| disease | Esophageal Injury |
Esophageal injury is a disease primarily characterized by esophageal rupture and perforation, often caused by instruments or foreign bodies. If not treated promptly, it almost invariably leads to acute mediastinitis, esophageal-pleural fistula, and can be fatal. Due to the unique anatomical location of the esophagus, it can be injured by various causes. Despite significant advances in thoracic surgery in recent years, including the use of broad-spectrum antibiotics and improved nutritional support, which have enhanced treatment outcomes for such conditions.
bubble_chart Etiology
The esophagus can be injured by various causes, which are broadly categorized into mechanical injuries and chemical injuries. Mechanical injuries can further be divided into intraluminal injuries and extraluminal injuries. In recent years, with the rapid increase in cases involving diagnostic and therapeutic procedures using instruments within the esophageal lumen, the proportion of iatrogenic esophageal injuries among such conditions has also been steadily rising. Additionally, esophageal injuries can be classified based on their location into cervical esophageal injuries, thoracic esophageal injuries, and abdominal esophageal injuries.
1. Intraluminal Injuries The use of intraluminal medical instruments for diagnosing and treating esophageal diseases is relatively safe today, but it is not entirely without risks. Intraluminal esophageal injuries often occur during diagnostic or therapeutic procedures performed with these instruments inside or through the esophagus. Complications are more frequent with rigid esophagoscopy compared to fiberoptic esophagoscopy. Patients with conditions such as epiphrenic diverticulum, achalasia, or esophageal stenosis are at higher risk of esophageal injury if the procedure is not performed carefully.
2. Extraluminal Injuries Extraluminal injuries are primarily caused by contusions or penetrating wounds such as gunshot or knife injuries to the chest or neck, and they often coexist with other injuries in the chest or neck.The submucosal layer of the intestinal structure contains collagen and elastic fibers with tensile resistance. Unlike other parts of the digestive tract, the esophagus lacks a serosal layer, making it more prone to injury. The posterior wall of the cervical esophagus is covered by a thin fibrous membrane, the middle segment is only covered by the right pleural membrane, and the lower segment is covered by the left pleural membrane. With no surrounding soft tissue support and the normal intrathoracic pressure being lower than atmospheric pressure, these are anatomical factors that make the esophagus susceptible to injury. The main complication caused by instrumental examination and treatment within the esophageal lumen is esophageal perforation. The site of esophageal perforation is often the cervical esophagus at the junction of the cricopharyngeal muscle and the pharyngeal sphincter. Approximately 50% of esophageal perforations occur in the Lannier's triangle of the cricopharyngeal region, which is formed by the pharyngeal sphincter and the cricopharyngeal muscle at the level of the 5th and 6th cervical vertebrae. When cervical spine protrusions or hyperextension of the neck occur, perforation is highly likely. The second site where instrumentation is prone to cause esophageal injury is the upper esophagus, which is relatively narrow and partially fixed by the hilum of the lung, the aortic arch, and the left main bronchus. Other vulnerable sites include the distal esophagus at its junction with the stomach, the proximal segment of obstructive lesions, areas affected by esophageal cancer, and sites undergoing examination or dilation.
bubble_chart Clinical Manifestations
The symptoms and signs of esophageal injury vary depending on the cause. The clinical manifestations also differ based on the location and size of the perforation, as well as the time elapsed between perforation and medical consultation. However, in all cases, approximately 90–97% of patients experience severe pain in the neck or behind the sternum, which worsens with swallowing. 31% exhibit dyspnea, tachycardia, hypotension, or even shock. Almost all cases present with mediastinal or lower cervical subcutaneous emphysema, and in the late stage [third stage], mediastinal abscess or pyopneumothorax may occur. Fever and elevated white blood cell counts are observed in 87–90% of cases.
(1) Cervical Esophageal Perforation
Cervical esophageal perforation often occurs in the thinner posterior wall of the esophagus, as the prevertebral fascia attached to the esophagus limits the lateral spread of contamination. In the first few hours after perforation, there may be no signs of inflammation in the neck. However, within hours, oral or gastric fluids may enter the retroesophageal space through the perforation and spread along the esophageal plane into the mediastinum, causing mediastinitis. Patients complain of neck pain, stiffness, vomiting bloody gastric contents, and dyspnea. Physical examination reveals a critically ill patient with varying degrees of respiratory distress. Coarse breath sounds through the nasal passages are often audible. Palpation of the neck reveals stiffness and crepitus due to subcutaneous emphysema. Systemic signs of infection and toxicity typically develop within 24 hours.
Unlike cervical perforation, thoracic esophageal perforation directly contaminates the mediastinum, rapidly leading to mediastinal emphysema and mediastinitis. Although initially limited to mediastinal contamination, it can quickly progress to necrotizing inflammation. When the thin mediastinal pleura is breached by inflammation, gastric fluid and contents reflux into the mediastinum and pleural cavity, causing pleural contamination and effusion, resulting in suppurative mediastinitis and pleuritis. Perforations in the mid-to-upper esophagus often rupture into the thoracic cavity. The inflammatory process and significant fluid accumulation caused by esophageal perforation clinically manifest as severe unilateral chest pain, exacerbated by breathing and radiating to the scapular region. Dysphagia is evident at the perforation site, along with hypovolemia, fever, tachycardia disproportionate to the fever, and varying degrees of systemic infection, toxicity, and dyspnea, depending on the severity of pleural contamination, the volume of hydropneumothorax, and potential airway compression. Esophageal injury following mediastinoscopy is more challenging to diagnose. Sometimes, the diagnosis is only made when the patient develops mediastinitis and subcutaneous emphysema or when pathological examination of biopsy specimens reveals esophageal mucosa or muscle. Physical examination may reveal varying degrees of toxicity, reluctance to breathe deeply, and rales at the lung bases. When breath is held, mediastinal friction rubs or crepitus synchronized with the heartbeat may be heard. Subcutaneous emphysema may be palpable at the root of the neck or anterior chest wall. If the perforation ruptures into the pleural cavity, signs of hydropneumothorax may appear, including hyperresonance on percussion in the upper thorax and dullness in the lower thorax, with diminished breath sounds on the affected side. In rare cases, tension pneumothorax with tracheal deviation and mediastinal compression may develop. Mediastinal and pleural inflammation can irritate the diaphragm, presenting as abdominal pain, epigastric muscle rigidity, and tenderness, which must be differentiated from acute abdominal conditions.
(3) Abdominal Esophageal Perforation
Injury to the abdominal segment of the esophagus is rare. When it occurs, gastric fluid enters the free abdominal cavity, primarily causing peritoneal contamination, with clinical manifestations resembling acute peritonitis. This closely mimics gastric or duodenal perforation, and it should be noted that injury to the distal thoracic esophagus can present similarly. Occasionally, contamination may occur in the retroperitoneum rather than the peritoneal cavity, complicating diagnosis. Due to the proximity of the abdominal esophagus to the diaphragm, patients often exhibit epigastric pain and dull substernal pain radiating to the shoulders, which are more typical features.
Although esophageal perforation has these clinical manifestations, it can sometimes be difficult to make an immediate diagnosis based on these nonspecific symptoms. Other auxiliary examinations are often required to confirm the diagnosis. It also needs to be differentiated from other diseases such as gastric and duodenal {|###|}ulcer{|###|} perforation, pancreatitis, myocardial infarction, descending aortic {|###|}stirred pulse{|###|} tumor, pneumonia, and spontaneous pneumothorax.
bubble_chart Auxiliary Examination
1. X-ray Examination Based on the location and cause of the perforation, X-ray plain films are performed. For cervical perforations, gas may be detected in the cervical fascial planes, along with tracheal displacement, widening of the retroesophageal space, and loss of the normal cervical physiological curvature. In some patients, air-fluid levels in the retroesophageal space, cervical or mediastinal emphysema, pneumothorax, or pneumoperitoneum may be observed. For thoracic esophageal perforations, widening of the mediastinal shadow, gas or air-fluid levels in the mediastinum, and air-fluid levels in the pleural cavity may be detected. For abdominal esophageal perforations, free gas under the diaphragm may be seen. Conventional X-ray examinations fail to reveal these X-ray signs suggestive of esophageal perforation in approximately 12% to 33% of cases, and the results are also influenced by the time elapsed since perforation.
2. Esophagography Many patients do not present with typical symptoms but instead exhibit severe dyspnea, hypotension, sepsis, shock, unconsciousness, or vague acute abdominal or thoracic emergencies. Therefore, esophagography should be performed in patients suspected of having esophageal perforation and whose general condition permits, to confirm the diagnosis. Even in cases where conventional X-ray suggests esophageal perforation, esophagography should still be used to determine the size and location of the perforation. Under fluoroscopy, oral contrast agents can reveal the esophageal lumen, the site of perforation, and the presence of distal esophageal strictures. Oral iodized oil contrast agents are preferable due to their good imaging effect and minimal irritation. If barium is used and extravasates outside the esophagus, surgical removal becomes difficult. Foley et al. recommend first using a water-soluble contrast agent; if no fistula is visualized, barium can then be added to further clarify the diagnosis. It should be noted that despite the routine use of contrast imaging, there is still a 10% false-negative rate, so esophageal perforation cannot be completely ruled out even with a negative result.
3. Fiberoptic Esophagoscopy This is of significant diagnostic value for esophageal injuries caused by chest trauma or foreign bodies. When esophagography is negative, fiberoptic esophagoscopy can sometimes directly visualize the esophageal injury, provide precise localization, and assess the extent of contamination. The findings from esophagoscopy also aid in selecting the appropriate treatment.
4. CT Examination Today, CT scans of the chest and abdomen are widely used. When clinical suspicion of esophageal injury exists but X-rays fail to provide definitive diagnostic evidence, further diagnostic steps include CT scans of the chest or abdomen. For patients with "normal" esophagography, diagnosis should be based on medical history, physical examination, and CT findings. The following CT imaging signs should raise suspicion of esophageal perforation: ① Gas in the mediastinal soft tissues surrounding the esophagus. ② An abscess cavity in the mediastinum or pleural cavity adjacent to the esophagus. ③ Communication between the air-filled esophagus and a nearby fluid-filled cavity in the mediastinum or para-mediastinal region. Pleural effusion, especially on the left side, further suggests the possibility of esophageal perforation. If any of the above signs are present, esophagography should be performed to confirm the diagnosis and determine the perforation site, which is crucial for guiding surgical treatment. Additionally, CT is a highly effective method for initial follow-up observation of treatment efficacy.
5. Other Methods In patients with esophageal perforation, saliva, gastric juice, and large amounts of digestive fluids enter the pleural cavity. Diagnostic thoracentesis revealing pleural fluid with a pH below 6.0 and elevated amylase levels is a simple and diagnostically significant method. In suspected cases of esophageal injury, oral administration of a small amount of methylene blue may result in blue-colored pleural fluid upon thoracentesis, which also aids in diagnosis.
The complications and mortality of esophageal perforation are significantly related to the time from onset to diagnosis, so early and rapid diagnosis of esophageal perforation is crucial. For any patient who experiences neck, chest, or abdominal pain after undergoing esophageal instrumentation, the possibility of esophageal perforation should be considered. When Mackler's triad—vomiting, lower chest pain, and subcutaneous emphysema in the lower neck—is present, suspicion of esophageal perforation should be heightened, and further examinations should be conducted. In cases of chest trauma, particularly in patients with traumatic injuries near the esophagus, routine checks for esophageal injury are necessary. By paying attention to and frequently considering the occurrence of this condition, along with relevant medical history, symptoms, signs, and necessary auxiliary examinations, timely and accurate diagnosis can often be achieved. In a few cases, early diagnosis is delayed until the late stage (third stage) when empyema develops, or even when food particles are found in thoracentesis or pleural drainage fluid.
bubble_chart Treatment Measures
(I) Principles of Treatment
After esophageal injury, surgical or non-surgical treatment can be used. Regardless of the method, the goals are to prevent further contamination of surrounding tissues from the rupture, eliminate existing infection, restore the integrity and continuity of the esophagus, and recover and maintain nutrition. To achieve these four objectives, different methods should be selected based on factors such as the condition of the injured esophagus (whether the tissue at the injury site is normal); whether the primary disease is benign or malignant; whether there is obstruction distal to the perforation; the extent of contamination in the mediastinum and thoracic cavity; and the time elapsed from the injury to treatment.
(II) Indications for Surgical Treatment
The choice of surgical treatment is related to the following factors: the cause of the injury; the location of the injury; whether other esophageal diseases coexist; the time from perforation to diagnosis; the degree of contamination after esophageal perforation; the extent of inflammation spread; whether adjacent organs are injured; the patient's age and overall health; and the hospital's conditions and the doctor's skill level. Surgical treatment should be prioritized in cases of early diagnosis; mild thoracic contamination; large perforations; younger patients; good overall health; perforations accompanied by pneumothorax, pleural effusion, pneumoperitoneum, mediastinal emphysema, or abscess; retained foreign bodies; concomitant malignant esophageal disease or distal esophageal stenosis; and non-iatrogenic esophageal injuries. For very mild esophageal injuries or cases where full-thickness perforation cannot be clinically confirmed, non-surgical treatment may be considered first.
Non-surgical treatment is increasingly being adopted for esophageal perforations for the following reasons: ① Most esophageal perforations are caused by instrumental injuries, which typically result in more localized and less severe contamination compared to spontaneous esophageal ruptures. ② Early diagnosis is often possible. ③ New and more effective antibiotics can effectively control infections caused by esophageal perforations. ④ With CT guidance, effective drainage can be accurately placed percutaneously. ⑤ Safe and effective parenteral and enteral nutrition methods are available. Additionally, many conservative treatments serve not only as therapeutic measures but also as methods to monitor disease progression and as essential preoperative preparations for surgery. Non-surgical treatment may be considered first in the following situations: ① Instrument-induced perforations, especially those in the cervical region. ② Perforations caused by dilation in cases of ulcerative strictures, achalasia, or after sclerotherapy for esophageal varices, where surrounding fibrosis limits mediastinal contamination. ③ Several days have passed since the perforation, but symptoms are mild. ④ Early diagnosis of small, localized perforations. ⑤ Contamination is limited to the mediastinum or between the mediastinum and parietal pleura, with no contrast leakage into nearby body cavities. ⑥ Effective drainage of the abscess minimizes thoracic contamination. ⑦ No oral intake occurred from injury to diagnosis. ⑧ The perforation site is not in a tumor, the abdominal cavity, or proximal to an obstruction. ⑨ Symptoms are mild, with no signs of systemic infection.
(III) Conservative Treatment
Specific methods include the following:
(1) Fasting: If esophageal injury is suspected or preliminarily diagnosed, oral intake of food and water should be stopped immediately, and the patient should be instructed to minimize swallowing actions. In practice, it is impossible to demand absolute avoidance of swallowing.
(2) Gastrointestinal decompression: Although some advocate selective use of gastrointestinal decompression, arguing that inserting a decompression tube may prevent complete closure of the lower esophageal sphincter and exacerbate gastric reflux, most believe it should be routinely employed to reduce gastric fluid retention. Multi-orifice tubes should be placed above and below the esophageal perforation for effective suction and prevention of leakage. In addition to gastrointestinal decompression, intermittent suction of oropharyngeal secretions via the nasal cavity may sometimes be necessary.
(3) Broad-spectrum antibiotics: The main pathology caused by esophageal perforation is inflammatory infection of the surrounding tissues, such as mediastinitis, pleuritis, or peritonitis. Therefore, once esophageal injury is suspected, broad-spectrum effective antibiotics should be selected early. Broad-spectrum antibiotics should be used for at least 7 to 14 days.
(4) Maintaining nutrition: Due to the prolonged treatment period for esophageal perforation, oral intake often needs to be suspended for more than 10 days. Therefore, whether conservative treatment is adopted or not, it is necessary to establish preventive parenteral nutrition or effective gastrointestinal nutrition (such as jejunostomy) during the initial treatment.
(5) Promptly correct and maintain water and electrolyte balance.
(6) Esophageal lavage: In 1986, Santos reported successful experiences in treating esophageal rupture with esophageal lavage in 8 cases. Among them, 3 cases initially failed surgical treatment but were cured after switching to esophageal lavage. Domestically, Chen Weihua also reported using the same method to treat intrathoracic esophageal rupture. Their approach involved placing a thoracic drainage tube into the abscess cavity, reaching the fistula opening, and applying negative pressure suction. The oral cavity was rinsed with a Furacilin solution, followed by oral intake of sterile saline containing antibiotics (such as gentamicin) at 50–100 ml per hour. Intake was suspended from 10 PM to 6 AM. When the thoracic drainage fluid appeared turbid or the volume was excessive, the oral intake volume was increased. Once the drainage volume decreased and the fluid became clear, the patient began consuming milk and soy milk. After each meal, antibiotics were taken, and the esophagus was rinsed with sterile water to prevent food residue from remaining outside the esophageal lumen. When the drainage volume was less than 30–50 ml, an esophageal contrast study or oral methylene blue was performed to confirm the closure of the fistula. If the chest X-ray showed no fluid accumulation, the drainage was switched to open drainage and gradually withdrawn. This method facilitates early lung expansion, eliminates residual cavities, and promotes early esophageal healing. When not eating, a gastrointestinal decompression tube was placed at the perforation site, and irrigation was performed with saline or antibiotic solution.
(7) Inserting a tube or stent into the esophageal lumen through the tumor or tracheoesophageal fistula site can also be used to treat esophageal perforation.
If symptoms do not improve or worsen after 24 hours of conservative treatment, further surgical intervention should be considered.
(IV) Surgical Treatment
The principle of surgical treatment is to remove all inflamed and necrotic tissue. Depending on the location, an appropriate method should be used to securely close the perforation and correct or eliminate distal obstruction of the esophagus. Direct repair of the injured esophagus is contraindicated if the injury occurs proximal to or at the site of obstruction or if the diagnosis is delayed (generally >24 hours). Preventing further contamination of the mediastinum and pleural cavity and maintaining nutrition are critically important.
1. Surgical Approaches: Vary depending on the location of the perforation.
(1) Cervical perforation: For small cervical esophageal perforations, treatment often only requires placing a drain near the perforation, allowing the fistula to close on its own without further surgical intervention. The drainage method involves making a longitudinal incision along the anterior border of the sternocleidomastoid muscle, directly exposing the esophagus anterior to the internal jugular vein and artery, and inserting a soft rubber drain. The drain is then brought out through a separate stab incision below the main incision. Blunt dissection should be performed at the level of the cervical vertebrae, as improper handling in this area may extend the perforation toward the mediastinum and introduce infection into the mediastinum.
(2) Thoracic perforation: For mid-to-upper esophageal perforations, access is gained through the 4th or 5th intercostal space, while lower esophageal perforations are accessed through the 6th or 7th intercostal space. If there is no pleural contamination, the mid-to-upper esophagus is approached from the right side, and the lower esophagus is approached from the left side. If the esophagus has ruptured into one side of the pleural cavity, the corresponding side should be opened for surgical management.
(3) Abdominal perforation: If the thoracic cavity is not contaminated, surgical exploration can be performed directly through an upper midline abdominal incision. Regardless of the perforation site, after exposing the esophagus, the location of the perforation can be confirmed by injecting methylene blue or air into the esophageal lumen via an intraluminal catheter.
2. Surgical Treatment Methods
(1) Drainage: Regardless of the treatment method chosen, effective drainage is essential, especially in cases of extensive inflammation or poor systemic conditions. If necessary, a drainage tube should be placed under CT guidance. This approach is effective for both cervical and thoracic perforations. Additionally, drainage may be locally applied if there are doubts about the initial-stage [first-stage] repair or if the reinforcing tissue is unreliable. Effective drainage promotes early lung expansion and increases the chances of a successful repair. For large thoracic esophageal perforations, some practitioners insert a 6–10 cm long T-shaped drainage tube through the perforation site. The perforation is then closed around the T-tube to create a controlled esophagocutaneous fistula for continuous negative-pressure suction. The T-tube is removed after 3 weeks once a sinus tract has formed. This method is also used for perforations requiring extrapleural mediastinal drainage.
(2) Initial stage [first stage] suture: Initial stage [first stage] suture, whether reinforced with surrounding tissues or not, is a commonly used surgical method for treating esophageal perforations. In patients with early diagnosis and surgical indications, emergency surgery should be performed to suture and repair the perforated esophagus. To achieve a tight initial stage [first stage] suture, the muscle layer should be further incised during the operation to fully expose the mucosal injury and thoroughly remove non-viable tissues. In most cases of benign lesions, the mucosa remains normal. During surgery, the edges of the perforation should be trimmed to create fresh wound edges. For large perforations, the mediastinum should be explored to carefully identify the edges of the perforation. The perforated esophagus should be repaired with interrupted sutures using 2-0 absorbable sutures, such as Vicryl, or non-absorbable fine sutures, along with local drainage. Layered closure of the mucosa and muscle layer is key to successful surgical repair. Inadequate exposure and insufficient suturing are the main causes of postoperative fistulas. If the injury has persisted for a long time and tissue edema has developed, only the mucosal layer may be closed, accompanied by thorough irrigation and removal of contaminated tissues. A large-caliber closed drainage should be used, and an esophageal contrast study should be performed 7–10 days later. If no contrast leakage is observed, oral feeding can be resumed. If the esophageal perforation has lasted more than 24 hours or if there is severe local contamination, inflammation, or tissue necrosis, only local drainage should be performed without repairing the perforation. Initial stage [first stage] closure is best performed on healthy esophageal tissue. In cases of distal obstruction, simple initial stage [first stage] closure is ineffective, and the obstruction must be addressed simultaneously to achieve successful repair.
(3) Reinforced suture: Due to the risk of dehiscence and fistula formation with initial stage [first stage] suturing of esophageal injuries, especially when several hours have passed between perforation and treatment, reinforced suturing is necessary to close the esophageal perforation. In the thoracic cavity, many tissues can be used for reinforcement, particularly the thickened pleural membrane with inflammatory reactions around the esophagus. Other available tissues include the omentum and diaphragmatic flaps, which are resistant to necrosis, possess tension, elasticity, and strong regenerative capacity. A full-thickness flap 12 cm long and 5–7 cm wide, with its base at the esophagus, can be lifted upward for repair of the lower esophagus. If a diaphragmatic flap is used, its base should be medial, near the paravertebral groove, and of sufficient length to wrap around the esophageal repair. Regardless of the tissue used for reinforcement, it is best applied within the repair and esophageal wall rather than simply covering the repair.
(4) Simultaneous management of esophageal diseases: If the perforation occurs above a stricture or tumor, with distal obstruction, such perforations rarely heal on their own. If the patient's condition permits surgery and the diseased esophagus can be resected, the best approach is surgical removal of the affected esophagus. After esophageal resection, whether to perform initial stage [first stage] or intermediate stage [second stage] digestive tract reconstruction depends on the degree of contamination and the patient's condition. Matthews et al. recommend that once esophageal resection is decided, a cervical anastomosis should be performed because it is easier to perform. If the lesion or tumor cannot be resected, esophageal perforation will be a fatal complication in most cases. If achalasia or severe reflux esophagitis coexists, efforts should be made to address them simultaneously.
(5) Esophageal diversion: Esophageal diversion or exclusion surgery has been rarely used in recent years. It is only considered in cases of extreme malnutrition where other methods are unsuitable or ineffective, involving cervical esophageal diversion with fistula formation or gastric decompression via gastrostomy. This procedure includes closing the cardia, exteriorizing the thoracic esophagus from the neck to reduce intrathoracic contamination, and performing jejunal or colonic interposition in the late stage [third stage].
The factors leading to death after esophageal perforation are influenced by the cause of the perforation, its location, whether pre-existing esophageal lesions are present, and whether timely and appropriate treatment is administered. Most patients who receive early diagnosis and correct treatment have a favorable prognosis.
