Esophageal Rupture Treatment & Management

  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Nov 21, 2011
 

Medical Therapy

  • Standard therapy includes the following:[8, 13, 14]
    • Admission to medical/surgical ICU
    • Nothing by mouth
    • Parenteral nutritional support
    • Nasogastric suction
    • Broad-spectrum antibiotics
    • Narcotic analgesics
  • Features that support conservative therapy include the following:[15]
    • 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
    • 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.
    • Drainage of perforation into the esophagus

Medication

Drug Category: 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 done when the initial diagnosis is suspected.

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Surgical Therapy

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[16]
  • Diversion
  • Diversion and exclusion
  • Esophageal resection
  • Thoracoscopic repair[2]
  • Esophageal stent[17, 18]
  • Endoscopic placement of fibrin sealant[19]
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Follow-up

Further inpatient care (conservative management)

  • Consider early surgical repair when indicated because delayed repair (>24 hours) may alter the surgical approach and increases the mortality rate.
  • Maintain nasogastric suction until evidence exists that esophageal perforation has healed, is smaller, or is unchanged.
  • Deterioration in a patient's condition should prompt consideration of surgery, the need for which may be confirmed by contrast esophagrams to look for leakage or CT scans to detect an abscess.

Transfer

  • Transfer patients from hospitals without an experienced thoracic surgeon to a hospital with an experienced surgical team.
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Complications

  • Mediastinitis
  • Intrathoracic abscess
  • Sepsis
  • Respiratory failure
  • Shock
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Outcome and Prognosis

Esophageal perforation remains a highly morbid condition with a high mortality rate if not diagnosed and treated promptly. Mortality rates are reported from 5-89%, based predominantly on time of presentation and etiology of perforation. Postemetic perforation has a higher reported mortality rate of 2% per hour and an overall mortality of 25-89%, while iatrogenic instrumental perforation has a lower mortality of 5-26%. If treatment is instituted within 24 hours of symptoms, reported mortality rates are 25%; rates rose to above 65% after 24 hours and 75-89% after 48 hours. The mortality rates are higher in patients with delayed presentation or treatment, thoracic/abdominal rupture, spontaneous rupture, and underlying esophageal disease.

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Future and Controversies

Controversy exists regarding indications for surgery for esophageal rupture.[6, 8, 20, 21, 15, 22] 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.

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Contributor Information and Disclosures
Author

Dale K Mueller, MD  Clinical Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois College of Medicine; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Director, Adult ECMO, Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

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, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Thomas E Kowalski, MD  Assistant Professor, Department of Medicine, Director, Gastrointestinal Endoscopy Unit, Thomas Jefferson University, Consulting Staff, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

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, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Benson B Roe, MD  Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

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, and Society of University Surgeons

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Nothing to disclose.

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Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
 
 
 
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