Esophageal Rupture Treatment & Management
- Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM more...
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
Features that support conservative therapy include the following :
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
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
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.
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 with reinforcement with pleura, intercostal muscle, diaphragm, pericardial fat, pleural flap 
Diversion and exclusion
Thoracoscopic repair 
Esophageal stent [18, 19]
Endoscopic placement of fibrin sealant 
Early surgical repair should be considered when indicated because delayed repair (>24 hours) may alter the surgical approach and increases mortality.
Complications of esophageal rupture include the following:
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. 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.
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.
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.
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].
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.
Curci JJ, Horman MJ. Boerhaave's syndrome: The importance of early diagnosis and treatment. Ann Surg. 1976 Apr. 183(4):401-8. [Medline].
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].
Bradley SL, Pairolero PC, Payne WS, Gracey DR. Spontaneous rupture of the esophagus. Arch Surg. 1981 Jun. 116(6):755-8. [Medline].
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].
Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med. 1989 May. 86(5):559-67. [Medline].
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].
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].
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].
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].
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].
Brown RH Jr, Cohen PS. Nonsurgical management of spontaneous esophageal perforation. JAMA. 1978 Jul 14. 240(2):140-2. [Medline].
Cameron JL, Kieffer RF, Hendrix TR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg. 1979. 27:404-408.
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].
Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. 1994 Jun. 81(6):863-5. [Medline].
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].
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].
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].
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].
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].
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].
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].
Anderson RL. Spontaneous rupture of the esophagus. Am J Surg. 1957 Feb. 93(2):282-90. [Medline].
DeMeester TR. Perforation of the esophagus. Ann Thorac Surg. 1986 Sep. 42(3):231-2. [Medline].
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].
Infatolino A, Ter RB. Rupture and perforation of the esophagus. The esophagus. 3rd ed. 1999. 595-605.
Justicz AG, Symbas PN. Spontaneous rupture of the esophagus: immediate and late results. Am Surg. 1991 Jan. 57(1):4-7. [Medline].
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].
Kossick PR. Spontaneous rupture of the oesophagus. S Afr Med J. 1973 Oct 6. 47(39):1807-9. [Medline].
Larrieu AJ, Kieffer R. Boerhaave syndrome: report of a case treated non-operatively. Ann Surg. 1974. 181:452-454.
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].
Netter FH. Upper digestive tract. The Ciba collection of medical illustrations. 1971. 3:44.
O'Connell ND. Spontaneous rupture of the esophagus. Am J Roentgenol Radium Ther Nucl Med. 1967 Jan. 99(1):186-203. [Medline].
Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg. 1990 Jan. 49(1):35-42; discussion 42-3. [Medline].
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].
Sozio MS, Cave M. Boerhaave's syndrome following chiropractic manipulation. Am Surg. 2008 May. 74(5):428-9. [Medline].
Tong BC, Yang SC, Harmon J. Esophageal perforation. Principles of Surgery. 8th ed. 2004. 10-14.
Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. 1994 Jul. 106(1):297-9. [Medline].
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].