Esophageal perforation etiology, outcome, and the role of surgical management – an 18-year experience of surgical cases in a referral center

EP is a surgical emergency with a high rate of morbidity and mortality [11]. Unfortunately, the prevalence of EP has been increasing dramatically in the last decades [12]. In this study, we aimed to report our 18-year experience with this rare, life-threatening condition. We demonstrated that EP is more prevalent amongst men compared to women. Also, our study introduced foreign body ingestion, as the main etiology of EP. According to our study, the most common cause of EP was foreign body ingestion, followed by trauma, and iatrogenic injuries. EPs caused by foreign body ingestion most often affect the cervical esophagus, while spontaneous and iatrogenic ruptures are more common in the distal segment [13, 14].

The main reason for this finding is the presence of anatomical narrowing of the esophagus at the cricopharynx, aortic arch, and the gastroesophageal junction, which most often leads to obstruction by foreign bodies and subsequent wall necrosis and rupture [15]. Also, our study showed that penetrating injuries are mainly associated with damage to the cervical esophagus. Contrary to our results, previous studies suggested that traumatic EP mainly injures the distal third of the esophagus, and is a life-threatening cause of esophageal rupture, especially penetrating injuries from bullets or stab wounds that are frequently associated with extensive damage to other vital organs [16]. Iatrogenic injuries to the esophagus were the 3rd main cause of EP in our study. Interventions using therapeutic endoscopies, such as pneumatic dilation, stent placement, foreign body removal, and endoscopic ablation techniques can significantly increase the risk of perforation [17].

Regarding the location of esophageal rupture, our study reported that thoracic EP (n = 32; 46.4%), followed by abdominal (n = 30; 43.5%), and cervical esophagus (n = 19; 27.5%) were most commonly injured locations, respectively. On the contrary, various reports have suggested the cervical esophagus to be the most common site of EP [9, 15, 16]. Fortunately, cervical esophageal ruptures are associated with less mortality than thoracic and abdominal EP which is due to limited spreading of infection to the mediastinum, pleura, and better accessibility for treatment [13].

Early diagnosis and treatment are essential to achieve optimal results and reduce mortality. Although direct x-ray and contrast-associated tomography could provide important findings for the diagnosis of EP initially, it could be misleading [18]. Diagnostic endoscopy, which is performed almost exclusively with flexible endoscopes (FE), provides direct visualization of the esophagus that could be used in the closure of small mucosal defects associated with EP. However, the usage of esophagoscopy in the diagnosis of EP is controversial. Despite the low risk of perforation, the availability of other modalities has always questioned the indications for performing FE. Operate dependence, contamination of the ruptured esophagus increased chance of sepsis, and extending the perforation due to mucosal manipulation by endoscopes are considered significant downfalls of esophagoscopy [19].

To date, many treatments have been tried, but a single gold standard treatment option is still unclear. The main goals in the treatment of esophageal rupture are hemodynamic stabilization, repair of the damaged wall, prevent further extraluminal contamination, and antibiotic therapy [20]. Thus, choosing the best treatment strategy for patients should be individually discussed. Several factors are associated with the selection of the type of therapeutic intervention, including time of diagnosis(most influential factor), the cause of injury, the primary location of the EP, age, and clinical comorbidities of the patient [21].

Overall, three main treatment options exist for better management of EP. First, non-surgical interventions including conservative treatments to improve patients’ nutritional status, as well as antibiotic therapy for sepsis prevention [22]. Also, minimally invasive techniques including endoscopic treatments are being used increasingly in the last decades [23]. However, endoscopic interventions remain for patients with stable hemodynamic status without any signs of sepsis, who were diagnosed early. Endoscopic clips and stenting are the most common endoscopic interventions used for the repair of the damaged esophageal wall.

Surgery plays a major role in the treatment of EP. It provides sufficient esophageal rupture closure and allows the removal of esophageal contents from the thoracic cavity. These interventions include drainage with or without decortication, primary esophageal repair, esophagectomy, or esophageal exclusion [24]. The selection of surgical intervention mainly depends on the patient’s hemodynamic status, previous comorbidities, and the extent of esophageal damage. Accordingly, initial repair with or without augmentation is probably the standard treatment for EF in most centers. However, few studies suggest that initial repair should only remain for patients with primary perforations, and recommend resection or diversion when the perforation is longer than 24 h [25].

The most common surgical method used in our study was primary esophageal repair (91.3%) compared with secondary repair (15.9%). Also, the primary suture was performed for half of patients with EP with 2 cases this repair was amplified by a flap. However, primary surgical repair may not always be effective especially if signs of advanced mediastinitis or infection were observed, in which case discontinuity resections are a better choice for further surgery [26]. Our previous report has demonstrated the higher efficacy of continuous sutures in reconstructive surgery [27]. More aggressive surgical methods including esophageal resection, diversion, exclusion, or T-tube insertion could be considered for patients with severe esophageal injury and simultaneous infection [28]. Also, based on the location of EP, concomitant damage to the adjacent organs should always be considered. In our study, 16 patients underwent jejunum reconstruction due to the severity of the damage.

Surgical Treatment for cervical esophageal rupture should be done within the first 16 to 24 h following the injury. Previous studies suggest that conservative treatment with antibiotics and a nasogastric tube may be helpful in small ruptures less than 2 cm [29]. However, primary repair and drainage remain an old standard surgical technique for large EPs. Cervical esophagostomy with gastrostomy or jejunostomy is mainly used for patients with extensive mediastinitis, signs of esophageal necrosis or obstruction, hemodynamic instability, and patients who are unable to tolerate surgical repair or resection [30].

An abdominal puncture should be performed with a midline laparotomy. After debridement of necrotic tissue, single- or double-layer tension-free closure of the hole should be performed. It is recommended to tighten the esophageal suture with gastroplasty using the gastric fundus (such as complete or partial fundoplication) and to insert the nasogastric tube, making a nourishing jejunostomy, and perform external drainage of the subphrenic space [18].

In our study, no significant association were observed between study variables and the rate of mortality. It can be speculated that the low death rate of our patients might be the reason that we did not find any significant relations between type of surgical interventions and the overall mortality rate. In addition, patients having foreign body ingestion are generally associated with more favorable outcomes when it comes to surgical repair of EP. Generally, one of the most important determinants of mortality is the time interval between the onset of symptoms and treatment. In a review of 726 cases of esophageal rupture, Brinster et al. reported that the mortality rate amongst patients that received treatment less than 24 h after the onset of symptoms, was only 14% [9, 16]. There was no significant association between the surgical approach and mortality in our study, which seems that it depends more on the characteristics of esophageal rupture and the general condition of the patient than on the surgical method. Among the limitations of this study, is the lack of a long-term follow-up period for patients with EP. Also, based on the retrospective nature of our study, we were unable to obtain all of the patients’ information, especially regarding their clinical presentations, due to incomplete hospital records. Thus, due to the challenging nature of this disorder and the lack of a single therapeutic strategy, future studies are required to determine a specific surgical strategy to conclude the most effective therapeutic approach in the face of this condition.