Esophageal perforation: surgical, endoscopic and medical

management strategies
Boris Sepesi, Daniel P. Raymond and Jeffrey H. Peters
Division of Thoracic and Foregut Surgery, Department
of Surgery, University of Rochester Medical Center,
Rochester, New York, USA
Correspondence to Jeffrey H. Peters, MD, Professor &
Chairman, Department of Surgery, 601 Elmwood
Avenue, Box Surg, Rochester, NY 14642, USA
Tel: +1 585 275 2725; fax: +1 585 273 1252;
e-mail: jeffrey_peters@urmc.rochester.edu
Current Opinion in Gastroenterology 2010,
26:379–383
Purpose of review
The purpose of this article is to review current therapeutic strategies and outcomes in
the management of esophageal perforation. The relative rarity and unpredictability of
esophageal perforation has precluded a randomized or multiinstitutional study of this
condition. Practice standards are based primarily on retrospective reviews and expert
opinions.
Recent findings
The last decade has observed a shift from an aggressive early operative intervention to a
judicious, nonoperative management of esophageal perforation in selected patients.
Encouraging outcomes for nonoperative management published in recent literature
result from advancements in esophageal stent technology, imaging sciences, and
critical care.
Summary
Perforation of the esophagus, regardless of the cause, remains a major life-threatening
event. Early recognition and aggressive care by a clinical team with experience in a
variety of treatment modalities is increasingly important in achieving optimal outcomes in
this difficult problem. Recently, encouraging results have been published utilizing
esophageal stents and diligent nonoperative care in patients with esophageal
perforation. The guiding principles in the treatment of this challenging condition remain
early diagnosis, appropriate resuscitation, sepsis control, nutritional support, and re-
establishment of esophageal continuity. Herein, we review the recent reports on the
surgical, medical, and endoscopic treatment of esophageal perforation.

Keywords
esophagus, outcomes, perforation, stents

Curr Opin Gastroenterol 26:379–383

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0267-1379

mortality remain significant whether the esophageal

Introduction
More than 250 years have passed since Hermann
Boerhaave’s well known description of a spontaneous
esophageal perforation in Barron van Wassenaer, the
Grand Admiral of the Dutch fleet. A universally fatal
circumstance for over 200 years, the first successful surgical
repair of esophageal perforation was reported in 1947 by
Barrett [1] and Olson and Clagett [2]. Today, spontaneous
perforation known as Boerhaave’s syndrome accounts for
approximately 15% of perforations. Iatrogenic perforation
of the esophagus during diagnostic or therapeutic pro-
cedures represents the most common cause. Perforations
due to foreign body ingestion, trauma, operative injury,
and tumors are uncommon and comprise the few remain-
ing causes.
injury is spontaneous, traumatic, or iatrogenic. The over-
all mortality following esophageal perforation in a recent
review of 726 published patients (1990–2003) was 18%
[3]. Paramount in the management of esophageal per-
foration is timely diagnosis and appropriate clinical
judgment. Although the ideal therapeutic strategy con-
tinues to be debated, care should be individualized in
each patient based on a host of variables including the
patient’s underlying medical condition and comorbid-
ities, the time from perforation to treatment, the cause
and location of the perforation, and the presence of
underlying esophageal disorder. Individually tailored
therapy including medical, endoscopic, and surgical
alternatives offers the best chance for a successful out-
come.

The evolution of diagnostic technology, endoscopy,

surgical techniques, antibiotics, and critical care have Principles of management
improved the outcomes of esophageal perforation. Management goals include expedient and accurate diag-
Despite these advancements, the morbidity and nosis, aggressive cardiopulmonary resuscitation, source
0267-1379 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOG.0b013e32833ae2d7

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 380 Esophagus

control of infection including control of extraluminal Table 1 Esophageal perforation severity score
contamination, appropriate broad spectrum antibacterial Variable Score (range 1–3)
coverage, enteral access for nutritional support, and Age >75 years 1
ultimate restoration of the gastrointestinal continuity. Tachycardia >100 beats/min 1
Therapeutic options for achieving these goals range from Leukocytosis >10 000 WBC/ml 1
Pleural effusion (on CXR or CT) 1
nonoperative management, placement of a covered stent, Fever >38.58C 2
surgical exploration with primary repair and drainage, to Noncontained leak (on CT or 2
esophageal resection, and, in extreme circumstances, barium swallow)
Respiratory compromise 2
esophageal exclusion and diversion. Variables known to (respiratory rate >30,
influence the outcome of esophageal perforation include mechanical ventilation)
the location of the perforation, the degree of tissue destruc- Time to diagnosis >24 h 2
Cancer 3
tion, the degree of contamination and sepsis, the time Hypotension 3
interval from the injury, and the presence of underlying Total potential score 18
esophageal disorder [3]. Even prior to confirmatory studies,
CT, computed tomography; CXR, chest x-ray; WBC, white blood cell.
all patients with suspected esophageal perforation should Data from [6
].
be maintained nothing per os and undergo aggressive fluid
resuscitation along with broad antibiotic coverage of both all, patients successfully treated with nonoperative
aerobic and anaerobic organisms. management were more likely to have a lower clinical
score. The investigators concluded that patients with
minimal mediastinal contamination and no respiratory
Nonoperative and endoscopic management compromise (low clinical score) can be successfully man-
The last decade has seen a rapidly increasing interest and aged nonoperatively, reserving surgical repair if signs of
use of nonoperative and endoscopic management of clinical deterioration develop.
esophageal perforation. Although the term ‘nonoperative’
may be misleading due to the fact that many patients Other single-center retrospective case series assessing
receive some form of interventional therapy such as stent outcomes of nonoperative management, including
placement, tube thoracostomy, feeding gastrostomy, or restriction of oral intake, parenteral antibiotics, gastric
jejunostomy, the outcomes without traditional surgical acid suppression, and fluid resuscitation also support the
repair have been encouraging. use of nonoperative management strategies in appropri-
ately selected patients. Vogel et al. [7] reported no
Criteria, supported by level 1 evidence, for identifying mortality among a subset of 32 patients (four with cervi-
patients suitable for nonoperative management are not cal, 28 with thoracic perforation) treated without surgery.
available. The early report of Cameron et al. [4] (1970) led Utilizing an ‘aggressive conservative’ approach with
to a proposal of the key components of conservative repetitive radiographic studies and image-guided drai-
management. These criteria were later expanded by nage as well as surgical intervention when indicated,
Altorjay et al. [5] and include early diagnosis of intramural the authors documented esophageal healing in 96% of
perforation, transmural perforation within the neck or patients and an impressive overall survival of 96%
mediastinum with free drainage back into the esophagus (n ¼ 47). Even in the group with spontaneous perforation,
on an esophagogram, the absence of benign or malignant they achieved a remarkable 93% survival. Notably,
obstructive esophageal disease, and minimal symptoma- roughly 30% of the patient population required surgical
tology without evidence of sepsis. The utilization of serial intervention for drainage or esophageal repair. Hasan
imaging studies and the availability of an experienced et al. [8] reported a 15.3% mortality in a series of 26
thoracic surgeon have also been suggested to improve the iatrogenic perforations managed using a similar conser-
likelihood of successful nonoperative management. vative approach. Importantly, 85% were recognized
within 6 h of injury and 23% ultimately required surgi-
The Pittsburgh group [6
] recently suggested an esopha- cal intervention including four esophagectomies for
geal perforation severity score utilizing 10 clinical vari-
ables commonly available at the time of presentation Table 2 Outcomes of patients with esophageal perforation
(Table 1). Retrospectively classifying 119 patients based on a perforation score (0–18)
according to this score, the prevalence of complications, Clinical score
mortality, and the length of hospital stay varied signifi-
cantly among those with clinical scores 2 or less, 3–5, and 2 (n ¼ 44) 3–5 (n ¼ 49) >5 (n ¼ 26)
higher than 5 (Table 2) [6
]. Importantly, the data Complication rate (%) 53 65 81
suggested that patients with low clinical scores managed Mortality (%) 2 6 27
operatively had worse outcomes than patients with low Length of stay (days) 10 16 28
clinical score treated with nonoperative measures. Over- Data from [6
].

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Table 3 Recent publications utilizing stents for the treatment of
esophageal perforation
Authors Number of patients Mortality rate (%)
Kiev et al. [9] 14 0 resume oral intake 72 h after stent placement. Compli-
Freeman et al. [10] 17 0 cations included respiratory failure, myocardial infarc-
Kim et al. [11] 16 6
Salminen et al. [12
] 32 16
Leers et al. [13
] 31 6 was no mortality. After a mean of 52 days, all stents were
esophageal cancer following healing of the perforation.
The deaths in this study included a nonagenarian and two
patients with advanced stage malignancies who were not
candidates for more aggressive intervention.
Many believe, and data to date would suggest, that the
development of esophageal stent technology has been a
significant advance in the nonoperative management of
esophageal perforation. Historically, stents have been
utilized to palliate malignant dysphagia. With the intro-
duction of removable plastic and/or covered metal eso-
phageal stents, their use to treat esophageal perforation
has been increasingly widespread over the past several
years. Multiple reports establishing feasibility and suc-
cess of stent therapy in the treatment of esophageal
perforation have recently been published (Table 3).
The selection of appropriate candidates for endoscopic
stent therapy is likely important and remains a topic of
continued study. Further, it deserves emphasis that the
principles of management outlined above remain the
same whether a stent is used or not.
Kiev et al. [9] reported 14 consecutive patients with
perforation due to a variety of causes including primary
esophageal perforations (n ¼ 2), iatrogenic injuries
(n ¼ 4), trauma/foreign body (n ¼ 3), and leaks following
previous attempts at surgical repair (n ¼ 5). All patients
were treated solely with a covered Polyfex stent (Rush
Inc., Teleflex Medical, Duluth, Georgia, USA) except
one who underwent concomitant thoracoscopic drainage.
There were no deaths, all were able to resume oral intake
by day 6, and none of the patients demonstrated extra-
vasation of contrast on swallow studies. Stent migration
into the stomach requiring repositioning occurred in
three (21%) patients. By 4 months following injury, all
stents were removed with the documentation of healed
esophageal mucosa. Interestingly, the time between the
recognition of esophageal leak and stent placement did
not negatively impact long-term morbidity or hospital
discharge, although this is likely due to patient selection
factors.
Freeman et al. [10] reported treatment via placement of
silicone-coated stents in 17 patients with iatrogenic eso-
phageal perforation after endoscopy or surgery. Patients
with malignancy were excluded from the study. Ninety-
four percent of leaks were successfully sealed on barium
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Esophageal perforation Sepesi et al. 381
esophagram, although two had to be repositioned and two
replaced. One patient with a persistent leak underwent
operative repair; all remaining patients were able to
tion, and deep venous thrombosis in three patients; there
successfully retrieved.
Kim et al. [11] utilized silicone salivary bypass stents in 16
patients with various causes of esophageal perforation. All
16 had prompt improvement of leakage and sepsis.
Thirteen patients achieved complete healing of the
esophageal mucosa. In three patients, the defect matured
into a controlled fistula. Complications included stent
migration in 35% (n ¼ 6) and empyema, gastrointestinal
bleed, and small bowel obstruction in three patients each.
One death occurred due to ruptured thoracic aorta. Suc-
cessful stent removal occurred in all patients.
Most recently, two groups from Germany published their
experience with stent treatment of esophageal perfor-
ation. Investigators from Muenster [12
] reported out-
comes in 32 patients with thoracic esophageal perforation
(n ¼ 10) or intrathoracic anastomotic leak following eso-
phagectomy or gastrectomy (n ¼ 22). Stent placement
was achieved in all patients, although only 78% achieved
functional seal without evidence of leak. Complications
from stent therapy occurred in 28% of patients and stent
extraction was feasible in 70%. The authors reported a
15.6% (n ¼ 5) mortality rate in this complex patient
population, which notably included two patients with
advanced stage cancer who had care withdrawn. The
second study [13
] included 31 patients treated with
self-expandable metallic stents following iatrogenic per-
foration. The investigators achieved 92% coverage of the
leak and the stents migrated in only 3%. Mortality from
myocardial infarction and bowel ischemia occurred in two
(6%) patients. Complications were limited to stent
migration in one patient. Stents were retrieved from all
remaining patients with documented mucosal healing.
Clearly, esophageal stenting is an attractive option for
restoring luminal integrity following esophageal perfor-
ation; however, one must be careful to adhere to the
principles mentioned previously in order to achieve
reasonable results. This includes source control of infec-
tion comprising control of extraluminal fluid collections
and the debridement of devitalized tissue. The authors
have found covered stents to be extremely useful in cases
of early presentation with minimal contamination,
especially in the iatrogenic setting. More invasive pro-
cedures are required in the setting of significant contami-
nation; however, in conjunction with aggressive surgical
debridement and drainage, the utilization of a stent
may help avoid esophageal resection and diversion,
 382 Esophagus
particularly in patients who may never be candidates for
restoration of gastrointestinal tract continuity.
Operative management
The surgical management of esophageal perforation
remains an important component of appropriate therapy.
Operative exposure provides clear visualization of the
perforation, allowing an assessment of surrounding tissue
damage as well as permitting definitive repair of the
defect, tissue debridement, and wide local drainage of
contaminated spaces. This is particularly true if done
during the first 24 h from the injury. Both the selection of
appropriate candidates for surgery and the choice of
approach and procedure require judgment and experi-
ence. Preoperative fluid resuscitation, broad spectrum
antibiotic therapy, accurate localization of the injury,
and appropriate hemodynamic monitoring are important
components of operative treatment. The location of the
injury, time from perforation to operation, mechanism of
injury, and preexisting esophageal disorder all should be
considered when weighing surgical options.
Cervical perforation is seldom lethal due to the contain-
ment by surrounding structures. It is best approached via
left cervical incision and can be managed by drainage and
primary repair if possible. In contrast, injury to the
thoracic or abdominal esophagus often results in signifi-
cant and ongoing pleural or abdominal contamination
and, therefore, restoring luminal integrity is necessary.
The ideal operative approach to the mid and proximal
thoracic esophagus is via right thoracotomy entering the
sixth intercostal space. For optimal exposure of the distal
esophagus, a left thoracotomy utilizing the seventh or
eighth intercostal space is recommended. The abdominal
portion of the esophagus is best approached through the
upper midline celiotomy incision.
Operative repair includes exposure of the site of perfor-
ation, debridement of devitalized mediastinal and eso-
phageal tissue, and esophageal myotomy proximal and
distal to the defect to allow assessment of the entire
extent of mucosal injury and suture repair. Repair should
be via a two-layer hand sewn technique with closure of
the esophageal mucosa with interrupted 4–0 absorbable
suture and closure of the esophageal muscle overtop with
interrupted 3–0 silk sutures. The repair can be buttressed
with an additional vascularized pedicle of available tissue
most commonly via an intercostal muscle, pleural or
omental pedicled flap, followed by wide drainage.
Although caution should be exercised when repairing
the esophagus in the setting of extensive contamination
and devitalized tissue, especially when the presentation
is delayed, primary repair is almost always possible. The
likelihood of breakdown of the repair is higher, however,
and alternative measures such as T-tube drainage or
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
esophageal resection with cervical esophagostomy and
distal feeding tube placement should be considered.
The presence of significant underlying esophageal dis-
order such as achalasia, stricture, severe reflux disease, or
malignancy further complicates the successful treatment
of esophageal perforation. Repair in a setting of either
mechanical (stricture or tumor) or functional (achalasia)
distal obstruction is contraindicated unless the obstruction
can be relieved. In the setting of achalasia, the perforation
should be closed primarily and a myotomy from the site of
perforation through the lower esophageal sphincter per-
formed on the contralateral side of the esophagus. Anti-
reflux procedures such as the Belsey Mark IV or Nissen
fundoplication may be considered in the treatment of
thoracic and abdominal perforations, respectively, pro-
vided the patient is stable and there is minimal contami-
nation. Perforations associated with obstruction due to
malignancy, refractory stricture, or end-stage achalasia
are generally best treated with esophageal resection and
delayed reconstruction. Whether or not to immediately
reconstruct such a patient versus perform proximal diver-
sion with adequate drainage and enteral access remains a
challenging clinical decision. When the patient requires
diversion, preserving a long proximal cervical esophagost-
omy helps facilitate subsequent appliance placement and
the ensuing reconstruction.
Brinster et al. [3] summarized the outcomes of primary
repair in 322 patients following esophageal perforation.
Overall mortality was 12%, varying between 0 and 31%.
As expected, the most critical determinants of a success-
ful outcome were complete exposure of the perforation,
primary repair of the defect, and elimination of the distal
obstruction. The type of reinforcement appeared to play
a less significant role. Richardson [14] reported encoura-
ging surgical outcomes even in the setting of delayed
primary repair in 21 patients. Mortality was only 3%, and
16% of patients had persistent leak following repair.
Slightly higher mortality in similar patient populations
was reported by Port et al. [15] (8%) and Jourgon et al. [16]
(13%). In the most recent retrospective case series of 91
patients, Abbas et al. [6
] reported 15% mortality, 62%
morbidity, and a median hospital stay of 24 days following
operative repair.
Conclusion
Perforation of the esophagus is a challenging clinical
problem associated with significant morbidity and
mortality. The relative rarity of the disease and the varied
cause and presentation confounds a meaningful compari-
son of treatment options. Recent evidence suggests that
optimal outcomes are achieved when treatment is indi-
vidualized and all available options are used including
medical, surgical, and endoscopic modalities. Prompt

identification of perforation as the cause of a patient’s
problem, resuscitation, and timely choice of a therapeutic
approach are keys to maximize successful outcomes.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest


of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 414).
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A recent publication comparing surgical and nonoperative management of eso-
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