Management of Iatrogenic Cervical Esophageal Perforations

Abstract

sophageal perforation is a rare but life-threatening condition that is difficult to diagnose and treat, with an incidence of 3.1 cases per 1 000 000 per year. 1 It has an overall mortality rate of 13.3%, but this percentage varies from 4% to 80% depending on the type of perforation and the time to diagnosis. 2 Discrepancies in the diagnosis and management of esophageal perforations also contribute to the wide range of mortality rates. The most common causes of esophageal perforation are iatrogenic (46.5%), spontaneous (37.8%), foreign body (6.3%), corrosive (1.8%), and traumatic (<1%). 2,3 Overall, 72.6% of esophageal perforations are thoracic, 15.2% are cervical, and 12.5% are abdominal. 2 Cervical esophageal perforations (CEPs) have a mortality rate of 6% to 8%, [4][5][6][7] which is the lowest mortality rate for esophageal perforations. However, there is little existing literature that focuses specifically on cervical perforations. A 10-year cross-sectional study 4 of CEPs found them to be due to iatrogenic injury (58%), foreign body ingestion (27%), and penetrating injury (15%). Iatrogenic CEPs (iCEPs) are unique among CEPs for various reasons. The increased frequency of endoscopy for diagnosis and treatment has led to a rising number of iatrogenic esophageal injuries. 8 In addition, the management of iCEPs is controversial and lacking in evidence. Conservative management includes antibiotics and feeding tube placement, but cervical drainage is also frequently added to this treatment regimen. More aggressive surgical approaches to treatment, such as pri-

Complications of diagnostic upper Gastrointestinal endoscopy: common and rare – recognition, assessment and management

“…This has a high sensitivity for locating the site of the perforation and allows characterisation of additional complications. [33][34][35] A plain chest X-ray may show pneumomediastinum, pneumothorax or pleural effusion, 33 but adds little information and may delay more sensitive and specific investigations. Contrast swallow is less able to define complications than CT scanning (figure 1).…”

“…Conservative management includes nil by mouth, broad-spectrum intravenous antibiotics, nutritional support, analgesia, cautious nasogastric drainage and the addition of percutaneous drainage of effusions or pneumothoraces where necessary. 34 The ESGE recommends attempting endoscopic closure of iatrogenic perforations depending on the site, size and expertise of available endoscopists. Endoscopic suturing should only be attempted by those with sufficient expertise.…”

Oesophageal perforation following cervical spinal surgery with instrumentation: A case report on primary repair with pedicled sternocleidomastoid muscle flap reinforcement and review of the literature

“…Muscle flap reinforcement lifts the oesophagus from the instrumentation, prevents it from further erosion, increases the delivery of antibiotics due to its vascularised nature 15 and contains leak. Several flaps have been advocated, including SCM, sternohyoid, sternothyroid, pectoralis major, latissimus dorsi, longus coli muscle, radial forearm free flap and omental flap.…”

“…14 The gold standard first-line screening in diagnosing oesophageal perforation is contrast oesophagography with oral iodinated watersoluble contrast, which can confirm the presence and demonstrate the site of the perforation. However, a negative result does not exclude perforation due to the rapid passage of the contrast bolus, 15 especially in perforations of the upper oesophagus. 12 In cases with high suspicion of oesophageal perforation, a contrast-enhanced computed tomography should be performed.…”

Development of a Bioinspired, Self‐Adhering, and Drug‐Eluting Laryngotracheal Patch

“…Adjuvant closure techniques for esophageal and laryngotracheal wounds include salivary bypass tubes, stents, and skin grafting. [9][10][11][12][13] These have had mixed success and are limited by associated morbidity from salivary bypass tubes or secondary harvest sites and subsequent skin graft changes which may still not provide air-or water-tight closure. 9,11 In addition, few available stents are capable of delivering therapeutics.…”