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Symptoms, complications, and pathoanatomic findings of three cases, in which the esophageal perforation originally caused the death, are demonstrated. The first case deals with an pressure-errosion as a result of gavage, the second an incised wound by a razor blade, and the third a through-and-through gunshot wound of the upper part of the esophagus.
Although esophageal perforation in children is associated with a spectrum of disease different from the one in adults, management is essentially the same for both groups. Over the past 11 years, 12 patients ranging in age from 2 days to 10 years were treated for 13 perforations. Perforation in the adult is associated with a high mortality rate. All children in this series survived. Injury was secondary to instrumentation in 10 cases and three resulted from the chronic erosion of a trapped foreign body. Of the 10 acute perforations, five occurred 12 days to 5 months after lye ingestion. Anastomotic narrowing was a factor in three other cases. Seven of the acute perforations involved the thoracic esophagus and were associated with a high morbidity rate. Management consisted of operative as well as nonoperative approaches. Consideration must be given to several clinical variables including location, cause, predisposing factors, underlying illnesses, associated injury, and promptness of medical attention.
The esophageal obturator airway (EOA) has been approved since 1973 as an adjunct for artificial ventilation. Description of the tube and contraindications to its use are presented. The two primary complications are tracheal intubation and esophageal perforation. A case report of esophageal perforation after EOA use is presented and a brief review of the previously reported cases is correlated with this case report. The true incidence of this complication has never been accurately studied but estimates vary between 0 and 2%. Possible factors contributing to this complication are discussed and recommendations regarding proper inflation are given. Because early diagnosis and treatment is essential, helpful historical, clinical, and radiographic findings that are presented should help to increase the index of suspicion of this complication. Increased familiarity with the EOA by physicians in the emergency department and the ICU is also necessary for early diagnosis and treatment.
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Esophageal perforation following use of the esophageal obturator airway (EOA) has been reported in a small number of patients. However, it has generally been discovered only in the presence of obvious clinical signs in patients otherwise resuscitated from cardiac arrest. Since it may well be overlooked in patients who succumb following the combined insult or primary cardiac arrest and secondary esophageal perforation, the true incidence of this adverse consequence of EOA use is unknown. We present a case of esophageal intubation with the EOA, and review in detail previous reported cases. We further suggest possible mechanisms leading to this catastrophic consequence of intubation with the EOA, and comment on its significance with regard to the controversy over EOA versus endotracheal (ET) tube training for paramedic pre-hospital personnel.
Spontaneous esophageal perforation (Boerhaave's syndrome) is a rare clinical entity in which overindulgence in a large meal precedes vomiting and chest pain. Early diagnosis and aggressive management are keys to minimizing the morbidity and mortality. We report an unusual presentation of this already uncommon occurrence in a 33-year-old female. She presented to the Emergency Department with severe chest pain following vomiting with hematemesis after a large meal. The initial chest radiograph showed up nothing in particular. Dyspnea developed two days later, and a right-sided pleural effusion was seen on chest x-ray. Panendoscopy was highly suggestive of Boerhaave's syndrome. She underwent emergency operation. After three months of hospital care, she was discharged in relatively good condition. This case of right-sided pleural effusion extends the reported description of Boerhaave's syndrome.
The authors give account of spontaneous esophageal perforation developed on the basis of fungal oesophagitis. The lesion of the lower third of the esophagus classified as grade 4. on Kodsi classification displayed the same picture as an advanced esophageal cancer. They review signs, symptoms and varieties in macroscopic appearance of esophageal candidiasis. They warn that in case of a spontaneous perforation of "malignant" esophageal tumor with no preceding signs the rare condition of fungal esophagitis must certainly be considered.
Congenital esophageal stenosis (CES) is a very rare embryologic anomaly of tracheoesophageal development that requires lifelong management, usually with frequent esophageal dilations and dietary precautions. We present a patient with spontaneous thoracic esopahgeal perforation in a setting of CES. The patient, a 27-year-old male, recovered uneventfully following open primary esophageal closure. A brief but comprehensive discussion of CES follows the case report.
The esophageal airway has gained increasing acceptance in airway management during cardiopulmonary resuscitation, and its enthusiastic advocates are urging expansion of its use. A fatal case of esophageal perforation following the use of an esophageal airway is presented. Possible contributing factors are discussed. A modified esophageal airway which seems safer and more versatile, effective, and economic is described.
A 60-year-old man was admitted to hospital because of severely impaired swallowing, retrosternal pain and marked weight loss. History and physical examination of the patient, whose general condition was obviously much reduced, pointed to carcinoma of the oesophagus. Contrast-medium swallow demonstrated subtotal stenosis in the oesophagus. Computed tomography and magnetic resonance imaging showed a space-occupying mass originating from the oesophagus, in close relationship to the trachea, main bronchi and descending aorta. Biopsy confirmed the diagnosis of oesophagus carcinoma and exploratory thoracotomy excluded curative surgical treatment. An attempt was made to introduce a feeding tube endoscopically to provide nutritional palliation. But the oesophagus was perforated during this manoeuvre and resulted in an oesophagobronchial fistula with subsequent mediastinitis and mediastinal emphysema. Using a self-expandable plastic-covered metal stent it was possible to cover the perforation and overcome the patient's dysphagia. The mediastinitis healed under intravenous administration of cefotaxim (2 g three times daily), netilmicin (400 mg daily) and metronidazole (500 mg three times daily), for 5 days.
Esophageal perforations are rare and usually occur after instrumentation. We relate here a case unsuspected spontaneous esophageal perforation. Computed chest tomography firstly showed signs of mediastinal abscess. Secondary barium meal confirmed the diagnosis.
A 32-yr-old, previously healthy man with severe chest pain of sudden onset was found to have purulent pericarditis and pleural effusions. Several days later, an esophagogram revealed a perforation of the thoracic esophagus. Endoscopy showed a picture highly suggestive of a late stage of an extensive herpes simplex virus (HSV) esophagitis. Biopsies revealed evidence of massive HSV infection, confirmed by immune microscopy and virus culture. At surgery, a mediastinal abscess was found, and an esophageal perforation was identified. These findings suggest that the etiology of the perforation was an unusually severe herpetic infection. To our knowledge, HSV esophagitis has not previously been implicated as the cause of spontaneous esophageal perforation.
Esophageal perforation from external blunt trauma is an exceedingly rare injury. Since 1900, including our five cases, we found 96 reported cases. The most common cause was violent vehicular trauma. The cervical and upper thoracic esophagus was the site of perforation in 82%. In 78% of the cases, there were findings consistent with esophageal injury, but there was a delay in diagnosis in two thirds of these. The diagnostic difficulty was due to lack of a specific symptom complex for esophageal perforation. Often esophageal perforation was not suspected and the symptoms were attributed to the more common injuries, or the diagnostic workup was incomplete. There were 24 (38%) infectious complications directly related to the esophageal perforation. In 21 of these, there was a delay in diagnosis. There were five (9.4%) deaths due to sepsis from the esophageal perforation.
OBJECTIVE: Esophageal perforation is a life-threatening condition that can be quickly diagnosed on the basis of findings on contrast esophagograms when the typical signs and symptoms of vomiting, chest pain, and subcutaneous emphysema occur. If the clinical features are atypical, CT may be performed early in the clinical course. Thus, recognition of the CT findings of esophageal perforation is important. MATERIALS AND METHODS: We reviewed the CT scans of 12 patients with esophageal perforation. The site of perforation was the cervical esophagus in three and the thoracic esophagus in nine. The causes of the perforations were neoplastic (four patients), idiopathic (three patients), iatrogenic (three patients), and traumatic (two patients). RESULTS: CT abnormalities included esophageal thickening in nine patients, periesophageal fluid in 11 patients, extraluminal air in 11, and pleural effusion in nine. The site of the perforation was visible on the CT scan in two patients. In four patients (33%), CT findings were the first indication of esophageal perforation. CONCLUSION: For patients who have atypical signs and symptoms, CT scans optimally define the extraluminal manifestations of esophageal perforation. Extraesophageal air is the most useful finding. The CT findings may be the first indication of the diagnosis.
The majority of esophageal perforations is caused by endoscopic procedures, while the spontaneous rupture, also known as Boerhaave's syndrome, is rare. Regardless of the cause the esophageal perforation is an urgent surgical problem. The main diagnostic method is a water-soluble contrast study of the esophagus, probably supplemented by a CT-scan. In case of uncertain diagnosis or localisation eosophagoscopy should be performed. We believe that esophageal perforation should be operated, the factor "time" seems to be important for prognosis. In case of early surgical treatment (within 24 hours) a primary suture is sufficient and safe. Only after a delay in diagnosis with extended mediastinal spillage and necrosis of the esophageal wall the use of autogenous tissue to buttress the esophageal repair may be necessary. Esophagectomy should only be performed for perforated carcinomas. We treated 10 patients in a 4-years-period by primary surgical repair combined with drainage. Nine of them survived, only a 82-years old patient died because of an unresectable perforated esophageal carcinoma.
Two cases of distal esophageal perforation following the use of the esophageal obturator airway are reported. Plain radiograph findings of pneumomediastinum, subcutaneous emphysema, mediastinal widening, or pleural effusion suggest this entity; esophagography should be performed in the appropriate clinical setting. The recognition of this uncommon but serious complication is important because medical and/or surgical management is urgent.
Instrumental perforation of esophageal malignancy is best managed by immediate esophagectomy. Transthoracic esophagectomy has been the technique most described in the management of patients with this injury. A recent series reported the successful use of transhiatal esophagectomy with primary cervical esophagogastrostomy in four patients with perforated esophageal cancers. We have also used this technique to treat a patient with instrumental perforation of a distal esophageal cancer. This case is presented to add to the published experience using transhiatal esophagectomy in the management of perforated esophageal malignancy. The merits of transhiatal esophagectomy warrant consideration of this approach as a useful alternative to transthoracic resection in the management of selected patients with perforated esophageal cancer.
Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.