Management of esophageal perforation

Mar 19 2008

Management of ingested foreign bodies is a common clinical encounter.

Complications of this pathology are dependent on a patient's age, the nature and localization of the foreign body, the presence of a perforation, and initial management procedures.

Dr. Christian Righini from the University Medical Center of Grenoble advocates the use of the rigid endoscope which is placed just above the proximal tip of the foreign body where it dilates the esophageal lumen to the extent that the impacted foreign body is movable.

This recommendation is based on Righini's description of a case involving a 52-yr-old man, with no relevant past medical history who presented to the ENT clinic complaining of severe dysphagia, substernal pain, and fever five days after chewing on a piece of chicken. Imaging revealed a fragment of bone in the upper part of esophagus, air in the retropharyngeal space and the upper part of the posterior mediastinum, and deep subcutaneous collection suggestive of cervical posterior mediastinal collection. The patient was managed surgically through both an endoscopic approach and an open cervical approach.

The use of a rigid endoscope during removal of an impacted foreign body has several advantages: it causes expansion of the upper esophagus, which can release totally or in part the impacted foreign body, and prevents aspiration and esophageal or pharyngeal injury. It must be practiced under general anesthesia by a trained operator.

The management of esophageal perforation is dependent on its size and location. Simple suture is recommended in case of small perforation in the cervical esophagus. It is not necessary to use mucosal flaps to reinforce the esophageal sutures, contrarily to the recommendations for injuries of the middle and lower parts of esophagus. In the case of cervical abscess and/or mediastinitis, drainage of the different affected spaces must be carried out.

In conclusion, perforation of the upper esophagus caused by a foreign body is rare, but can cause potentially life threatening mediastinal complications. CT-scanning enables accurate and timely diagnosis and provides valuable indications for treatment. Extraction of the esophageal foreign body with a rigid endoscope is an effective and safe treatment alternative. Non-operative management of esophageal perforation is not an option in the presence of neck and mediastinum abscesses and necessitates a surgical suture and drainage.