Treatment
Medical Therapy
- Standard therapy includes the following:9,13,14
- 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
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.
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 flap16
- Diversion
- Diversion and exclusion
- Esophageal resection
- Thoracoscopic repair2
- Esophageal stent17,18
- Endoscopic placement of fibrin sealant19
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.
Complications
- Mediastinitis
- Intrathoracic abscess
- Sepsis
- Respiratory failure
- Shock
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References
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Further Reading
Keywords
esophageal rupture, esophageal surgery, esophagus rupture, esophageal tear, tear esophagus, Boerhaave syndrome, boerhaave syndrome, Boerhaave, iatrogenic rupture, esophagus, esophageal perforation, esophageal disruption, anastomotic leak, esophagitis, esophageal ulcer, esophageal neoplasm, necrotizing mediastinitis, mediastinal emphysema, hydropneumothorax, sepsis, Mackler triad, endoscopy, esophagogastroduodenoscopy
Treatment: Esophageal Rupture