Operative and Nonoperative Management of Esophageal Perforations

Abstract

During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).

Cervical cellulitis and mediastinitis following esophageal perforation: A case report

“…Among the esophageal perforation etiologies, FB represent the second most common etiology after iatrogenic manipulation (esophagoscopy, esophageal dilatation, para-esophageal surgery, external trauma) [4] . The diagnosis of esophageal perforation is usually suspected on clinical basis, and suggestive history of sharp bodies ingestion (chicken and fish bones) [5] . Symptoms include pain, dysphagia, and rarely hematemesis; pain is the most frequent symptom (> 90%) [5] .…”

“…The diagnosis of esophageal perforation is usually suspected on clinical basis, and suggestive history of sharp bodies ingestion (chicken and fish bones) [5] . Symptoms include pain, dysphagia, and rarely hematemesis; pain is the most frequent symptom (> 90%) [5] . In case of upper esophagus perforation, tenderness and subcutaneous emphysema of the neck are the two main signs.…”

Esophageal Stenosis as a Cause of Spontaneous Esophageal Perforation (Boerhaave Syndrome): A Case Report and Explanation of Possible Mechanism

“…Conservative management (cessation of oral intake, total parenteral nutrition, intravenous broad spectrum antibiotics, nasogastric decompression, proton pump inhibitors and tube thoracostomy) may be considered in patients without mediastinal or pleural contamination on imaging studies and without systemic symptoms of infection [10,11]. Conservative treatment is also suggested for cases having intramural esophageal dissection [12].…”

Treatment of Early and Delayed Esophageal Perforation

“…Therapeutic options are diverse and results are often unsatisfactory. Overall mortality still ranges from 20 to 50 % despite advances in surgical and endoscopic techniques as well as intensive care treatment during the past several decades [1][2][3]. The etiology of esophageal perforation is often iatrogenic, trauma, or Boerhaave syndrome.…”

“…The etiology of esophageal perforation is often iatrogenic, trauma, or Boerhaave syndrome. The classical symptoms of esophageal perforation are pain, fever, cardiac arrhythmia, and the presence of subcutaneous or mediastinal air [3]. Different procedures described for early and delayed esophageal perforation include primary repair with or without reinforcement, simple drainage of the thoracic cavity, diversion esophagectomy, stenting of the perforation with a prosthesis, and esophageal resection with or without primary reconstruction [1,4,5].…”