eMedicine Specialties > Thoracic Surgery > Trauma

Esophageal Rupture: Treatment

Author: Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Coauthor(s): Yogesh Govil, MD, MRCP, Consulting Staff, Department of Internal Medicine, Division of Gastroenterology, Crozer-Chester Medical Center; Thomas E Kowalski, MD, Assistant Professor, Department of Medicine, Director, Gastrointestinal Endoscopy Unit, Thomas Jefferson University, Consulting Staff, Thomas Jefferson University Hospital; Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Sep 5, 2008

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
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.

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

More on Esophageal Rupture

Overview: Esophageal Rupture
Workup: Esophageal Rupture
Treatment: Esophageal Rupture
Follow-up: Esophageal Rupture
Multimedia: Esophageal Rupture
References
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References

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Further Reading

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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

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Contributor Information and Disclosures

Author

Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; 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 at 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, Southwestern Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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