From the Guidelines
Management of acute esophageal perforation requires immediate intervention with either surgical or non-surgical approaches based on the clinical scenario, with a strong consideration for urgent surgical consultation in all cases, even when endoscopic repair is technically successful, as recommended by the most recent guidelines 1. The approach to managing acute esophageal perforation should be individualized based on factors such as perforation size, location, time since injury, degree of contamination, and patient comorbidities.
- For hemodynamically stable patients with contained perforations detected within 24 hours, conservative management may be appropriate, including nothing by mouth, broad-spectrum antibiotics, proton pump inhibitors, and nutritional support via jejunal feeding or parenteral nutrition.
- For larger perforations, hemodynamically unstable patients, or those with mediastinal contamination, surgical intervention is necessary, with primary surgical repair preferred within the first 24 hours, involving debridement of devitalized tissue, closure of the defect, and reinforcement with adjacent tissue flaps, as outlined in the WSES guidelines 1.
- Endoscopic management with clips or stents may be suitable for small, clean perforations, with endoscopic closure pursued when feasible, utilizing through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for perforations <2 cm and endoscopic suturing for perforations >2 cm, reserving esophageal stenting with SEMS for cases where primary closure is not possible, as recommended by the AGA clinical practice update 1.
- Drainage of associated collections is essential, either surgically or via image-guided percutaneous techniques, and continuous monitoring in an ICU setting is required, with serial imaging (CT with oral contrast) to assess for leakage or collection development. The most recent and highest quality study, the AGA clinical practice update 1, emphasizes the importance of urgent surgical consultation in all cases of esophageal perforation, highlighting the need for a multidisciplinary approach to management.
From the Research
Management Principles
The management of acute esophageal perforation involves several key principles, including:
- Adequate fluid resuscitation 2
- Expeditious administration of appropriate broad-spectrum antibiotics 2, 3
- Repair, occlusion, exclusion, diversion, or exteriorization of the perforation site 2
- Drainage of extraluminal fluid collections 2, 4
- Relief of distal obstruction 2
- Nutritional support 2, 3, 5
Treatment Approaches
There are several treatment approaches for acute esophageal perforation, including:
- Operative intervention, which has been the mainstay of therapy for esophageal perforation 2, 4, 6
- Endoscopic therapies, such as stenting, clipping, suturing, or endoscopic vacuum therapy, which have been introduced as alternative treatment options 2, 4, 5
- Conservative management, which may be suitable for select patients with contained perforations and no clinical signs of sepsis 3, 4, 5
Factors Influencing Treatment
The treatment of acute esophageal perforation is influenced by several factors, including:
- The cause and location of the perforation 2, 4
- The time interval between the inciting event and presentation to the managing clinician 2, 4
- The overall medical stability of the patient 2, 3
- Comorbidities, including pre-existent esophageal pathology or prior foregut operations 2
- The location and extent of extra-esophageal fluid collections 2, 4
Outcomes
The outcomes of acute esophageal perforation management can vary depending on several factors, including: