GB, 83, PRESENTED to the ED complaining of retrosternal chest pain before eating dinner. He described the pain as sharp and burning and rated it a 10 on a 0 (no pain) to 10 (worst pain imaginable) pain intensity rating scale. Emergency medical service personnel administered sublingual nitroglycerin in the field without effect.
GB was hemodynamically stable upon arrival to the ED, his ECG showed no abnormalities, and his serum troponin levels were within normal limits. Because he had undergone a catheter radiofrequency ablation (RFA) 2 weeks prior to admission to treat atrial fibrillation (AF), a computerized tomography (CT) of the neck, chest, and abdomen was performed and demonstrated a thoracic esophageal perforation (EP). GB was taken to the OR for esophageal endoscopic covered stent placement with fluoroscopic guidance and transferred to the ICU.
This article focuses on EP as a complication of RFA, the standard treatment for drug-refractory symptomatic AF in certain patient populations.1
Traumatic esophageal injuries are rare, with most large trauma centers treating just one or two cases per year.2 EP is caused by an event that compromises the esophageal lining and structure. The esophagus lacks a protective serosal layer, which places patients at a higher risk for injuries during procedures involving the esophagus or areas in close proximity (see Normal esophageal anatomy). The most common cause of EP is iatrogenic injury, of which endoscopic procedures are the most common.3 (See What causes EP?)
The esophagus extends from the 7th cervical vertebra to the 11th thoracic vertebra and is divided into regions. Perforations are named according to the esophageal region involved: cervical, thoracic, and abdominal.4 EP results in leakage of esophageal and gastric contents into the mediastinum, producing a chemical burn and infection. Left untreated, this leads to a severe inflammatory response and sepsis.5
Signs and symptoms of EP depend on the site and cause of the perforation and the timeliness of the diagnosis and treatment.3 Patients with a cervical EP typically present with cervical pain, odynophagia (painful swallowing), subcutaneous emphysema, and neck tenderness and crepitus. Dysphagia, pain, tachycardia, and fever usually occur shortly after iatrogenic perforation. Perforation of the upper portion of the intra-thoracic esophagus results in a right-sided pleural effusion associated with fever. Patients with mid-thoracic esophageal perforation present with subternal or epigastric pain.6 Abdominal EP usually causes peritonitis. Late manifestations of untreated perforations often include hypoxemia, sepsis, and shock.2
As the standard treatment for drug-refractory symptomatic AF in certain patient populations, RFA usually targets the left atrium.1,7 RFA is generally safe, but the close proximity of the esophagus to the posterior wall of the left atrium makes the esophagus susceptible to injury, especially thermal injury.1 Many factors influence a patient's risk of esophageal injury in this procedure, such as the magnitude and duration of local tissue heating, atrial tissue thickness, thickness and character of the connective and adipose tissue between the heart and esophagus, as well as catheter size, contact pressure, and orientation. Surveillance endoscopy studies following RFA for AF have reported varying degrees of thermal esophageal injury in approximately 15% of patients.1
Complications from EP include pneumonia, empyema, sepsis, multiple-organ failure, peritonitis, and mediastinitis.5 If treatment is initiated within 24 hours, the mortality for EP is 10% to 25%, but it rises to 40% to 60% if diagnosis and treatment are delayed.3 EP is often initially misdiagnosed as an acute myocardial infarction.3
EP's high mortality may be due to the location of the esophagus. This creates an easy access point for bacteria and digestive enzymes that can lead to mediastinitis and sepsis. Moreover, the rarity of EP and its inconclusive presentation contribute to delayed diagnosis and treatment, which occurs in more than 50% of perforation cases.3
Diagnosis and management
Diagnostic studies will vary depending on the mechanism of injury, suspected location of EP, and clinical status of the patient. Diagnostic studies may include CT of the neck, chest, or abdomen; esophagoscopy; and esophagography.2
Treatment options depend on factors such as the severity of esophageal injury, cause and site of perforation, and the patient's general health status.3
Initiating treatment as early as possible is essential for optimal patient outcomes. Treatment includes airway management, fluid resuscitation, N.P.O. status, broad-spectrum antibiotics, analgesia, enteral nutrition, and surgical repair if indicated.3 Surgery is the mainstay of treatment, but some physicians may recommend a nonoperative approach if the perforation is small and there is negligible extraesophageal involvement or when the diagnosis is made late.3
When an esophageal injury is confirmed or suspected early in a hemodynamically unstable patient, treatment should be initiated as soon as possible and include fluid resuscitation, N.P.O. status, opioid analgesia, parenteral nutrition, and a determination regarding a surgical or nonsurgical approach.3
Esophageal injury is graded according to the American Association for the Surgery of Trauma injury severity scoring.8 (See American Association for the Surgery of Trauma: Esophagus Injury Scale.) The extent of the injury has a bearing on the nature of the repair. To repair cervical EP, an incision is generally made along the medial border of the left sternocleidomastoid. A right-sided, or if bilateral access is needed, a transverse incision also may be used.2
A posterolateral thoracotomy is used to repair a thoracic EP in hemodynamically stable patients.2 To repair an abdominal EP, a midline abdominal incision is used.2 Adjunctive esophageal stenting or endoscopically placed clips to seal or close small EPs are sometimes used.7 (See Esophageal stenting.)
GB was diagnosed with EP, underwent endoscopic covered esophageal stent placement with fluoroscopic guidance in the OR, and was transferred to the ICU postoperatively for monitoring, assessment, and further care.
Nutritional support is a crucial part of patient care in promoting tissue repair and healing. Patients with EPs are placed on strict N.P.O. status.9 For patients who can't receive enteral nutrition, parenteral nutrition is recommended. GB was N.P.O. and received enteral nutrition via a jejunostomy tube.
GB's post-op care focused on maintaining adequate oxygenation, assessing lab values, administrating antibiotics, maintaining N.P.O. status, and optimal pain management. Nursing care also included monitoring vital signs and oxygen saturation levels and serial physical assessments. The head of the bed was maintained at a 30- to 40-degree angle and frequent mouth care was performed. The team performed daily assessments of readiness to extubate, along with daily arterial blood gas evaluations and chest radiographic studies. Other nursing interventions included maintaining a calm, quiet environment, providing reorientation, and explaining all interventions.
Due to its rare incidence and variable presentation, EP is a challenge to diagnose. Timely diagnosis and treatment are essential in the management of this disorder.
The most frequent cause of EP is iatrogenic injury, of which endoscopic procedures such as RFA are the most common. Other causes include:
- trauma (blunt or penetrating)
- caustic agents (acid or alkali)
- infection (such as candida, herpes, syphilis, tuberculosis)
- foreign bodies
Temporary esophageal stenting allows healing of esophageal perforations following AF ablation procedures.
A: An iatrogenic esophageal perforation (arrow). B: Endoscopic view depicting complete coverage of perforation with a self-expanding stent.
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—a deadly complication. World J Gastroenterol
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. Ann Thorac Surg