Public Release:  What should we do when esophageal perforation occurs?

World Journal of Gastroenterology

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.

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This article reported by Dr. Christian A. Righini and his collegues to be published in the March 7, 2008 issue 9 of the World Journal of Gastroenterology.

Reference: Righini CA, Tea BZ, Reyt E, Chahine KA. Cervical cellulitis and mediastinitis following esophageal perforation: A case report. World J Gastroenterol 2008; 14(9): 1450-1452
http://www.wjgnet.com/1007-9327/14/1450.asp

Correspondence to: Christian Adrien Righini, Department of ENT-HNS, University Medical Center of Grenoble, 38043 Grenoble Cedex 09, France. Crighini@chu-grenoble.fr

About World Journal of Gastroenterology

World Journal of Gastroenterology (WJG), a leading international journal in gastroenterology and hepatology, has established a reputation for publishing first class research on esophageal cancer, gastric cancer, liver cancer, viral hepatitis, colorectal cancer, and H pylori infection for providing a forum for both clinicians and scientists. WJG has been indexed and abstracted in Current Contents/Clinical Medicine, Science Citation Index Expanded (also known as SciSearch) and Journal Citation Reports/Science Edition, Index Medicus, MEDLINE and PubMed, Chemical Abstracts, EMBASE/Excerpta Medica, Abstracts Journals, Nature Clinical Practice Gastroenterology and Hepatology, CAB Abstracts and Global Health. ISI JCR 2003-2000 IF: 3.318, 2.532, 1.445 and 0.993. WJG is a weekly journal published by WJG Press. The publication dates are the 7th, 14th, 21st, and 28th day of every month. The WJG is supported by The National Natural Science Foundation of China, No. 30224801 and No. 30424812, and was founded with the name of China National Journal of New Gastroenterology on October 1, 1995, and renamed WJG on January 25, 1998.

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