Esophageal Rupture Treatment & Management

Updated: Apr 09, 2019
  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Treatment

Approach Considerations

Controversy exists regarding indications for surgery for esophageal rupture. [7, 9, 17, 18, 19, 20] In general, however, operative therapy depends on a number of factors, including etiology, location of the perforation, and the time interval between injury and diagnosis. [9, 21] Other considerations include the extension of the perforation into an adjacent body cavity and the general medical condition of the patient.

General recommendations for surgery include the following:

  • Clinical instability with sepsis
  • Recent postemetic perforation
  • Intra-abdominal perforation
  • Absence of medical contraindications for surgery (eg, severe emphysema or severe coronary artery disease)
  • Leak outside the mediastinum (ie, extravasation of contrast into adjacent body cavities)
  • Malignancy, obstruction, or stricture in the region of the perforation

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 consist of conservative therapy, tube thoracostomy (drainage), repair, or diversion.

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Medical Therapy

Standard medical therapy for esophageal rupture includes the following [9, 22, 23] :

  • 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 [19] :

  • 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 for surgery (eg, severe emphysema or 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
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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 reported to have been 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 [24]
  • Diversion
  • Diversion and exclusion
  • Esophageal resection
  • Thoracoscopic repair [2, 25, 26]
  • Esophageal stenting [27, 28, 29, 30, 31]
  • Endoscopic placement of fibrin sealant [32]
  • Endoscopic suture ligation [33]
  • Endoluminal negative-pressure therapy [34]

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

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