The Case

A 74-year-old man with newly diagnosed with adenocarcinoma of the esophagus was admitted to the Gastroenterology laboratory for esophagoscopy with endoscopic ultrasound (EUS) to stage his disease. He received procedural sedation in the usual manner. The procedure was complicated by an esophageal perforation just proximal to the gastroesophageal (GE) junction, which was endoscopically closed using an over-the-scope clip system. There was a significant delay in the patient’s care based on communication issues involving the thoracic surgery, gastroenterology, and hospitalist teams. Specifically, there were challenges about 1) how to get the patient admitted to a hospital service from the Gastroenterology recovery room, 2) which service would admit this patient for a potential thoracic procedure, and 3) which service would observe the patient, in the event that surgical repair was not necessary. No recommendations were communicated by the thoracic surgery team, in part because there was no active inpatient encounter available in the electronic medical record to allow consultants to document their recommendations. Further confusion resulted from the fact that the thoracic surgery team recommended obtaining an esophagogram, but this procedure was canceled because the patient was still sedated (and therefore unable to swallow safely on command) when he arrived in the radiology suite.

The Commentary

By Megan Chalupsky, MD, Huixia Wei, MD, and Emily Marquet, MD

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care. A clear algorithm for the management of this procedural complication is needed to delineate which team should be primarily in charge of subsequent communication and recommendations, to allow for safe and efficient patient care.

Perforations – a complication of esophageal endoscopy

Endoscopy is an important tool for both diagnostic and therapeutic purposes, with continued expansion of its use as a safer alternative to traditional surgical approaches. Although it is considered generally safe and well tolerated, the risk of perforation as a complication varies greatly in the literature, from 0.03% to 17% depending on risk factors inherent to the patient and the procedure planned.¹ This rare but serious complication of esophageal endoscopy portends high morbidity and mortality, with an associated mortality rate between 2% and 36%.^2,3 There is no consensus on optimal management of iatrogenic esophageal perforation; however, timely diagnosis after symptom onset and expeditious management have been shown to improve outcomes.^4,5

Risk factors

Risk factors intrinsic to the patient must be assessed when evaluating the overall risk of the procedure. Existing foregut pathology, including esophageal malignancy or stricture, Zenker’s diverticulum, eosinophilic esophagitis, benign esophageal ulceration, and prior esophageal or mediastinal irradiation, is associated with increased risk of perforation.^6,7 Pathologic conditions involving surrounding anatomic structures, such as anterior cervical osteophytes, can increase the technical difficulty of the procedure. Additionally, systemic diseases such as advanced liver cirrhosis, diabetes mellitus, scleroderma, heart failure and kidney disease, as well as advanced age and heavy procedural sedation, are associated with higher overall risk of procedural complications^2,3 and increased mortality in the event of esophageal perforation.⁸

Both the operator and the planned operation play a role in procedural risk. In the aggregate, therapeutic procedures carry about ten times higher risk of perforation than purely diagnostic endoscopy.^9-11 Operator inexperience has been cited as a risk factor for complications;¹² however, involvement of trainees does not compromise the safety or success of a procedure.¹³ Interestingly, in a recent prospective study, gastroenterology fellows were shown to have a similar complication rate as attending endoscopists, while advanced endoscopy fellows had higher complication rates, likely reflecting the risk of more complex therapeutic interventions.¹⁰

Procedural safety can be optimized and the risk of complications reduced by fostering an effective team working environment including a pre-procedure safety checklist and appropriate patient selection.^12,14 Sites of luminal narrowing, such as the gastroesophageal junction and the cricopharyngeus, are at particular risk given the technical challenges of navigating these structures. Techniques such as maintaining direct visualization of the esophageal lumen, not attempting to advance through a closed upper esophageal sphincter, and passing a guidewire through the cricopharynx when esophageal intubation is difficult can mitigate risk in these areas.¹⁴ Endoscopic ultrasound employs a different endoscope with a larger diameter that is more rigid, so advancing these echoendoscopes may be a semi-blind maneuver.¹⁵

Signs and symptoms of esophageal perforation

Prompt diagnosis of esophageal perforation is important; signs and symptoms that raise suspicion for this complication can depend on the location of perforation. The most common site of perforation is at the thoracic esophagus (72.6%), followed by the cervical and least commonly the abdominal esophagus.⁴

Pain is the most frequent and sensitive finding in esophageal perforation, occurring in 70% of patients.^6,16 Symptoms concerning for cervical esophageal perforation include dysphonia (difficulty speaking), hoarse voice, dysphagia (difficulty swallowing) with anterior neck tenderness, and subcutaneous emphysema. Perforation in this area can lead to deep neck infections. Intrathoracic or abdominal perforation may manifest as chest or abdominal pain, dysphagia, odynophagia (painful swallowing), with signs including sudden inability to maintain intraluminal distention, hemodynamic instability, pneumothorax, subcutaneous emphysema, fistula development, mediastinitis.¹⁷ In a systematic review, the second most common presenting sign or symptom of esophageal perforation after pain was fever (44% of patients affected), followed by dyspnea (26%), emphysema (25%), pneumomediastinum (19%), nausea or vomiting (19%) and less commonly dysphagia (12%).¹⁶

Contamination of surrounding structures by esophageal contents following perforation can result in chemical injury or infection. This can rapidly lead to systemic signs of sepsis and multisystem organ failure as a result of deep space neck infection or mediastinitis. Identification of perforation only after the onset of sepsis is associated with increased mortality.¹⁸ One systematic review found early diagnosis (defined as the first 24 hours after injury) to be associated with a 23% decrease in the risk of ICU admission (46% versus 69%), a 22% decrease in need for re-intervention (23% versus 45%), and a 35% decrease in mean length of hospital stay (13 versus 20 days).⁵ These data underscore the importance of maintaining high clinical suspicion for perforation to aid in timely diagnosis and prompt intervention.

Workflow for improving patient safety and communication after endoscopic perforation

Procedural complications such as esophageal perforation can be catastrophic. Management of esophageal perforation requires clear communication and hand-offs between the proceduralist and other involved services (e.g., general surgeons, thoracic surgeons, hospitalists, radiologists). In this case, the proceduralist consulted both the hospitalist and thoracic surgery teams and asked them to triage and decide who should admit the patient. This led to confusion amongst the teams and delay in the patient’s care. To ensure consistent and optimal patient care, a standard workflow must be implemented.

Upon recognition of an esophageal perforation, the proceduralist should evaluate the defect and attempt endoscopic closure if appropriate, consider nasogastric or nasojejunal tube placement to allow for feeding, initiate intravenous broad-spectrum antibiotics and a proton pump inhibitor, and order imaging with oral contrast to confirm closure and assess for complications.^1,3,19 In addition, the patient should be admitted with “nothing by mouth” (NPO) orders and a surgical consultation.

Successful endoscopic closure is achieved in 87-90% of cases, depending on the approach.¹ The proceduralist’s confidence of closure helps determine the urgency of post-procedure imaging and the service to which the patient should be admitted for post-procedure monitoring. For perforations less than 3 cm with high confidence of closure, the risk for complications is low enough to allow for non-urgent follow up imaging within 24 hours, and the patient can safely be admitted to a medicine service with surgical consultation. For perforations greater than 3 cm, with low confidence of closure, or any clinical instability, the patient should be transferred to the emergency department (ED) for expedited imaging and close monitoring with subsequent triage to a surgical or medical service, depending on the results of imaging. The gastroenterology proceduralist is responsible for making this triage decision and requesting either admission to the hospitalist service or transfer to the ED for urgent evaluation. It is generally inappropriate for a consultant to order imaging studies or leave recommendations while the patient is still in an outpatient postprocedure holding area. Once the patient has been admitted or transferred to the ED, the surgical consultant can then be involved in recommendations for follow up imaging and interpretation of the results, in close communication with the primary team and the proceduralist. The surgical consultant should generally avoid ordering tests, as this is the prerogative of the team with primary responsibility for the patient, and it can lead to delays in care and communication. Instead, the surgical consultant may provide explicit instructions or explanations regarding follow-up testing, in real time, to ensure timely action.

The handoff of care from the proceduralist to other services is important. This handoff needs to include documentation of details of the procedure, size of the defect, confidence of closure, implementation of the above standard of care, urgency of imaging, and any recent communications with the surgical and medical teams. The proceduralist should clearly recommend if patient is stable for admission to a hospitalist service or needs urgent imaging and evaluation in the ED. When urgent imaging is indicated but the most appropriate study is unclear, as in this case, the proceduralist should communicate directly with the radiologist to help determine the most appropriate imaging modality. Prompt discussion with the patient and family to update them on the complication and treatment plan should be initiated by the proceduralist.¹⁹ Lastly, the proceduralist should be expected to review the imaging to confirm closure and assess for complications, in addition to communicating the results and next steps with both medical and surgical colleagues. When clear communication is utilized in this multidisciplinary approach, each provider involved in the care plan can confidently follow through on their responsibility during the post-procedure monitoring period.

Take Home Points

• Iatrogenic esophageal perforation is a rare but potentially catastrophic complication of endoscopy. Timely diagnosis and management improve outcomes.
• When postoperative complications arise, the proceduralist should be designated as the main point of contact communicating procedural details, recommendations, and further guidance to other involved services to minimize harm and coordinate care transition. The proceduralist should also inform the patient and family of the postoperative complication and associated treatment plans.
• The urgency of diagnostic imaging and the determination of appropriate unit for patient disposition for post-procedure monitoring depend on the size of perforation and confidence of endoscopic closure. Developing a hospital workflow while considering these factors will help ensure timely and safe transition of patient care.

Megan Chalupsky, MD
Resident Physician
Internal Medicine
UC Davis Health
mchalupsky@ucdavis.edu

Huixia Wei, MD
Associate Physician
Division of Hospital Medicine
UC Davis Health
Hxwei@ucdavis.edu

Emily Marquet, MD
Assistant Professor of Clinical Medicine
Vice Chief, Division of Hospital Medicine
Department of Internal Medicine
UC Davis Health
emarquet@ucdavis.edu

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