Review
Evolving options in the management of esophageal perforation

https://doi.org/10.1016/j.athoracsur.2003.08.037Get rights and content

Abstract

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

Section snippets

Material and methods

A review of the literature by search of the MEDLINE database limited to human studies published in English was performed with the keywords “esophageal perforation,” and “Boerhaave's syndrome,” which were then matched to “surgery,” “nonoperative,” and “primary repair.” Articles cited in the references retrieved by MEDLINE search were reviewed. The etiology, pathogenesis, and clinical, diagnostic, surgical, and nonoperative features of esophageal perforation, as well as the current mortality rate

Results

The overall mortality associated with esophageal perforation in 726 patients from series between 1990 and 2003 was 18% (Table 1). The cause and location of the injury, the presence of underlying esophageal pathology, the delay in diagnosis, and the method of treatment determine the rate of morbidity and mortality 5, 7, 8, 42. A comprehensive review of published evidence from 1990 to the present 6, 7, 8, 11, 12, 14, 15, 16, 17, 42, 55, 88, 89, 90, 91, 92 allows an accurate evaluation of common

Comment

Esophageal perforation is a serious disorder that is difficult to diagnose and manage. The majority of cases are caused by instrumentation, and mortality remains close to 20%. Early diagnosis and treatment are essential and reduce mortality by at least 50%. Optimal therapy includes primary repair of the perforation site and elimination of distal obstruction. Nonoperative therapy is appropriate in certain well-defined situations. An immediate and individualized approach is required with each

References (96)

  • J.M. Kratz et al.

    A comparison of endoesophageal tubes. Improved results with the Atkinson tube

    J Thorac Cardiovasc Surg

    (1989)
  • F. Venuta et al.

    Esophageal perforation after sequential double-lung transplantation

    Chest

    (2000)
  • N. Doll et al.

    Esophageal perforation during left atrial radiofrequency ablation. Is the risk too high?

    J Thorac Cardiovasc Surg

    (2003)
  • D.S. Weiman et al.

    Noniatrogenic esophageal trauma

    Ann Thorac Surg

    (1995)
  • J.A. Henderson et al.

    Boerhaave revisitedspontaneous esophageal perforation as a diagnostic masquerader

    Am J Med

    (1989)
  • J.W. Pate et al.

    Spontaneous rupture of the esophagusa 30-year experience

    Ann Thorac Surg

    (1989)
  • M.S. Adkins et al.

    Esophageal perforation in a patient with acquired immunodeficiency syndrome

    Ann Thorac Surg

    (1990)
  • M.G. Sarr et al.

    Management of instrumental perforations of the esophagus

    J Thorac Cardiovasc Surg

    (1982)
  • L.B. Reeder et al.

    Current results of therapy for esophageal perforation

    Am J Surg

    (1995)
  • R. Sawyer et al.

    Short- and long-term outcome of esophageal perforation

    Gastrointest Endosc

    (1995)
  • A.E. James et al.

    Barium or gastrografinwhich contrast media for diagnosis of esophageal tears?

    Gastroenterology

    (1975)
  • M.R. Bladergroen et al.

    Diagnosis and recommended management of esophageal perforation and rupture

    Ann Thorac Surg

    (1986)
  • C.L. Backer et al.

    Computed tomography in patients with esophageal perforation

    Chest

    (1990)
  • P.J. Pasricha et al.

    Endoscopic perforations of the upper digestive tracta review of their pathogenesis, prevention, and management

    Gastroenterology

    (1994)
  • S.K. Ohri et al.

    Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave's syndrome

    Ann Thorac Surg

    (1993)
  • G.H. Santos

    Late management of esophageal perforation

    J Thorac Cardiovasc Surg

    (1994)
  • H.C. Grillo et al.

    Esophageal repair following late diagnosis of intrathoracic perforation

    Ann Thorac Surg

    (1975)
  • C.D. Wright et al.

    Reinforced primary repair of thoracic esophageal perforation

    Ann Thorac Surg

    (1995)
  • M. Urbani et al.

    Repair of esophageal perforation after treatment for achalasia

    Ann Thorac Surg

    (2000)
  • M.B. Orringer et al.

    Esophagectomy for esophageal disruption

    Ann Thorac Surg

    (1990)
  • R.H. Feins et al.

    Palliation of inoperable esophageal carcinoma with the Wallstent endoprosthesis

    Ann Thorac Surg

    (1996)
  • M.B. Orringer

    Transhiatal esophagectomy for benign disease

    J Thorac Cardiovasc Surg

    (1985)
  • L.A. Brewer et al.

    Options in the management of perforations of the esophagus

    Am J Surg

    (1986)
  • H. Ojima et al.

    Successful late management of spontaneous esophageal rupture using T- tube mediastinoabdominal drainage

    Am J Surg

    (2001)
  • Y.C. Lee et al.

    New technique of esophageal exclusion for chronic esophageal perforation

    Ann Thorac Surg

    (1991)
  • R. Bardini et al.

    Temporary double exclusion of the perforated esophagus using absorbable staples

    Ann Thorac Surg

    (1992)
  • T. Kiel et al.

    The use of thoracoscopy in the treatment of iatrogenic esophageal perforations

    Chest

    (1993)
  • Y. Ikeda et al.

    Thoracoscopic repair of a spontaneous perforation of the esophagus with the endoscopic suturing device

    J Thorac Cardiovasc Surg

    (2001)
  • N.T. Nguyen et al.

    Thoracoscopic management of postoperative esophageal leak

    J Thorac Cardiovasc Surg

    (2001)
  • J.L. Cameron et al.

    Selective nonoperative management of contained intrathoracic esophageal disruptions

    Ann Thorac Surg

    (1979)
  • M. Infante et al.

    Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space

    Surgery

    (1996)
  • H. Mumtaz et al.

    Successful managment of a nonmalignant esophageal perforation with a coated stent

    Ann Thorac Surg

    (2002)
  • J.L. Port et al.

    Thoracic esophageal perforations. A decade of experience

    Ann Thorac Surg

    (2003)
  • W.G. Jones et al.

    Esophageal perforationa continuing challenge

    Ann Thorac Surg

    (1992)
  • C.H. Chang et al.

    One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation

    Ann Thorac Surg

    (1992)
  • Barrett N. Spontaneous perforation of the esophagus: review of the literature and a report of three new cases. Thorax...
  • N. Barrett

    Report of a case of spontaneous rupture of the esophagus successfully treated by operation

    Br J Surg

    (1947)
  • A. Olson et al.

    Spontaneous rupture of the esophagus. Report of a case with immediate diagnosis and successful surgical repair

    Postgrad Med

    (1947)
  • Cited by (0)

    View full text