Esophageal Perforation and Tears

Excerpt

Esophageal perforation poses a significant interprofessional challenge to the entire therapeutic team. It can occur in three different anatomical compartments and therefore presents with diverse symptoms; most of them are highly non-specific which can significantly delay the time between perforation and final diagnosis. Despite the marked improvement in the availability of diagnostic techniques and therapeutic approaches, esophageal perforation remains a direct life-threatening condition with mortality rates reaching as high as 50%. The frequency of esophageal perforation is 3 in 100,000 in the United States, with intrathoracic perforations being most common (54%) followed by cervical esophagus perforations (27%), then intra-abdominal perforations (19%).

Anatomy

The esophagus is a 25-cm long fibromuscular tube that connects the pharynx to the stomach. It starts in the neck at the level of C6 vertebra, extending through the mediastinum until its insertion in the diaphragm at the level T10 vertebra via a separate opening in the right crus of the diaphragm. Along its vertical course, the esophagus has three constrictions:

1. The first constriction is approximately 15 cm from the upper incisor teeth, where the esophagus begins at the cricopharyngeal sphincter at the level of the sixth cervical vertebra.

2. The second constriction is approximately 23 cm from the upper incisor, which is the landmark of the crossing of the aortic arch and the left main bronchus.

3. The third constriction is approximately 40 cm from the upper incisor, where it pierces the diaphragm and forms the physiologic lower esophageal sphincter at the tenth thoracic vertebra.

The esophagus is divided into three portions:

1. The cervical esophagus extends from the cricopharyngeus muscle to the suprasternal notch and is supplied by the inferior thyroid artery.

2. The thoracic esophagus, considered the longest segment, extends from suprasternal notch to the diaphragm and is supplied by bronchial and esophageal branches of the descending thoracic aorta.

3. The abdominal esophagus, the shortest division, extends from the diaphragm to the cardia of the stomach and is supplied by branches of the left phrenic and left gastric arteries.