Esophageal rupture is a potentially life-threatening condition that is difficult to diagnose and manage. The incidence continues to rise because of the in?creased use of esophageal instrumentation during invasive diagnostic procedures. Precise diagnosis is essential for effective treatment and depends on early recognition of clinical features and accurate interpretation of diagnostic imaging. The authors report the case of an elderly woman who had trans?esophageal echocardiography monitoring during coronary artery bypass graft surgery. The patient had a complicated postoperative recovery, and a swallow study 10 days later showed a large noncontained esophageal perforation. Because of her multiple comorbidities and the risks of surgery, she was successfully treated conservatively with a continuous antibiotic irrigation-drainage system through a nasogastric tube above the perforation and a chest tube for drainage. This case suggests that conservative management of esophageal perforation is a valid option for patients with multiple comorbidities who are diagnosed late, even after the onset of sepsis.

Since described by Barrett in 1946, esophageal perforation continues to present a diagnostic and therapeutic challenge to the surgeon.^1,2 It still carries a high rate of morbidity and mortality because of delays in diagnosis, ex?tensive mediastinal contamination, and inadequate surgical repair. The incidence of esophageal perforation has increased with the expanding use of invasive diagnostic technology. The etiology has changed from mostly spontaneous or traumatic to mostly iatrogenic.

We report the case of esophageal perforation in a woman who had transesophageal echocardiography (TEE) during coronary artery bypass graft (CABG) surgery. Despite sepsis, multiple comorbidities, and the character of the eso?ph?ageal extravagation, we successfully treat?ed the patient's iatrogenic esophageal perforation using a conservative approach.

Case report
A 72-year-old woman came to the hospital reporting chest pain and shortness of breath. Her medical history was significant for end-stage renal disease, diabetes mellitus, hypercholesterolemia, hypertension, gastroesophageal reflux disease, sarcoidosis, and breast cancer treated with lumpectomy and radiation. An ab?normal electrocardiogram (EKG) and elevated cardiac enzymes were consistent with an inferior-wall myocardial infarction.

Cardiac catheterization showed that the patient had four-vessel disease, re?quiring CABG surgery. Prior to the skin incision, TEE was performed to evaluate cardiac function. The patient underwent a one-vessel coronary bypass. A mediastinal and left and right pleural chest tubes were placed intraoperatively. The mediastinal and left pleural chest tubes were removed on postoperative day 1, and the right chest tube was removed on postoperative day 2. On postoperative day 4, the patient developed tachypnea, shortness of breath, and hypoxia. A chest radiograph showed a right hydropneumo-thorax and bilateral basal lung consolidation. A right chest tube was placed, which drained about 1 L of milky fluid per day. The fluid had high amylase levels. The patient's fever rose from 37?C to 39?C, and her white blood cell count increased to 21,000/?L. Ten days after surgery, a Gastrografin and barium swallow study showed disruption of the midesophagus with communication into the right pleural space, which was confirmed by a chest radiograph (Figure 1).

On postoperative day 11, the patient underwent an upper endoscopy and placement of an esophageal irrigation catheter, left chest tube, and feeding jejunostomy. The patient had two nasogastric tubes placed intraoperatively: a drainage tube in the stomach and an irrigation tube proximal to the perforation. The patient received 10,000 units of bacitracin in 1 L of normal saline through the irrigation tube at 50 mL to 75 mL per hour for 14 days. Bacitracin irrigation was followed by 20 g of cefazolin in 1 L of normal saline administered at 50 mL per hour for 12 days. The patient also received gatifloxacin and clindamycin intravenously during this time.

While undergoing this conservative treatment, the patient received enteral feeds via a jejunostomy tube. She re?quired a tracheostomy and continuous ventilation after prolonged intubation and failure to wean from the ventilator. She also developed several episodes of sepsis, which were treated effectively with antibiotics.

During the course of treatment, barium studies were repeated and showed interval improvement of the esophageal perforation. The patient was able to tolerate tracheostomy collar trials after 24 days of treatment. The chest tube drainage cleared and irrigation was discontinued after 26 days of continuous esophageal irrigation. The chest tube output decreased to less than 10 mL per day, and 33 days after the irrigation was stopped, the chest tube was removed. After 56 days of conservative treatment, the patient was started on a liquid diet, which was slowly advanced to a regular diet. She was discharged to a nursing facility 3 months after surgery.

A follow-up barium swallow study 5 months postoperatively showed no evidence of esophageal perforation (Figure 2). A chest radiograph and a computed tomography (CT) scan 7 months after sur?gery showed resolution of the right pleural effusion with no extravasations (Figure 3).

Discussion
The cause and location of an eso?phageal perforation are significant in predicting the success of treatment. Other key factors include whether the patient has any underlying esophageal disease and how much time elapses between the injury and commencement of medical treatment. Delaying medical attention 24 hours or more after injury can double the 20% mortality rate normally ascribed to esophageal perforation.³

Iatrogenic injury to the esophagus is the most common cause of esophageal perforation, with instrumentation during diagnostic procedures accounting for 59% of all cases and 15% occurring spon?taneously.^4-7 Other causes include for??eign body ingestion (12%), trauma (9%), opera?tive injury (2%), and tumor (1%). Proce?dures that commonly cause esophageal perforation include TEE, eso?ph?agoscopy, sclerotherapy, variceal liga?tion, pneumatic dilation, bougienage, and laser the?r?apy. Esophageal manipulation should be minimized in patients with risk factors for esophageal perforation, such as exposure to radiation or those with scleroderma.

To diagnose and treat an esophageal perforation effectively, it is important to recognize the clinical signs and symptoms of the injury and accurately analyze diagnostic images. Symptoms include pain, fever, chills, dysphagia, and he?ma?te?mesis. Signs include chest or cervical ten?der?ness on palpation, mediastinal crunch heard on cardiac auscultation (Hamman's sign), and crepitation. The presence of undigested food, a pH of less than 6.0,8 or an elevated salivary amylase level in pleural fluid collected by thoracentesis all indicate esophageal perforation. Plain chest radiographs for 90% of patients show pleural effusion, pneumomediastinum, subcutaneous emphysema, hydrothorax, hydropneumothorax, or subdiaphragmatic air, but can appear normal if taken early.⁹ Any left-sided pleural effusion strengthens suspicion of perforation.

Contrast esophagography remains the standard for diagnosing esophageal perforation. Water-soluble contrast agents, such as Gastrografin, are advocated for first-line screening of suspected perforation. If perforation is not detected with a water-soluble agent, serial barium contrast esophagography should follow.¹⁰ Because a negative result cannot rule out the possibility of perforation, an accurate diagnosis may require a CT scan or flexible esophagoscopy, or both.

l Conservative management?Conser?vative management has been a controversial treatment method since the first successful series was reported in 1965 by Mengold and Klassen.¹¹ Over the years, thoracic surgeons have postulated the best scenario to use this treatment, taking into consideration timing of diagnosis, location of the perforation, extent of in?jury, and the overall clinical picture. Several studies show high survival rates when instrumental perforations are treated within 24 hours of diagnosis.^11-13 In contrast, a study by Junginger and colleagues showed that conservative treatment of early diagnosed esophageal rupture was associated with a high mortality rate.¹⁴ Michel and colleagues found that pa?tients with cervical lesions had a higher risk of mortality with conservative management than with surgical repair.¹⁵ In a study by Altorjay and colleagues, two of 20 patients died, revealing a mortality rate of 10% using a conservative ap?proach.¹⁶ The rate of comp?lications in the conservatively treated group was 20% (4 of 20 patients) compared with 50% in the operative group (33 of 66 patients). Other studies advocate use of conservative man?agement in patients with cervical perforations.^17,18 To date, there is no strict criterion regarding the use of conservative management for esophageal perforations.

Traditionally, patients with esophageal perforations are treated surgically; however, treatment of these patients with esophagectomy or primary repair is associated with a high mortality rate.¹⁹ Conservative management is made possible due to improved antibiotics and advances in nutritional support.¹³ It is thought to be appropriate for patients who fulfill Cameron's criteria, which include minimal signs of clinical sepsis, disruption contained in the mediastinum, drainage of the cavity back into the esophagus, minimal symptoms, delayed diagnosis, and clinically stable pa?tients.^7,20 Conservative management is considered to be the first therapeutic choice in children.²¹ One retrospective study on 57 patients concluded that esophageal perforation requires aggressive treatment.²² We find that treatment depends on whether there is perforation of a healthy esophagus or perforation with a preexisting underlying intrinsic esophageal disease causing distal ob?struction. Esophageal perforation associated with stenotic lesions (benign or malignant) requires esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Conservative management is appropriate when there is delay in diagnosing esophageal perforation.^22,23

Conservative management includes taking nothing by mouth for at least 48 to 72 hours, at which time clear liquids can be initiated if the patient shows improvement. Because mediastinal sepsis is primarily responsible for deaths associated with delayed diagnosis of esophageal perforation, proper drainage and antibiotics are the keystones in management. Conservative management should in?clude administering broad-spectrum antibiotics for at least 7 to 14 days and total parenteral nutrition. Irrigating with an antibiotic solution and providing intravenous antibiotics are beneficial and may help control sepsis and local inflammatory reaction, allowing subsequent healing and closure of the esophageal opening.^24,25 This should be carried out through esophagogastroduodenoscopy (EGD)-directed placement of two nasogastric tubes: one above and one below the esophageal perforation. The proximal tube is used for irrigation, and the distal tube should be used for gastric decompression and as an underwater seal chest tube for drainage. Because EGD allows direct visualization, it is a precise way to insert the irrigation-drainage system.

Several factors are responsible for causing esophageal perforation, thus treatment for this life-threatening event has become more individualized. En?suring adequate pleuromediastinal drain?age with sufficient irrigation is imperative for all patients. Spontaneous eso?phageal perforations may require early surgical exploration with drainage and irrigation of the mediastinum and pleural cavity, whereas most iatrogenic lesions can be managed conservatively.²⁶

We used a conservative approach for managing esophageal perforation in a septic patient with a noncontained per-foration because surgery had an especially high mortality risk. The irrigation-drainage system we used resulted in a satisfactory outcome. Enteral nutrition maintains gut functioning while giving superior alimentation to parenteral nutrition. Close monitoring in the intensive care unit was necessary for quickly diagnosing and treating the patient's septic episodes.

Conclusion
How best to treat esophageal perforation depends on the extent and location of the injury, the etiology, whether there is underlying esophageal disease, the pa?tient's general condition, and, most im?portantly, the time interval between perforation and diagnosis. A high index of suspicion and diligent follow-up are essential in diagnosing and treating esophageal perforation. Whether or not to use a conservative approach must be determined on a case-by-case basis. Our experience indicates that conservative man?agement might be safely extended to high-risk patients even in the setting of non?contained ruptures and sepsis.

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