MEDizzy - During endoscopic biopsy of a distal esophageal cancer,

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Cardiothoracic Surgery

During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient?

ExplanationD. Perforation of the esophagus in the chest is a surgical catastrophe that requires aggressive intervention in virtually all circumstances. Diagnosis is typically confirmed with a contrast esophagogram. A study using water-soluble contrast (such as a Gastrografin swallow) is typically ordered initially; if no leak is identified, the study is repeated using thin barium. A water-soluble contrast is used initially because of concerns for mediastinitis due to barium in the presence of an esophageal perforation. The management, in a patient with no underlying esophageal disorder, is primarily surgical—directed at primary repair of the perforation and drainage of the mediastinum. In patients with an underlying motility disorder, stricture, or malignancy, surgical intervention must address both the perforation and the esophageal abnormality. For patients with a distal esophageal carcinoma, treatment usually requires esophagectomy. Esophageal exclusion or proximal diversion (with a cervical esophagostomy or “spit fistula”) are typically reserved for patients in whom a late diagnosis of esophageal perforation was made.