Iatrogenic Esophageal Injuries - Causes, Symptoms, Diagnosis, and Management

Introduction

Injuries to the esophagus caused during an endoscopy or other surgical procedures are called iatrogenic esophageal injuries. Endoscopy is one of the safest procedures in the medical field. Yet it is also considered the most common way to injure the esophagus. Iatrogenic esophageal injuries can be surgical or non-surgical. The average mortality rate for an iatrogenic esophageal injury is 19 %.

What Are the Causes of Iatrogenic Esophageal Injuries?

One of the leading causes of perforation in an iatrogenic esophageal injury is esophageal instrumentation, which results in piercing or shearing in the procedure, especially endoscopy and dilation of a narrow esophagus. This usually occurs at a place in the esophagus that is weak, like the pharyngoesophageal junction. In addition, the esophagus is surrounded by loose stromal connective tissue. Hence, a tear or perforation in the esophagus can cause blood to flow into the surrounding vital organs, making it a medical emergency. The risk of perforation is highest in the abdominal esophagus.

Spontaneous esophageal rupture occurs following a sudden increase in intraluminal pressure, as in vomiting or retching. This is usually followed by a heavy meal and alcohol intake. In most cases, the perforation occurs in the lower third of the esophagus, usually in the left posterolateral region. There is a high chance of a tear on the left side due to the lack of supporting structures and muscle thinning in the lower esophagus.

What Are the Procedures That Can Cause Iatrogenic Esophageal Injuries?

Iatrogenic esophageal injuries can have surgical or non-surgical causes. Non-surgical esophageal injuries can occur during nasogastric tube placement, endoscopic removal of foreign bodies, esophageal dilation and stricture, etc. Surgical esophageal injuries can include esophagectomy, Nissen’s fundoplication (the most common form of surgery for a hiatus hernia, and is done using laparoscopy), esophageal perforation repair, esophageal myotomy (a procedure used to treat the motility disorder of the esophagus), surgical removal of foreign bodies, etc.

What Are the Symptoms of Iatrogenic Esophageal Injuries?

The injury symptoms depend on the site and the extent of the injury. Pain is the most commonly associated symptom. Most of the time, the pain suddenly starts after an endoscopic procedure. The location of the pain is dependent on the injury location or perforation. Other symptoms include:

• Dysphagia (difficulty in swallowing).

• Dyspnoea (shortness of breath).

• Nausea.

• Vomiting.

• Fever.

• Tachycardia (increased heart rate).

• Tachypnoea (breathing that is rapid and shallow).

There can be a significant delay in diagnosing an esophageal injury after a surgical procedure as the patient will be on painkillers. This makes the other symptoms nonspecific and confusing. Cervical perforation of the esophagus can cause neck stiffness, rigidity, and subcutaneous emphysema, which happens when air gets trapped under the skin. Extravasation of saliva, food boluses, and refluxed gastric content into the mediastinum (the cavity in the chest holding the lungs and other organs). Pleural spaces are seen in a thoracic esophageal perforation. The progression into multiorgan failure and sepsis can be fast.

How Are Iatrogenic Esophageal Injuries Diagnosed?

Identifying an esophageal injury is very challenging. As per estimates, only about 58 % of all esophageal injuries are reported and treated within 24 hours.

• Appropriate imaging should be carried out in every patient suspected of having an esophageal perforation following an endoscopy.

• Imaging, including plain radiography and contrast imaging, should be done.

• Indirect signs of esophageal perforation like pleural effusion (fluid buildup in between the layers lining the lungs), pneumothorax (air leaks into the space between the lungs and the chest wall, giving the appearance of a collapsed lung), pneumomediastinum (presence of air in the space between the two lungs), pneumopericardium (air accumulation in the sac around the heart), or the presence of free air under the diaphragm, etc.) can be seen on a plain radiograph.

• Computed tomography is more sensitive than X-rays and is the first line of diagnosis to avoid delays.

• Soluble contrast imaging will help find the perforation accurately.

• An oral contrast CT will be preferred to fluoroscopy, particularly for detecting small leaks and planning the treatment.

• The chances of aspiration of soluble contrast and the resultant necrotizing pneumonia in severely ill patients should be considered.

How Are Iatrogenic Esophageal Injuries Managed?

The management of an iatrogenic esophageal injury can be conservative, endoscopic, or surgical. This depends on the location and severity of the injury and the underlying esophageal cause for which the procedure was carried out. Regardless of the procedure, the delay in diagnosing the condition will negatively impact the prognosis.

1. Conservative Treatment: The main elements of conservative support are fluid resuscitation, antimicrobial delivery, nil by mouth, gastric decompression, nutritional support, monitoring hemodynamic stability and providing necessary support, and so on. These elements hold support for the endoscopic approach as well as the surgical approach. The selection criteria for a purely conservative approach are controversial. However, the commonly accepted criteria include early diagnosis (in less than 24 hours), no extraluminal contamination, the absence of sepsis, and esophageal pathology that can delay or prevent healing. In most cases, iatrogenic perforations of the cervical esophagus comply with this criteria and are, therefore, most successfully managed conservatively. Close monitoring with CT scan and esophagogram and proper drainage of extraluminal fluid helps in faster recovery and provides a good prognosis. The most successful conservative management has survival rates of 84 to 100 percent.

2. Surgery: Surgery has been the mode of treatment for esophageal perforations. As in the other approach, the surgical extent will depend upon the extent of the injury, the location of the injury, the degree of contamination and sepsis, the clinical status of the patient, the presence of any underlying esophageal pathology, and the expertise of the surgeon. The surgical approach in fit patients where the perforation is diagnosed early and the esophagus is healthy is thorough debridement of the contaminated tissue followed by primary repair. Diversion and exclusion techniques have been used in cases where primary repair is not possible due to extensive damage. Resection and reconstruction are indicated in large circumferential perforations, early malignancy stages, and end-stage benign (non-cancerous) diseases.

3. Endoscopy: In the current medical era, stents are used to occlude perforations through endoscopy. Limitations of this technique include perforation in the cervical esophageal esophagus or gastroesophageal junction, large injuries of more than 6 cm, etc.

Conclusion

Iatrogenic esophageal injuries are relatively uncommon yet potentially devastating, with high morbidity and mortality rates. Therefore, early diagnosis is challenging but very important for a good prognosis. Unfortunately, only half the cases of iatrogenic esophageal perforation are diagnosed and treated within 24 hours.