Introduction:

Esophageal perforation is considered a disastrous problem and it is associated with a mortality of 20–30% inspite of the development of the management strategies (1). The cause of the high mortality in those cases is the association of the mediastinitis. The inaccessibility of the esophagus put the patient under higher risk of delayed presentation with greater threat to his life. The operative intervention was the role in the management of the esophageal perforation before the era of the antibiotics (2).  The rate of esophageal perforation has increased in the last decades due to the prevalence of upper gastrointestinal endoscopy procedures. Early diagnosis is very important to avoid the development of the mediastinitis.  It is lucky to say, esophageal perforations following upper gastrointestinal endoscopy in children are rarely occurred (3).  Mengoli and Klasser (4) were the formers to define the conservative management  of esophageal perforations and recently it has converted an accepted choice especially for small localized perforations. The Pittsburgh esophageal perforation scoring system (PSS) was considered to reveal the significance of esophageal perforation and align patients into low-, intermediate-, and high-risk groups with variant morbidity and mortality results. (5)

At our referral hospital, we managed the delayed diagnosis of pediatric esophageal perforations conservatively using the PSS. The aim of this research was to assess the sequences of conservative management in those cases. 

Materials and methods

We studied the archives of 12 patients with delayed presentation of esophageal perforation admitted and treated at our Hospitals from 2013 to 2017. The average age of the patient was 8 years (ranging between 2 and 14 years). There were 8 boys and 4 girls. In six patients (50%), esophageal perforation was iatrogenic after endoscopic maneuvers. The perforation happened in two patients (16.7%) due to trauma. Four patients (33.3%) had post-corrosive esophageal perforation. This study included patients who were presented with delayed presenting esophageal perforations (detected after 24 hours of the perforation time) and associated with pleural collections.  All cases were referred from other peripheral hospitals.

Presentation and diagnosis

The diagnosis was made late (after 24 hours of the esophageal perforation) in all cases by presence of right sided pleural effusion in 10 cases and left sided pleural effusion in 2 cases. The commonest symptom was high grade fever (above 38.5c) in all cases. Back pain was present in 3 patients (25%).  Surgical emphysema in the neck was present in 2 patients (16.7%) and another 5 patients (41.7 %) were presented with shock. A chest X-ray was performed on all patients, and the right sided pleural effusion was found in 10 (83.3%) patients, associated with pneumothoraces in the same number, left sided pleural effusion in 2 patients (16.7%), pneumomediastinum in 9 patients (75%), pneumoperitoneium in 1 patient (8.3%).  The perforation was confirmed by combined CT chest and esophagogram in all patients. Thoracic esophageal perforations were found in 9 patients (75%) and cervical perforations were present in 2 patients (16.7%). Abdominal esophageal perforations was seen in 1 patient (8.3%) and was discovered with routine abdominal ultrasound and erect abdominal x ray.

According to the PSS, which is a clinical score based on preexisting esophageal pathology and clinical findings at the time of presentation (6), all variables are assigned points (range, 1-3) for a possible total score of 18. Points are given to each variable according to the following scale:

1 point is given for:  age>75 years, tachycardia (>100 bpm), leukocytosis (>10,000 white blood cells/mL), or pleural effusion (on chest radiograph, computed tomography, or barium swallow).
2 points are given for:  fever (>38.5C), non-contained leak (on barium swallow or computed tomography), respiratory compromise (respiratory rate > 30, increasing oxygen requirement, or need of mechanical ventilation), or time to diagnosis >24 hours.
And 3 points are given for: presence of cancer or hypotension.

According to this scale, we found all cases that are equal or pass score 5 should be considered (score 5 or above) as a high risk PSS group and this is associated with the worst outcome (5). Table (1)                                                                                                             

The plan of conservative esophageal perforation management here includes insertion of chest tube, irrigation of the pleural space with warm povidone-iodine solution 1:20 diluted with saline every 8 hours and insertion of nasogastric tube (NGT=Silicone Foley catheter used as nasogastric tube). The advantage of chest tube insertion was to drain the pleural fluid from the leaked esophagus and purulent fluid which was turned into empyema. Cleaning of the pleural space with warm povidone-iodine solution was done to treat the mediastinitis caused by the contamination with esophago-gastric contents. Insertion of the nasogastric tube (Silicone Foley catheter was used to inflate the balloon as a gastric balloon) was done for all patients. We didn’t use total parenteral nutrition and the enteral feeding was done by the nasogastric tube from the first day of admission except in cases of evident abdominal part of esophageal perforations. Gastroesophageal reflux was treated by medical treatment (giving I.V. proton pump inhibitors) and inflation of the gastric balloon of the NG tube under the gastroesophageal junction. All patients were under umbrella of intravenous broad spectrum antibiotics (vancomycin, gentamycin and metronidaloze). Respiratory physiotherapy was a routine in all cases and analgesics were prescribed as needed.

Follow up were done by CT chest with contrast swallow to examine the healing process of the esophageal perforation. Two patients only need urgent laparotomy due to presence of abdominal collection, and one of them was died due to septic shock after 6 hours of the operation (Table 2).

Results

Eleven of the twelve patients (91.7%) survived on this conservative therapeutic regimen and their perforations were successfully healed. One patient (8.3%) underwent exploration laparotomy due to evident perforation of abdominal part of the esophagus and passed successfully (Table 2). One patient who had post-corrosive thoracic esophageal perforation died (8.3%). We discovered another delayed gastric perforation (by routine abdominal ultrasound follow up) after two weeks of admission and urgent laparotomy was done. He died due to septic shock after 6 hours of the operation. The median hospital stay was 25 days (ranged from 18 to 45 days). One patient developed the esophago-cutaneous fistula. Other patient suffered from lung abscess and was cured on medical treatment only.

Table 1

Patients’ characters

Table 2

Morbidity and Mortality

Discussion

Many authors selected the primary surgical interferences in the management of early presenting perforations of the esophagus, but the challenge here on conservative versus surgical management for iatrogenic perforation is never to be ended. Surgery was originally the chosen method as conservative management was always serious before the antibiotic use (7).

A review documented 100% survival in a series of pediatric patients undergoing what is called aggressive conservative treatment (8). Only one patient suffered from long term esophageal stricture requiring dilatation. This outcome underlines the significance of non-operative management in pediatric age-group. Patients with post-perforation long segment strictures may need resection anastomosis and colonic interpositions (9). Late presented esophageal perforations with extensive forms and esophago-cutaneous fistulas, which are relatively contraindicated to conservative management, can still be managed successfully by aggressive conservative approach in children (10).

Another review evaluated a series of 47 patients with esophageal perforation and said that the aggressive treatment of sepsis and pleural fluid collections treats the primary cause of mortality and morbidity, avoids the major surgery including esophageal resection, and allows the native esophagus to heal (11). Conservative management was recommended by some authors in different situations which the surgery in those cases had a higher suspected morbidity and mortality (4).

Many studies mentioned that model of management is going toward conservative management in children with esophageal perforation. It is currently the standard as the perforation closure is considered to occur spontaneously. But the condition should be without distal obstruction or widespread contamination due to perforation or bad nutritional status. Surgical intervention is necessary in case of bad clinical condition which it is mostly present in delayed diagnosed esophageal perforation (1, 10).

Like the previous studies, the aim here is the management of pediatric delayed diagnosis of the esophageal perforation conservatively by a special protocol as it is mentioned before. The contest here was the treatment of cases that were come in bad clinical condition due to presence of mediastinitis. The benefit of this protocol is avoiding the risks of the surgery in those late cases. Those situations of late diagnosis affect the prognosis whatever the cause of the perforation (12).

Only one of the 12 patients died in our study of conservative management (8.3%). This patient was 3 years old boy and died due to presence of post-corrosive gastric perforation and development of septic shock. Mortality of 8.3% is the accepted outcomes in comparison with any kind of treatment in other studies. Accordingly, as Mishra et al said, we recommend the aggressive conservative management as a first option in pediatric population whatever the cause or the site except in evident abdominal perforation (10). It is not only recommended for proved local mediastinal extravasation as Vogel et al. and others mentioned before (7, 13, 14).

We offer an enteral feeding through the nasogastric tube that gives our patients advantages over the total parenteral nutrition (TPN) e.g. fewer infectious complications, reduced cost, earlier gut function, reduced length of stay, improvement of the general condition and the power of healing (15). Surgical feeding gastrostomy and jejunostomy (16) were replaced in this study by nasogastric tube insertion. This way, we provided full nutritional support, prevented retrograde soiling of mediastinum with gastric secretions via inflated gastric balloon and avoided the possible complications of surgical interventions.

Some authors suggested nasogastric drainage to prevent mediastinal contamination (17). Others claimed that it increases gastro-esophageal reflux and more aggravate mediastinal contamination (10, 18, 19). We recommend nasogastric drainage with distal gastric balloon inflation under the gastro-esophageal junction in our protocol, beside proton pump inhibitor, to control the gastro-esophageal reflux and reduce the possibility of mediastinal contamination with gastric contents. Irrigation of the pleura with antiseptic solution treats locally the mediastinitis – beside the broad-spectrum antibiotics- where there is soiling of the mediastinum and the pleura with food and gastric contents.

Endoscopy could be used as an additional option for diagnosis and possible therapeutic role in the same sitting (14). Stents, until this moment, are not included in our practice in the management of esophageal perforations this technique needs more studies about its usage. Other new ways of management, e.g. endoscopically placed clips and endoscopic vacuum sponge, still need more trials inspite of their promising result (20).

The research is limited due to small sample size which makes a point of weakness in the study. In our limited experience, conservative management for delayed diagnosis of pediatric esophageal perforation gives better outcomes than emergency operations which the possibilities of higher mortalities as studies reported. We can, also, say, that healing of the esophageal perforations with conservative management can happen even in cases of distal stricture and, accordingly, emergency resections are not essential in those cases.

Conclusion

This research argued a form of conservative management when applied to a limited number of late diagnosis of esophageal perforations in children which provided outcomes greater than the reported series where surgical management was performed. This rule doesn’t include the cases of abdominal perforation which it is a serious indication of the urgent surgical intervention. Delayed recognition and treatment is the most risky factor in this problem. It can be achieved by broad antibiotic coverage, well nutritional support via the nasogastric tube without need of gastrostomy or jejunostomy or TPN, drainage of esophageal leaks with topical antiseptic irrigation via intercostal drains and esophageal isolation by gastric balloon. Larger sample size should be considered in the future studies for better evaluation and judgment.