysema over the lower neck region, atelectasis of the right lower lung field, and bilateral blunting of the costophrenic angle (Fig. 1). An esophagogram with water-soluble contrast medium revealed no evidence of leakage. A contrast-enhanced computed tomographic (CT) scan of the neck and chest showed cervical subcutaneous emphysema, pneumomediastinum, and multiple pockets of accumulated turbid fluid over the neck, superior mediastinum, and bilateral pleural spaces (Fig. 2). Based on these findings, an emergent exploratory procedure with cervical and right parasternal mediastinotomy was performed for a high suspicion of delayed perforation of the esophagus with severe comorbidities. The operation revealed accumulated air, and a large quantity of odoriferous fluid over the deep neck, anterior mediastinum, and left parascapular region, complicated with necrosis of the left lower neck fascia and muscles. Adequate debridement and irrigation was carried out, followed by the placement of multiple drainage ports and bilateral chest tubes. Perioperative abdominal laparoscopy with feeding gastrostomy was also performed. Five days postoperatively, the patient underwent a thoracoscopic delobulation of the left empyema. After adequate drainage and antibiotic administration (ampicillin-sulbactam), the cervical wound was closed on the 18th postoperative day after oral testing with diluted methylene blue water. The patient began oral intake on the 20th postoperative day, and was discharged home without digestive impairment.

Esophageal perforation has been regarded as the most serious injury of the digestive tract. Once a perforation occurs, saliva, retained gastric contents, bile, and acid enter the mediastinum, resulting in mediastinitis. Perforations at the mid or distal esophagus lead to collections in the respective pleural cavities, resulting in serious complications such as mediastinitis, abscess, empyema, pericarditis, or cardiac tamponade. (2) Medical instrumentation in the esophagus is the most common cause of esophageal perforation (1) and rarely occurs secondary to foreign body ingestion. (3) The usual affected sites are three points of anatomic narrowing: the cricopharynx, the crossing of the left mainstem bronchus or aortic arch, and the gastroesophageal junction. (4)

Patients typically present with pain localized along the course of the esophagus followed by fever, dysphagia, tachycardia, tachypnea, or pain throughout the neck, chest, epigastrium, and upper abdomen. On examination, mediastinal crunch sounds (Hamman sign) can be heard. The most diagnostically useful sign is cervical emphysema, which may occur immediately, or as late as two weeks after perforation. (4) Once suspected, a posteroanterior (PA) and lateral upright chest x-ray should be obtained to identify cervical or mediastinal emphysema, pneumopericardium, or pleural effusion. If clinical suspicion remains, a water-soluble contrast esophagogram and/or chest CT scan should be considered. (5)

Prior reviews of delayed esophageal perforation have reported mortality rates ranging from 40 to 60%, associated with greater duration of delay in diagnosis and treatment. The most common cause of death is multiorgan failure resulting from sepsis. (5) Indications for surgery include Boerhaave syndrome (esophageal rupture from violent retching), clinically unstable patients with sepsis, contamination of the mediastinum or pleural space, perforation with retained foreign bodies, and failed medical therapy. (3) In addition to primary repair with or without flap, alternative treatment strategies include exclusion and diversion of the perforation with or without T-tube drainage, and esophagectomy. Esophagectomy, multiple open drainage and adequate medical treatment should be a good choice in treating such critically ill patients.

Liang-Tsai Wang, MD

Division of Colon and Rectal Surgery

Shih-Chun Lee, MD

Ching Tzao, PhD

Hung Chang, PhD

Yeung-Leung Cheng, PhD

Division of Thoracic Surgery

Department of Surgery

Tri-Service General Hospital 

National Defense Medical Center

Taipei, Taiwan, Republic of China

References

1. Jones WG II, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534-543.

2. Sharland MG, McCaughan BC. Perforation of the esophagus by a fish bone leading to cardiac tamponade. Ann Thorac Surg 1993;56:969-971.

3. Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation: emphasis on management. Ann Thorac Surg 1996;61:1447-1452.

4. Attar S, Hankins JR, Suter CM, et al. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;50:45-51.

5. Reeder LB, DeFilippi VJ, Ferguson MK. Current results of therapy for esophageal perforation. Am J Surg 1995;169:615-617.