Skip to main content

Main menu

  • Latest content
    • Latest content
  • Archive
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
    • The American Association for the Surgery of Trauma
  • Submit a paper
    • Online submission site
    • Information for authors
  • Email alerts
    • Email alerts
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising
  • BMJ Journals

User menu

  • Login

Search

  • Advanced search
  • BMJ Journals
  • Login
  • Facebook
  • Twitter
TSACO

Advanced Search

  • Latest content
    • Latest content
  • Archive
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
    • The American Association for the Surgery of Trauma
  • Submit a paper
    • Online submission site
    • Information for authors
  • Email alerts
    • Email alerts
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising
Open Access

Esophageal perforations: one is bad, two is worse

Dustin Price, David Skarupa
DOI: 10.1136/tsaco-2018-000206 Published 27 March 2019
Dustin Price
Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David Skarupa
Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

A 48-year-old man was admitted for medical management of recurrent Clostridium difficile (C-dif) colitis. One month prior to presentation, he underwent right thoracotomy and lower lobectomy for a carcinoid tumor at another hospital. His postoperative course was complicated by C-dif colitis, gastroesophageal reflux, and epigastric pain. He underwent two esophagogastroduodenoscopy (EGD) procedures demonstrating mild esophagitis on the first procedure, followed by a linear ulcer on the second procedure 2 weeks later. On hospital day 9 of his current admission, he developed an acute abdomen and underwent an urgent exploratory laparotomy for presumed fulminant colitis. Findings included a healthy-appearing colon with only moderate distension, so a loop ileostomy was created for antegrade colonic irrigation. Postoperatively, a chest X-ray demonstrated a tension-appearing left pleural effusion, prompting tube thoracostomy placement. Initial output was greater than 2L of thin dark-brown fluid. An esophagram demonstrated a distal esophageal perforation (EP) and EGD was performed. Two medium-sized EPs were identified which appeared to arise from chronic-appearing ulcerations, one at 39 cm and one at 45 cm from the incisors (figure 1). A single 19mm×100 mm EndoMAXX fully covered stent was placed. Video-assisted thoracoscopic (VATS) drainage of the left hemithorax was performed in addition to placement of a right tube thoracostomy. Due to continued high output from the left thoracostomy tube, the stent was exchanged for a longer 23mm×100mm EndoMAXX fully covered stent. The patient stabilized for several days but again developed worsened sepsis, with EGD demonstrating inadequate coverage of the proximal perforation.

Figure 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1

Endoscopic photograph showing left-sided esophageal perforation/fistula (black arrow). Gastroesophageal junction indicated by white arrow. NG, Nasogastric tube.

What would you have done?

  1. Repeat esophageal stenting with wide drainage of the thoracic cavity.

  2. Esophageal T-tube placement and wide drainage of the thoracic cavity.

  3. Esophageal resection with gastrostomy drainage and proximal diversion.

  4. Bilateral tube thoracostomies and antibiotic/antifungal therapy.

What we did and why

Choice B

The esophageal stent was removed and a right VATS was performed. A 24-French T-tube was placed in the inferior mid-EP and externalized. The pleural space was irrigated and widely drained (figure 2). A re-exploration of his abdomen was performed and an 18-French Stamm gastrojejunostomy tube was placed. We attempted to mobilize his gastroesophageal junction for proximal gastric exclusion; however, adhesions from his recent exploratory laparotomy precluded adequate mobilization. The following day, a left thoracotomy was performed and a 24-French T-tube was placed in the lower thoracic EP just proximal to the gastroesophageal junction. The T-tube was secured to the diaphragm, externalized through the left chest, and the pleural space was irrigated and widely drained (figure 3). Intraoperative cultures of the pleural fluid grew Candida albicans, C. glabrata, and Serratia liquefaciens, which were treated with broad-spectrum intravenous antibiotic and antifungal therapy. A complicated postoperative course ensued, including reintubation, fluctuating vasopressor requirements, and development of a subsegmental pulmonary embolism requiring anticoagulation therapy. He developed an acute right hemothorax requiring packed red blood cell transfusion on hospital day 32. Additionally, he became more fatigued and frustrated with his oscillating clinical course and requested no further resuscitative efforts. He died on hospital day 35 after initiating comfort care measures.

Figure 2
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2

Intraoperative photograph demonstrating the T-tube within the right mid-thoracic esophageal perforation (white arrow). The left-sided perforation was of similar size, quality and configuration.

Figure 3
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3

Postoperative chest X-ray demonstrating the right T-tube (red) and left T-tube (blue), and widely drained bilateral pleura spaces.

Our case demonstrates an atypical and uncommon presentation of two distal EP/fistulas of uncertain etiology and chronicity. The patient presented with significant weight loss (>20lbs, BMI 17 kg/m2) with evidence of malnutrition and recent EGD with several biopsies. Pathology from these biopsies did not reveal an explanation for the development of the EP/fistulas and it is unclear if the biopsy procedures themselves contributed to the esophageal injuries. Treatment algorithms for EP classically vary depending on chronicity with management of acute perforations favoring primary repair and chronic perforations managed through wide drainage of the pleural cavity. Treatment often includes a multimodal and multidisciplinary approach including surgeons, advanced endoscopists and intensivists. Esophageal stenting has become more widely utilized and is often an initial modality in the modern era for both acute and chronic perforations, providing a minimally invasive means of management with the intent of improved morbidity compared to surgical management. However, as demonstrated by our case, there is still a role for surgical management of EP, whether for salvage of failed stent therapy or as initial management. Despite the array of treatment options, morbidity and mortality from EP remains high and these patients often require prolonged organ support in an intensive care setting. An EP can present a significant clinical challenge, and an even larger challenge when more than one perforation exists.

Footnotes

  • Contributors DP and DS are the sole contributors of this submission.

  • Funding The authors have not declared a specific grant for this research from anyfunding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

PreviousNext
Back to top
Email

Thank you for your interest in spreading the word on TSACO.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Esophageal perforations: one is bad, two is worse
(Your Name) has sent you a message from TSACO
(Your Name) thought you would like to see the TSACO web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Esophageal perforations: one is bad, two is worse
Dustin Price, David Skarupa
Trauma Surg Acute Care Open Mar 2019, 4 (1) e000206; DOI: 10.1136/tsaco-2018-000206

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Cite This
  • APA
  • Chicago
  • Endnote
  • MLA
Loading
Esophageal perforations: one is bad, two is worse
Dustin Price, David Skarupa
Trauma Surg Acute Care Open Mar 2019, 4 (1) e000206; DOI: 10.1136/tsaco-2018-000206
Download PDF

Share
Esophageal perforations: one is bad, two is worse
Dustin Price, David Skarupa
Trauma Surgery & Acute Care Open Mar 2019, 4 (1) e000206; DOI: 10.1136/tsaco-2018-000206
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Respond to this article
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Article
    • Abstract
    • What we did and why
    • Footnotes
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • Management of an acutely bleeding hepatic adenoma
  • Perforation of the cervical esophagus due to an ingested toothbrush
  • Duodenal perforation due to multiple foreign bodies: consideration for operative approach and surgical repair
Show more Challenges in trauma and acute care surgery

Similar Articles

 
 

CONTENT

  • Latest content
  • Archive
  • eLetters
  • Sign up for email alerts
  • RSS

JOURNAL

  • About the journal
  • Editorial board
  • Thank you to our reviewers
  • The American Association for the Surgery of Trauma

AUTHORS

  • Information for authors
  • Submit a paper
  • Track your article
  • Open Access at BMJ

HELP

  • Contact us
  • Reprints
  • Permissions
  • Advertising
  • Feedback form

©Copyright 2023 The American Association for the Surgery of Trauma