Management of Esophageal Perforation
Emergency surgical repair within 24 hours is the treatment of choice for esophageal perforation, as mortality increases from <10% when treated within 24 hours to >30% after this time. 1
Diagnostic Approach
- Initial imaging: Contrast-enhanced CT and CT esophagography (sensitivity 95%, specificity 91%) 2, 1
- Look for: Pneumomediastinum, pleural effusions, paraesophageal collections, free air, contrast extravasation 1
- Adjunct: Flexible endoscopy for direct visualization of injury site 1
Treatment Algorithm
1. Non-Operative Management (NOM)
Can be offered to patients who meet ALL of the following criteria:
- Stable vital signs
- Early presentation
- Contained esophageal disruption
- Minimal contamination of surrounding spaces
- Absence of sepsis 2, 1
NOM protocol includes:
- ICU monitoring
- Broad-spectrum antibiotics
- NPO status
- Nasogastric tube placement
- Nutritional support
- Percutaneous drainage of collections 1
- Endoscopic adjuncts (clips, stents) may be used 2
2. Surgical Management
Indicated when patients do not meet NOM criteria. Surgery should be performed as soon as possible - mortality is <10% when treated within 24 hours vs >30% after this timeframe 2, 1.
Surgical approach based on perforation location:
A. Cervical Perforation
- Approach through left neck incision along sternocleidomastoid or collar incision
- Circumferential esophageal mobilization
- Debridement of perforation site
- Single or double-layer tension-free closure
- Buttressing with vascularized tissue (sternocleidomastoid/digastric muscle)
- Adequate drainage
- Feeding tube placement 2
B. Thoracic Perforation
- Primary repair with:
- Immediate interruption of mediastinal/pleural contamination
- Debridement to healthy tissue
- Tension-free primary repair
- Buttressing with viable tissue (intercostal muscle flap, pleural/pericardic patch)
- Adequate external drainage 2
- Thoracotomy usually required (side determined by CT findings)
- Consider laparotomy/laparoscopy for feeding jejunostomy and decompressive tube gastrostomy 2
C. Abdominal Perforation
- Primary repair with control of associated injuries
- Consider Nissen fundoplication as buttress if approached transhiatally 2
3. Alternative Surgical Approaches
When direct repair is not feasible (hemodynamic instability, delayed diagnosis >24h, extensive damage):
- External drainage
- Esophageal exclusion
- Diversion
- Resection 2
Special Considerations
Minimally Invasive Approaches
- Laparoscopy or thoracoscopy may be considered in specialized centers with appropriate expertise 2
Post-operative Care
- ICU monitoring with continuous vital signs and temperature monitoring
- Vigilance for complications: persistent pain, dyspnea, fever, tachycardia 1
- Nutritional support is essential 2
Common Pitfalls to Avoid
- Inadequate debridement of necrotic tissue
- Tension on repair suture line
- Inadequate drainage of contaminated spaces
- Failure to provide nutritional support
- Underestimating severity of condition 1
- Delayed diagnosis and treatment (>24 hours) significantly increases mortality 2, 1