Keywords

Introduction

Esophageal perforation is a life-threatening condition whose diagnosis is challenging and management controversial, despite decades of clinical experience and innovation in surgical technique. The mortality rate for esophageal perforation is 19.7% (range 3–67%), and the most important predictor of survival is the interval between injury and initiation of treatment (1). Accurate diagnosis and early treatment are essential to the successful management of patients (Table 33-1).

Table 33-1 – Causes of esophageal perforations
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Surgical Considerations

Principles of Management

The choice of treatmentis dependent on the cause and location of the perforation (Table 33-2), the presence of underlying esophageal disease, the interval between injury and initiation of treatment, and the age and general status of the patient (2). Although many treatment options have been used to date, the optimal treatment is still controversial for some scenarios. Treatment options include:

Table 33-2 – Common operative approaches and implications
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  • Nonoperative treatment (antibiotics, non-oral nutrition, observation)

  • Drainage

  • Fibrin glue, adhesives (for small perforations)

  • Primary repair

  • Resection (esophagectomy)

  • Exclusion

  • Stent

Objectives of treatmentinclude prevention of further contamination from the perforation, control of infection, restoration of the integrity of the gastrointestinal tract, and establishment of ­nutritional support (3). Treatment options diminish with time, and esophageal perforation should be treated as a legitimate surgical emergency. Gaining control of the mediastinitis is the first imperative. Twenty-four hours is the typical window for repair. If repair is impossible, exclusion and drainage are performed. Figure 33-1shows an algorithm for management strategies of esophageal perforation.

Figure 33-1
figure 1_33

– Algorithm for management of esophageal perforation (4), with permission.

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Anesthetic Considerations

Esophageal perforation requires a prompt, but flexible and well-prepared, anesthetic response. Communication with the ­surgeon regarding the anticipated surgical procedure and approach is paramount. Flexible esophagogastroduodenoscopy (EGD) is ­commonly performed initially to localize the rupture or perforation or assess the extent of pathology. Anticipate changes in the surgical plan or anesthetic requirements depending on EGD and intraoperative findings. Anesthetic equipment should be available for all options, including lung isolation and invasive monitoring.

Preoperative Patient Preparation

Patients may present for surgery either early (<24 h) or delayed and in varying degrees of sepsis and/or respiratory compromise. In general, patients with iatrogenic perforations are less ill because they would have been fasted prior to the procedure which led to the perforation. This is in contrast to other causes of perforation, where partially digested food may be found in the thorax or abdomen.

Assessment and considerations include:

  • The risk of aspirationand need for pharmacological prophylaxis

  • Pleural or gastric decompressionprior to induction of anesthesia

  • Volume status, coagulation profile, fluid resuscitation, and appropriate antibiotics in impending sepsis

  • Urgent treatment of the existing uncontrolled medical comorbidities

  • Differentiating chest pain caused by the perforation from a cardiac source

Lines and Monitors

Depending on the patient’s comorbidities, hemodynamic parameters, and the extent of surgery planned, invasive monitoring (arterial and central venous lines) may be indicated. Even when patients are thought to be in an early phase of a septic trajectory, invasive lines and monitors aid subsequent ICU management. A ­central line for parenteral nutrition may be requested by the surgeon.

Regional Anesthesia

The decision to include a central neuraxial technique must be made on an individual basis considering the analgesic alternatives, the benefits of regional anesthesia, and the risk of central nervous system infection, which may occur in any bacteremic patient (5). The benefits of thoracic epidural analgesiaor paravertebral cathetersfor thoracotomy and/or upper abdominal surgery have to be weighed against the risk of adverse patient hemodynamics and epidural abscess/hematoma. Central neuraxial blocks should not be performed in patients with untreated systemic infection or coagulopathy (5, 6). When delayed extubation is anticipated (e.g., septic or debilitated patients undergoing esophageal resection), the epidural is best postponed.

Securing the Airway

The aspiration risk is variable and must be carefully assessed. Patients with Boerhaave’s syndrome or perforation from ingestion are obviously at high risk. Those with iatrogenic perforations from dilatations following a fast are at relatively lower risk. Rapid sequence induction is generally advisable as long as the airway anatomy suggests an easy intubation. Raising the head of the bed is of more value than cricoid pressure, which is not endorsed in this scenario. Inadvertent esophageal intubation may extend an esophageal tear. Maneuvers commonly employed to mitigate aspiration risk or damage (oral antacids, gastric propulsants, awake nasogastric tube evacuation of stomach contents) may be ill advised in the presence of a significant esophageal perforation. A low threshold for awake fiber-optic intubation or use of a videolaryngoscope to improve certainty of intubation is advisable if the airway anatomy is in any question.

Bronchoscopy to rule out a related injury (or tumor involvement) to the membranous trachea should be performed following intubation due to its proximity to the esophagus. This calls for a large ETT. If lung isolation is required and massive fluid resuscitation is anticipated, a bronchial blockeris recommended because it obviates the need for additional tube exchanges.

Hemodynamic Management

Patients often present with significant deficits of intravascular volume, together with various degrees of sepsis-related disruption of vascular tone and third space losses. Critical perfusion is further threatened by vasodilation, blood loss, and interference with venous return following induction (general anesthesia, positive-pressure ventilation, surgical manipulations). Fluid resuscitation should err on the generous sideif signs of septic physiology are apparent. A history of delayed diagnosis, signs of mediastinitis, tachycardia, hypotension, oliguria, respiratory variation on arterial line tracings, depressed mental status, etc. are components of the “septic picture,” which should trigger more aggressive monitoring and therapy. Maintenance of perfusion pressure and oxygen delivery is important to avoid hypoperfusion and ischemia of the flap utilized to reinforce a primary repair, as well as critical end organs. Vasopressor and/or inotropic supportmay be required in sepsis.

Postoperative Monitoring

Immediate or early extubation is reasonable in selected, ­hemodynamically stable patients with little or no contamination intraoperatively. More frequently, an anticipated septic postoperative course justifies postoperative intubation and aggressive fluid resuscitation. Intensive care unit management isusually required in major esophageal resections, sepsis, and patients with hemodynamic compromise or uncontrolled medical conditions.