Algorithm 43-1. Evaluation and treatment of esophageal perforation.

Esophageal Stents

4 Endoscopic placement of endoluminal stents for perforations has been a concept which has been

discussed for several decades.23 In the last 10 years, the technology of stents has improved such that

deployment is easier and our indications have expanded to include placement for perforations. Starting

with small limited series,24–30 their use has expanded dramatically to the point that they have become

one of the main tools in the management of select, contained perforations. Highly selected patients with

perforations are candidates for stenting in the context of a thoracic surgical practice according to the

principles outlined in this section. Our own investigations and use in our practice has found that

esophageal stent placement for perforations facilitates source control, may minimize stricture

formation, and frequently allows for early oral intake. However, success depends on a uniform

approach that focuses on appropriate patient selection, proper stent placement technique, thorough

drainage procedures which cannot be underemphasized, and meticulous postoperative care. Our

recommended uniform approach is presented here and this approach has yielded excellent results.31–33

DIAGNOSTIC EVALUATION

A computerized tomography (CT) scan, with or without oral and intravenous (IV) contrast, is a good

initial diagnostic test. The role of a CT scan is to help determine whether additional source-control

measures are needed (e.g., tube thoracostomy, decortication). We frequently perform the contrast

esophagram second as the barium may interfere with the CT scan and the only reason we omit this step

is in the case of aspiration risk. The barium esophagram is regarded as a real-time image, whereas the

contrast delivery of the CT scan does not provide the same functional and anatomic details of the site

and tracking of the leak, thus we prefer both when possible.

PATIENT SELECTION

For perforations proximal to the cricopharyngeus, stents have little or no role. For perforations 2 cm or

more distal to the cricopharyngeus, a stent may work if the proximal extent seats just below the

cricopharyngeus muscle. If the stent seats at or above the cricopharyngeus, patients experience

intolerable foreign-body sensations during deglutition and reflux and coughing are generally severe.

Also of note, stents placed in the proximal esophagus may cause pressure and compression of the

posterior membranous trachea leading to dyspnea and, in severe cases, critical airway compromise. If a

stent is considered in the proximal esophagus, the physician should strongly consider performing a

simultaneous bronchoscopy to assess airway patency. Perforations below this area may be good

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candidates for stenting when there is limited perforation, and there is good purchase of esophagus

above and below the site of the perforation. This might include perforations associated with malignancy

and in benign diseases such as iatrogenic perforation, Boerhaave syndrome, and select cases of

achalasia. Patients with perforations from near-obstructing cancers can be ideal candidates for stents as

the stent will purchase well against the tumor, leading to sealing of the perforation and relieving any

coexisting blockage above or below the perforations. In addition, operating on perforated cancers can

be a significant clinical problem as this may occur at the initial diagnosis or the endoscopic ultrasound

(EUS), or may occur during chemo and radiation, thus making stenting our procedure of choice in the

setting of cancer.

Initial broad-spectrum antimicrobial therapy is directed to cover common gram-negative bacteria,

anaerobic bacteria, and fungi. We generally use a beta-lactam agent in combination with fluconazole,

which is usually sufficient. We adjust therapy to culture findings. Duration of therapy is patient

dependent, but it is typically continued for 10 to 14 days after resolution.

In addition to antimicrobial therapy, we tailor further source control in accordance with clinical, CT

scan, endoscopic, and intraoperative findings. We emphasize aggressive source control, and operative

drainage of any extraluminal material. Stent placement without drainage in the setting of mediastinal

soilage is a risky approach and if it is done, one may question whether the perforation was small

enough to need intervention and, if larger, we would typically perform a VATS or thoracotomy to

debride any soilage. If patients deteriorate clinically following any treatment, consideration of the

presence of undrained sepsis should always be considered. At times, a patient might require several

interventions to control the local and regional sepsis.

Source control measures vary depending on clinical and anatomical findings:

Mediastinal air (no fluid): antibiotics only without additional source control measures.

Mediastinal fluid collection or abscess: operative drainage; the approach varies by anatomical location:

Neck and superior mediastinum: lower neck incision with blunt mediastinal dissection, irrigation,

open packing, and, if deemed appropriate, drain placement.

Posterior mediastinum at any level: right thoracoscopy or thoracotomy with wide pleural incision,

drainage, irrigation, and large-bore chest tube(s) placement.

Lower posterior mediastinum only: left thoracoscopic or open drainage.

Free-flowing pleural effusion: large-bore tube thoracostomy.

Empyema: thoracoscopic or open decortication.

STENT SELECTION

Numerous stents are available for use. We prefer the Wallflex fully covered stent and find that the

longer stents (15 cm) work better to cover defects and minimize migration.

STENT PLACEMENT TECHNIQUE

We perform our procedures in the operating room and with the patients under general endotracheal

anesthesia. The key components of our stent placement technique are the following:

1. Position: supine position with the head of the bed elevated 30 degrees.

2. Intraoperative fluoroscopy:

Radiopaque skin markers: large-bore IV needles taped to the skin. Lock the fluoroscopy arm into

position once the desired image has been obtained and before skin marker placement; moving the

fluoroscopy arm after marker placement may lead to inaccurate marking.

At times, we will use intraoperative esophagram: if the leak is small, we will inject contrast through

the esophagoscope to clearly identify it; we always confirm leak sealing with contrast injection

after stent placement. We use isomolar and water-soluble contrast dye (iodixanol [Visipaque]; GE

Healthcare Inc, Princeton, NJ) to minimize respiratory complications in case of aspiration.

3. Wire of choice: superstiff, angled or straight tip, 0.035-in (0.8-mm) diameter, 260-cm length.

4. Stent position:

Minimum coverage: at least 3 to 4 cm above and below the leak or perforation.

Minimum distance from cricopharyngeus muscle (upper esophageal sphincter): 1 to 2 cm.

Distal end position: we avoid the distal end from crossing the GE junction.

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5. Stent foreshortening or “jumping” on deployment: this varies by stent.

6. Intraoperative evaluation of stent position and proper sealing: every stent is placed and evaluated

with fluoroscopic guidance and endoscopy.

7. Tools and techniques for stent repositioning (if stent is too distal or too proximal): the “rattooth”

forceps is the best tool to pull the stent proximally if needed after deployment. If we need to advance

the stent in a patient with a gastric conduit, then we will advance the gastroscope into the distal

stomach, retroflex, lock the “rat-tooth” grasper on the distal end of the stent, and push the

gastroscope forward.

8. Indications for immediate stent removal: we never leave a stent in place if it is not in perfect

position, angulated too much, or obstructed.

POSTSTENT MANAGEMENT

1. Nutrition: enteral feeding access should be ensured as soon as possible, preferably at the time of

endoscopic and operative interventions. We place an operative jejunostomy tube or percutaneous

endoscopic jejunostomy tube in the occasional postesophagectomy patient who does not already have

enteral feeding access. In patients with perforations, we place a percutaneous endoscopic gastrostomy

(PEG) tube at the time of endoscopic or operative intervention but before stent placement. In our

experience, placing a PEG tube has no effect on the perforation; placing a PEG tube after stent

placement will likely displace the stent.

2. Aspiration and reflux precautions: these precautions are imperative in all postesophagectomy patients

and in patients with stents that cross the gastroesophageal junction.

3. Postprocedure follow-up:

a. Chest radiograph: we obtain chest radiography immediately after the procedure and daily

thereafter to monitor for migration.

b. Sepsis resolved: we wait until the patient is able to swallow appropriately; then we perform an

esophagram.

c. Ongoing sepsis: we thoroughly reassess the patient; ongoing sepsis is generally due to poor source

control and/or nonsealing of the leak or perforation. Reintervention is then tailored to the situation

but might require aggressive surgical intervention and stent removal and/or replacement.

d. Stent migration: mandates replacement unless leak has resolved. This is typically not an emergency

but should be addressed in a timely fashion.

4. Resumption of oral intake: this depends on the clinical scenario. A speech pathologist evaluates every

patient before an esophagram. Only patients who are safe to swallow undergo an esophagram. Oral

intake is then resumed.

5. Eventual stent removal or exchange: We generally repeat endoscopy at 3-week intervals and remove

the stent. If a small leak persists, we restent so that the distal end of the stent is slightly proximal or

distal to that of the previous stent to allow the area of inflamed gastric mucosa to heal.

6. Pain: pain appears to be less common in patients with leaks and perforations than in patients with

malignant strictures. Persistent pain should prompt reevaluation, because it might represent ongoing

mediastinal or pleural contamination.

Operative Treatment

The operative management of esophageal perforation is dictated by the location of the injury, extent of

injury, and underlying pathology. The operative approaches include the following options: drainage

alone, primary reinforced repair, esophagectomy with immediate/delayed reconstruction, and

esophageal exclusion.

Perforations of the upper third of the esophagus to the level of the carina and treated by cervical

drainage that is approached via a left neck incision as depicted in Figure 43-2. Traditionally it is not

necessary to find or close the perforation as this will seal during the process of healing. In order for this

to be successful, however, wide and complete drainage must be accomplished. The posterior

prevertebral fascia is opened completely to accomplish this. Preoperative imaging via CT scan will aid

in ensuring that the important areas of contamination are addressed surgically. In the operating room

we liberally use on-table flexible endoscopy to evaluate the defect and the location of the hole. If the

hole is identified and it is small, we advocate for closure of the hole. The neck incision is loosely closed

with staples over a drain. Postoperatively, broad-spectrum antibiotics are continued. One may consider

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a gastrostomy or jejunostomy tube for nutritional access during the time the patient is NPO. Typically

at 5 to 7 days postoperatively a contrast esophagram is obtained, the patient’s diet is advanced, and the

drain is removed. If there is continued leak, the patient is left NPO or on clear liquids and restudied in 1

week. There should be no distal obstruction on the contrast study and if there is a stricture that prevents

normal contrast flow, we advocate for dilation to aid in eventual closure of the esophageal fistula. As

long as there is no underlying pathology and there is distal flow through the esophagus in the presence

of adequate drainage, the esophageal perforations will heal spontaneously.

Perforations of the middle third of the esophagus are best approached through the middle third of the

esophagus via a right 5th interspace posterolateral thoracotomy. After adequate IV access and arterial

line placement, a single-lumen tube is placed and bronchoscopy/esophagoscopy is performed. The

single-lumen endotracheal tube is changed to a double-lumen endotracheal tube and the patient is

positioned in the left lateral decubitus position. We routinely start thoracoscopically, but typically these

patients are very ill and thoracotomy is indicated early. At the time of entry into the chest, an

intercostal m. flap is routinely taken. We use papaverine solution to enhance blood flow and great care

is taken not to injure the flap when the retractors are placed. A Doppler is routinely used to confirm

blood flow in the flap. All pleural collections are drained, the lung is decorticated, and the site of

perforation identified after opening the posterior mediastinal pleura. Necrotic tissue at the site of the

perforation is debrided and the esophagus is mobilized. A vertical myotomy is performed to expose the

mucosa and the full extent of the tear (Fig. 43-3). The mucosa is repaired with interrupted or running

absorbable suture. The muscular layer is reapproximated with interrupted fine silk suture. On-table

endoscopy is performed to ensure the leak is repaired. The intercostal m. is then secured as an onlay

patch. Large chest tubes are placed and a 10-French Jackson–Pratt drain is left in the area of the repair

and placed to bulb suction. Typically nutritional access is not addressed at the time of the index

operation as the patients are quite ill, and this can be accomplished at a later date. On POD 7, a contrast

study is obtained and if there is no leak, the diet is advanced. Persistent leaks are treated with JP

drainage, provided CT imaging demonstrates that there are no undrained collections. Esophageal

dilation may be required to ensure proper forward flow. Reoperations for adequate drainage may be

required. Esophageal stenting may be used to exclude the leak provided that there is adequate drainage

and the principals described in the stenting portion of this chapter are followed. If the repair breaks

down or there are signs of clinical sepsis, esophageal exclusion may be required with cervical

esophagostomy, esophageal resection, and gastrostomy tube. When the patient recovers and walks into

clinic begging for reconstruction (this usually occurs at 6 to 12 months postexclusion), they may be

considered for reconstruction most commonly approached as a substernal gastric pull-up.

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Figure 43-2. Approach for drainage of a cervical esophageal perforation. A: Skin incision parallel to the anterior border of the left

sternocleidomastoid muscle, extending from the level of the cricoid cartilage to the sternal notch. B: With the sternocleidomastoid

muscle and carotid sheath retracted laterally and the trachea and thyroid gland medially, blunt dissection along the prevertebral

fascia in the superior mediastinum is carried out. Injury to the recurrent laryngeal nerve in the tracheoesophageal groove must be

avoided. C: Schematic drawing of the prevertebral space drained by this cervical approach. D: Two 1-in rubber drains placed into

the superior mediastinum are brought out through the neck wound to allow establishment of an esophagocutaneous fistula, which

usually heals spontaneously.

Figure 43-3. Primary repair of esophageal perforation. The edematous mucosa pouting through the muscular defect (inset) is

grasped with Allis clamps and elevated. A 1-cm vertical esophagomyotomy is made at either end of the muscular defect to expose

the entire limits of the tear. This is facilitated by using a right-angle clamp to direct muscularis away from underlying submucosa

around the entire circumference of the tear. The result of this mobilization is exposure of a circumferential rim of normal

submucosa that can then be closed.

Perforations of the distal third of the esophagus are approached via a left 7th intercostal space

thoracotomy. Similar to the approach for middle-third perforations, after adequate IV access and arterial

line placement, a single-lumen tube is placed and bronchoscopy/esophagoscopy is performed. The

single-lumen endotracheal tube is changed to a double-lumen endotracheal tube and the patient is

positioned in the left lateral decubitus position. Thoracoscopy may be an option, but typically these

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