Esophageal Rupture Treatment & Management

  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
 
Updated: Mar 12, 2015
 

Medical Therapy

Standard medical therapy for esophageal rupture includes the following[7, 14, 15] :

  • Admission to a medical or surgical intensive care unit (ICU)
  • Nothing by mouth
  • Parenteral nutritional support
  • Nasogastric suction - This should be maintained until there is evidence to indicate that the esophageal perforation has healed, is smaller, or is unchanged
  • Broad-spectrum antibiotics - No randomized clinical trials exist for antibiotics and esophageal perforation; however, empiric coverage for anaerobic and both gram-negative and gram-positive aerobes should be initiated when the initial diagnosis is suspected
  • Narcotic analgesics

Features that support conservative therapy include the following[16] :

  • Absence of clinical signs of infection
  • Contained perforation in the mediastinum and the visceral pleura without penetration to another body cavity
  • Perforation draining back into the esophagus

Criteria for nonoperative treatment include the following:

  • Recent iatrogenic perforation or late iatrogenic or postemetic esophageal perforation
  • Intrathoracic perforation
  • Absence of sepsis
  • Medical contraindications to surgery (eg, severe emphysema, severe coronary artery disease)
  • Isolation of the leak within the mediastinum or between the mediastinum and visceral pleura (no extravasation of contrast into adjacent body cavities)
  • No malignancy, obstruction, or stricture in the region of the perforation
  • Minimal symptoms
  • Drainage of perforation into the esophagus

Some authors believe that if treatment is instituted more than 24 hours after the perforation, the mode of treatment does not influence the outcome and can be conservative, tube thoracostomy (drainage), repair, or diversion.

Next

Surgical Therapy

Deterioration of a patient's condition should prompt consideration of surgery, the need for which may be confirmed by contrast esophagography to look for leakage or computed tomography (CT) to detect an abscess.

If the institution does not have an experienced thoracic surgeon, the patient should be transferred to a hospital with an experienced surgical team.

Surgical techniques used for esophageal rupture include the following:

  • Tube thoracostomy (drainage with a chest tube or operative drainage alone)
  • Primary repair
  • Primary repair with reinforcement with pleura, intercostal muscle, diaphragm, pericardial fat, pleural flap [17]
  • Diversion
  • Diversion and exclusion
  • Esophageal resection
  • Thoracoscopic repair [2]
  • Esophageal stent [18, 19]
  • Endoscopic placement of fibrin sealant [20]

Early surgical repair should be considered when indicated because delayed repair (>24 hours) may alter the surgical approach and increases mortality.

Previous
Next

Complications

Complications of esophageal rupture include the following:

  • Mediastinitis
  • Intrathoracic abscess
  • Sepsis
  • Respiratory failure
  • Shock
Previous
Next

Outcome and Prognosis

Esophageal perforation remains a highly morbid condition, and if it is not diagnosed and treated promptly, mortality is high. Reported mortality ranges from 5% to 89%, depending predominantly on time of presentation and etiology of perforation. Postemetic perforation has a higher reported mortality (2% per hour and 25-89% overall), whereas iatrogenic instrumental perforation has a lower mortality (5-26%).

If treatment is instituted within 24 hours of symptoms, the reported mortality is 25%; this rate rises to more than 65% after 24 hours and to 75-89% after 48 hours. Mortality is higher in patients with delayed presentation or treatment, thoracic or abdominal rupture, spontaneous rupture, or underlying esophageal disease.

An international study comparing the outcome of endoscopic stent insertion with that of primary operative management for spontaneous rupture of the esophagus found that the former had no advantage over the latter with regard to morbidity, ICU stay, or hospital stay.[21] In addition, endoscopic stenting was associated with frequent treatment failure eventually requiring surgical intervention and carried a higher risk of fatal outcome than primary surgical therapy did.

Previous
Next

Future and Controversies

Controversy exists regarding indications for surgery for esophageal rupture.[5, 7, 22, 23, 16, 24] However, operative therapy depends on a number of factors, including etiology, location of the perforation, and the time interval between injury and diagnosis. Other considerations include the extension of the perforation into an adjacent body cavity and the general medical condition of the patient.

Currently, no randomized trials exist for the appropriate treatment of esophageal perforation in regard to this controversy; therefore, future studies could be considered.

Previous
 
Contributor Information and Disclosures
Author

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Coauthor(s)

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Yogesh Govil, MD, MRCP Consulting Staff, Department of Internal Medicine, Division of Gastroenterology, Crozer-Chester Medical Center

Yogesh Govil, MD, MRCP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Thomas Kowalski, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Benson B Roe, MD 

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, Society of University Surgeons

Disclosure: Nothing to disclose.

References
  1. Derbes VJ, Mitchell RE Jr. Hermann Boerhaave's (1) atrocis, nec Descripti priu, morbi Historia; (2) the first translation of the classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc. 1955. 43:217.

  2. Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave's syndrome). J R Soc Med. 1995 Jul. 88(7):414P-415P. [Medline].

  3. Bobo WO, Billups WA, Hardy JD. Boerhaave's syndrome: a review of six cases of spontaneous rupture of the esophagus secondary to vomiting. Ann Thorac Surg. 1969. 172:1034-1038.

  4. Curci JJ, Horman MJ. Boerhaave's syndrome: The importance of early diagnosis and treatment. Ann Surg. 1976 Apr. 183(4):401-8. [Medline].

  5. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986 Sep. 42(3):235-9. [Medline].

  6. Bradley SL, Pairolero PC, Payne WS, Gracey DR. Spontaneous rupture of the esophagus. Arch Surg. 1981 Jun. 116(6):755-8. [Medline].

  7. Brewer LA, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the esophagus. The American Journal of Surgery. 1986 Jul. 152:62-69. [Medline].

  8. Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med. 1989 May. 86(5):559-67. [Medline].

  9. Richardson JD, Martin LF, Borzotta AP, Polk HC Jr. Unifying concepts in treatment of esophageal leaks. Am J Surg. 1985 Jan. 149(1):157-62. [Medline].

  10. Garas G, Zarogoulidis P, Efthymiou A, Athanasiou T, Tsakiridis K, Mpaka S, et al. Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. J Thorac Dis. 2014 Dec. 6(12):1655-8. [Medline]. [Full Text].

  11. Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg. 2011 Jul. 92(1):209-15. [Medline].

  12. Jaworski A, Fischer R, Lippmann M. Boerhaave's syndrome. Computed tomographic findings and diagnostic considerations. Arch Intern Med. 1988 Jan. 148(1):223-4. [Medline].

  13. Suarez-Poveda T, Morales-Uribe CH, Sanabria A, Llano-Sánchez A, Valencia-Delgado AM, Rivera-Velázquez LF, et al. Diagnostic performance of CT esophagography in patients with suspected esophageal rupture. Emerg Radiol. 2014 Oct. 21(5):505-10. [Medline].

  14. Brown RH Jr, Cohen PS. Nonsurgical management of spontaneous esophageal perforation. JAMA. 1978 Jul 14. 240(2):140-2. [Medline].

  15. Cameron JL, Kieffer RF, Hendrix TR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg. 1979. 27:404-408.

  16. Shaffer HA Jr, Valenzuela G, Mittal RK. Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med. 1992 Apr. 152(4):757-61. [Medline].

  17. Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. 1994 Jun. 81(6):863-5. [Medline].

  18. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg. 2006 Feb. 81(2):467-72. [Medline].

  19. Kim JH, Song HY, Shin JH, et al. Palliative treatment of unresectable esophagogastric junction tumors: balloon dilation combined with chemotherapy and/or radiation therapy and metallic stent placement. J Vasc Interv Radiol. 2008 Jun. 19(6):912-7. [Medline].

  20. Harries K, Masoud A, Brown TH, Richards DG. Endoscopic placement of fibrin sealant as a treatment for a long-standing Boerhaave's fistula. Dis Esophagus. 2004. 17(4):348-50. [Medline].

  21. Schweigert M, Beattie R, Solymosi N, Booth K, Dubecz A, Muir A, et al. Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): an international study comparing the outcome. Am Surg. 2013 Jun. 79(6):634-40. [Medline].

  22. Lyons WS, Seremetis MG, deGuzman VC, Peabody JW Jr. Ruptures and perforations of the esophagus: the case for conservative supportive management. Ann Thorac Surg. 1978 Apr. 25(4):346-50. [Medline].

  23. Pate JW, Walker WA, Cole FH Jr. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg. 1989 May. 47(5):689-92. [Medline].

  24. Griffin SM, Lamb PJ, Shenfine J, Richardson DL, Karat D, Hayes N. Spontaneous rupture of the oesophagus. Br J Surg. 2008 Sep. 95(9):1115-20. [Medline].

  25. Anderson RL. Spontaneous rupture of the esophagus. Am J Surg. 1957 Feb. 93(2):282-90. [Medline].

  26. DeMeester TR. Perforation of the esophagus. Ann Thorac Surg. 1986 Sep. 42(3):231-2. [Medline].

  27. Graeber GM, Niezgoda JA, Albus RA, Burton NA, Collins GJ, Lough FC, et al. A comparison of patients with endoscopic esophageal perforations and patients with Boerhaave's syndrome. Chest. 1987 Dec. 92(6):995-8. [Medline].

  28. Infatolino A, Ter RB. Rupture and perforation of the esophagus. The esophagus. 3rd ed. 1999. 595-605.

  29. Justicz AG, Symbas PN. Spontaneous rupture of the esophagus: immediate and late results. Am Surg. 1991 Jan. 57(1):4-7. [Medline].

  30. Kimberley KL, Ganesh R, Anton CK. Laparoscopic repair of esophageal perforation due to Boerhaave syndrome. Surg Laparosc Endosc Percutan Tech. 2011 Aug. 21(4):e203-5. [Medline].

  31. Kossick PR. Spontaneous rupture of the oesophagus. S Afr Med J. 1973 Oct 6. 47(39):1807-9. [Medline].

  32. Larrieu AJ, Kieffer R. Boerhaave syndrome: report of a case treated non-operatively. Ann Surg. 1974. 181:452-454.

  33. Macchi V, Porzionato A, Bardini R, Parenti A, De Caro R. Rupture of Ascending Aorta Secondary to Esophageal Perforation by Fish Bone. J Forensic Sci. 2008 Jul 17. [Medline].

  34. Netter FH. Upper digestive tract. The Ciba collection of medical illustrations. 1971. 3:44.

  35. O'Connell ND. Spontaneous rupture of the esophagus. Am J Roentgenol Radium Ther Nucl Med. 1967 Jan. 99(1):186-203. [Medline].

  36. Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg. 1990 Jan. 49(1):35-42; discussion 42-3. [Medline].

  37. Sherr HP, Light RW, Merson MH, Wolf RO, Taylor LL, Hendrix TR. Origin of pleural fluid amylase in esophageal rupture. Ann Intern Med. 1972 Jun. 76(6):985-6. [Medline].

  38. Sozio MS, Cave M. Boerhaave's syndrome following chiropractic manipulation. Am Surg. 2008 May. 74(5):428-9. [Medline].

  39. Tong BC, Yang SC, Harmon J. Esophageal perforation. Principles of Surgery. 8th ed. 2004. 10-14.

  40. Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. 1994 Jul. 106(1):297-9. [Medline].

  41. Walker WS, Cameron EW, Walbaum PR. Diagnosis and management of spontaneous transmural rupture of the oesophagus (Boerhaave's syndrome). Br J Surg. 1985 Mar. 72(3):204-7. [Medline].

 
Previous
Next
 
Water-soluble contrast esophagogram from patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
 
Medscape Consult
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.