Journal of Visceral Surgery (2010) 147, e117—e128

REVIEW

Esophageal perforations
M. Chirica a, A. Champault a, X. Dray b, L. Sulpice c,
N. Munoz-Bongrand a, E. Sarfati a, P. Cattan a,∗

a
Service de chirurgie générale, digestive et endocrinienne, hôpital Saint-Louis, 1, avenue
Claude-Vellefaux, 75010 Paris, France
b
Service de gastroentérologie, hôpital Lariboisière, 2, rue Ambroise-Paré,
75475 Paris cedex 10, France
c
Service de chirurgie hépatobiliaire et digestive, hôpital Pontchaillou, 2, rue
Henri-Le-Guilloux, 35000 Rennes, France

Available online 15 September 2010

KEYWORDS Summary The incidence of esophageal perforation (EP) has risen with the increasing use of
Esophageal endoscopic procedures, which are currently the most frequent causes of EP. Despite decades
perforation; of clinical experience, innovations in surgical technique and advances in intensive care man-
Systemic sepsis; agement, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event
Boerhaave’s and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed
syndrome; treatment and the difficulties in management are responsible for the high morbidity and mortal-
Endoscopic stent; ity rates. A high variety of treatment options are available ranging from observational medical
Esophagectomy; therapy to radical esophagectomy. The potential role of interventional endoscopy and the use
Mortality of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary
repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis
is mainly determined by the cause, the location of the injury and the delay between perforation
and initiation of therapy.
© 2010 Published by Elsevier Masson SAS.

Introduction
Esophageal perforation (EP) was described for the first time by Hermann Boerhaave who, in
1723, observed a spontaneous rupture of the esophagus occurring after repeated vomiting
in a Dutch Navy admiral [1]. It was not until 1947 that the first attempts at surgical repair
of EP were made by Barrett and Olson [2,3]. The incidence of EP has clearly increased
these last 20 years because of the generalization of diagnostic endoscopy and the fact
that new technologies of interventional endoscopy have become the principal cause [4].
In spite of recent progress in intensive care, diagnostic modalities and treatment of EP,
overall mortality is still close to 20% [4]. Diagnostic errors due to frequent atypical clini-
cal presentations, associated with the absence of clear management policies, can partly
explain this poor prognosis. Early diagnosis and adapted management are prerequisites for
these patients.
The goal of this update on EP was to provide the surgeon with a useful tool to guide
therapeutic choice when faced with EP. The principal surgical and endoscopic techniques
∗ Corresponding author. Tel.: +00 33 01 42 49 97 13; fax: +00 33 1 42 49 97 57.
E-mail address: [email protected] (P. Cattan).

1878-7886/$ — see front matter © 2010 Published by Elsevier Masson SAS.

doi:10.1016/j.jviscsurg.2010.08.003
e118 M. Chirica et al.

are described as well as their place in the therapeutic strat-

Other (%)
egy. The authors propose the most widely used therapeutic
procedures based on the literature and their personal expe-
rience.

5
15
2
1
6
6
—
—
—
—
—
7
Causes

Surgery (%)
Iatrogenic perforations
Endoscopic perforations

—
4
2
—
—
4
3
—
—
5
—
7
According to a review of the literature collecting reports
from 559 patients, endoscopy is presently responsible for
approximately 60% of EP [4] (Table 1). Forceful pneumatic

Tumor (%)
dilations for achalasia are complicated by perforation in 2
to 6% of cases and the risk is increased in women when the
achalasia is long-standing and when dilation is performed

—
—
1
—
—
—
—
—
3
5
—
—
for the first time [5,6]. This risk is estimated between 0.09
and 2.2% in case of dilation of strictures [7], and between
1 and 5% after sclerotherapy [8], but is anecdotic after
ligation of esophageal varices. Conversely, perforation com-

FB (%)
plicates diagnostic endoscopy in 0.03 to 0.11% of cases

20
—
12
7
35
—
—
20
3
7
—
9
when performed with flexible and rigid fibroscopes, respec-
tively. [7] Coexisting esophageal diverticules increase this
risk.
When the esophagus is healthy, most perforations occur
at Killian’s triangle, limited by the inferior pharyngeal Trauma (%)
constrictor and the cricopharyngeal muscle. Difficulty in
passage through Killian’s orifice and the flimsy esophageal
10
—
9
4
—
7
3
14
6
2
—
—
muscular layer with separation from the retropharyngeal
space only by the buccopharyngeal fascia are two possible
reasons. Along the same lines, these perforations occur pref-
erentially where the lumen is thin: cricopharyngeal region,
Spontaneous (%)

aortic arch or left bronchial imprint, esogastric juncture.

Last, osteophytosis, marked cyphosis or cervical hyperex-
tension leading to deviation of the esophagus, are promoting
factors for instrumental EP [4].
35
8
15
11
27
30
11
5
56
51
37
Operative trauma 20
Causes of esophageal perforations. Analysis of the literature.

Operative injury to the esophagus can occur during oper-

ations on the esophagus or nearby organs. The incidence
of EP after anterior osteosynthesis for cervical spine frac-
Iatrogenic (%)

ture can be as high as 3.4% [9]. These perforations are

related to intraoperative injury or migration of osteosyn-
thesis material, sometimes several years later. Thoracic
EP has been reported following bronchial artery emboliza-
30
73
59
77
32
53
83
61
32
30
63
57

tion, pneumonectomy and pulmonary transplantation [4].

In the lower third of the esophagus, perforation compli-
cates gastroesophageal reflux disease (GERD) and achalasia
in, respectively, 3.9 and 7% of cases [10].
20
26
559
57
34
47
28
44
34
43
119
44
n

Posttrauma perforations
Penetrating trauma are responsible for perforations of the
Vallbohmer et al. [46] (2009)

cervical esophagus. The severity of these lesions is due

Gupta et Kaman [50] (2004)
Braghetto et al. [52] (2005)

Griffiths et al. [23] (2009)

Erdogan et al. [48] (2007)
Brinster et al. [4] (2004)a

to associated tracheal lesions (up to 50%) [11]. Baroin-

Linden et al. [56] (2009)
Eroglu et al. [32] (2009)

a Review of the literature.

Abbas et al. [31] (2009)
Vogel et al. [34] (2006)

jury has been reported after blunt trauma (road accidents

Sung et al. [63] (2002)
Port et al. [53] (2003)

[12], Heimlich maneuver [13]). EP complicates caustic burns

References (year)

mostly when management is delayed. More than 100 phar-

FB: foreign body.

maceutical substances have been incriminated in the onset

of esophageal lesions [14], and notably those induced by
the encapsulated form of doxycycline [15]. EPs have been
Table 1

reported after difficult endotracheal intubation [16], car-

diac endoscopic sonography [17], or insertion of nasogastric
[18] or Blakemore tubes [19].
Esophageal perforations e119

Foreign bodies sometimes associated with dysphagia, dysphonia or fever

[4]. The diagnosis of thoracic EPs is particularly difficult.
Ingested foreign bodies are responsible for 80% of cervical In case of spontaneous perforation, the clinical signs most
perforations [4]. The foreign body usually impacts in the often observed are, by decreasing order of frequency, vom-
esophageal wall at the level of the physiological, narrow iting (84%), thoracic pain (79%), dyspnea (53%), epigastric
portion of the esophagus (cf. supra). Prolonged impaction pain (47%), or dysphagia (21%) [23]. Mackler’s triad (thoracic
can lead to extralumenal migration which can perforate pain, vomiting and emphysema), although highly suggestive
nearby organs such as the trachea or the aorta with often of the diagnosis, is found in less than one third of cases
fatal outcome [20]. The foreign bodies most often incrimi- [23]. In case of delayed diagnosis, sepsis is dominant. When
nated include dental prostheses and bones. The risk of EP the perforation is abdominal, guarding or rigidity can be
during endoscopic extraction of ingested foreign bodies is associated with mediastinal or pleural signs. The inaugural
estimated at 0.25% [21]. picture associates dorsal pain, exacerbated by dorsal decu-
bitus, or epigastric pain irradiating to the scapula, due to
Spontaneous perforations diaphragmatic irradiation, followed rapidly by septic shock.

Boerhaave’s syndrome is a spontaneous barotraumatic rup-

ture of the lower third of the esophagus secondary to Complementary investigations
an abrupt increase in intraesophageal pressure (up to
290 mmHg) during vomiting, associated with absence of Conventional radiology
relaxation of the superior sphincter of the esophagus [22]. Lateral cervical X-rays can show prevertebral free air in
By extension, most authors regroup under the name of cervical EPs. In thoracic EPs, the standard lung X-ray is
Boerhaave’s syndrome, all spontaneous perforations of an abnormal in 90% of cases [4] showing pleural effusion,
otherwise healthy esophagus, whether secondary to vomit- pneumothorax or hydropneumothorax, pneumoperitoneum
ing or not. They represent 8 to 56% of perforations in recent or retropneumoperitoneum. Pneumomediastinum or subcu-
series (Table 1). The perforation is located most often (80%) taneous emphysema require at least one hour to appear
on the left border of the lower third of the thoracic esoph- after perforation occurs explaining why X-rays performed
agus and measures 3 to 6 cm on the average [22]. Iterative too early can be falsely reassuring [26].
spontaneous perforations, occurring several months or years
afterwards, have also been reported [23,24].
Cervicothoracoabdominal CT scans
Perforations occurring on diseased esophagus
GI contrast enhanced CT is currently the initial investiga-
EP can occur in people with conditions such as esophageal tion of choice because sensitivity (92 to 100%) is better than
diverticules, Barrett’s esophagus, infective esophagitis (in that for esogastroduodenal follow-through [27]. Moreover,
the immunocompromised patient), even in the absence of contrast-enhanced CT can help delineate extension to adja-
instrumental maneuvers [4]. EP complicates 5 to 8% of cent structures (mediastinitis, pleural effusion, subpleural
esophageal cancers treated with palliative intent; one out abscess, intraperitoneal effusion) and thus guide therapy
of four are fatal [25]. Fistulas between a tumor of the (Fig. 1). Last, when EP is not confirmed by CT, other diag-
esophagus and the tracheobroncheal tree are found in 4.9% noses such as aortic dissection, duodenal ulcer perforation
of patients with esophageal cancer. These fistulas develop or pancreatitis can be made [4].
because of tumoral invasion or are secondary to radiation
therapy or after insertion of an endoprosthesis [25].
Esogastroduodenal follow-through (EGDFT)
EGDFT has a 50% sensitivity for the detection of cervical
Diagnosis EP and 75—80% for the detection of thoracic EP [4]. This
investigation provides a good idea of the location of the EP,
Clinical presentation indicates the importance of the extravasation and whether
the leak is contained or not (Fig. 2). Barium opacification is
The mean age of patients with EP is 60 years. The clinical more sensitive (60% for cervical and up to 90% for thoracic
expression of EP is extremely variable and initial diagno- EP) than hydrosolubles but should be reserved for suspected
sis is wrong in one out of two cases and 60% of the time, esotracheal fistula because of the toxicity of hydrosolubles
the time interval to diagnosis is longer than 24 hours [23]. for the lung. When the first opacification is negative but
The initial symptoms are often suggestive of myocardial there are strong clinical reasons to suspect the fistula, a
infarction, perforated ulcer, acute pancreatitis, aortic dis- second opacification is advised in the hours that follow [4].
section, spontaneous pneumothorax or pulmonary disease.
This underlines the importance of always keeping this diag-
nosis in mind and defining the circumstances surrounding
Esophageal endoscopy
the appearance of clinical signs. In fine, onset of any symp-
tom after digestive endoscopy or vomiting should lead to The sensitivity of endoscopy is nearly 100% and the speci-
suspicion of EP. ficity 83% for the detection of EP [28]. However, the only
The clinical expression of perforation depends on the truly diagnostic indication for endoscopy is the routine
location of the perforation and the delay between the search for EP in penetrating trauma. This investigation is not
perforation and presentation. Cervical perforations occur recommended for any other situation because insufflation
most often during upper GI endoscopy and, in general, the is capable of enlargement of a minimal transmural opening
diagnosis is obvious. The most frequent clinical signs are thus compromising the possibility of conservative treatment
subcutaneous emphysema (95%) and cervical pain (90%), [28].
e120 M. Chirica et al.

Figure 1. (A) Spontaneous perforation of cervical esophagus: ingested contrast-enhanced CT scan. Extravasation of contrast material
(curved arrow) and subcutaneous emphysema (full arrows). (B) Boerhaave syndrome: Atelectasia (curved arrow), pneumomediastinum (full
arrow), abundant pleural effusion (star).

Figure 2. Esogastroduodenal follow-through. (A) Perforation after endoscopic dilation of caustic stricture. Contained extravasation of
contrast material (arrow). (B) Boerhaave syndrome. Massive left pleural extravasation of contrast material.

Treatment provide nutritional support and restore digestive tract con-

tinuity.
There are several possible therapeutic strategies rang-
ing from medical treatment to the most aggressive, Medical treatment
esophagectomy. Somewhere between these two extremes,
one finds the mini-invasive techniques, including interven- Strict fasting is prescribed until performing a radiologic con-
tional endoscopy, eventually associated with surgical or trol (EGDFT or CT scan) on day 7. Total parenteral nutrition,
radiological drainage, but these modalities have not yet broad-spectrum antibiotic prophylaxis directed against aer-
been validated. The chances of preserving the native esoph- obic and anaerobic germs (14 to 21 days) as well as proton
agus and of patient survival depend on the success of initial pump inhibitors to check associated acid reflux are the basis
treatment. The principal objectives of treatment are to for treatment. Close monitoring is necessary to detect per-
treat infection, prevent continuing septic contamination, sistence or reappearance of symptoms, especially septic.
Esophageal perforations e121

abdominal EP are relative contraindications, because of the

Table 2 Indications for exclusive medical treatment of
high risk of migration in these locations. The success rates in
esophageal perforations.
the principal series in the literature [35—41] range from 92
Delay before management to 100%, the healing rates of the perforation range from 13
Early: less than 24 h to 69% and mortality, from 0 to 33% (Table 3). Stent migration
Clinical is the main complication (6 to 35%).
Absence of marked infective syndrome
Radiologic
Endoscopic clipping
Cervical or thoracic location of the perforation The idea of closing EP with hemostatic clips came from the
Contained perforation experience of endoscopic closure of gastric and colonic per-
Intramural perforation forations [42]. The relatively limited opening gap of clips
Limited extravasation of contrast material, into the (< 11 mm) only allows approximation of the mucosal edges.
esophageal lumen The technique consists of placing the clips on the breach
Absence of extravasation into the pleura from one extremity to the other. This technique can be used
for small EP because of the technical constraints and for per-
Patient characteristics
forations diagnosed early, before advanced contamination of
Non tumoral perforation
the mediastinum sets in. The ideal indication is iatrogenic
Absence of downstream obstacle
endoscopic EP, occurring during mucosal resection or dur-
Other ing submucosal dissection. In 17 selected patients (average
Possibility of clinical and radiologic surveillance by a size of perforation: 9 mm; range: 6 to 12 mm, time interval
team used to medicosurgery management of before management: 2 days [range 0 to 40 days]), Qaader et
esophageal disease al. [42] identified the time of perforation (and not its size)
as an independent risk factor of failure of this technique
although no deaths occurred.
Repeat CT is useful to guide changes in therapeutic poli-
cies.
The initial attempts at medical treatment were reported
Endoscopic gluing
by Mengold and Klassen in 1965: mortality was 6% in their The use of fibrin glue was initially proposed for manage-
series of 18 patients [29]. Indications are presently well ment of esophageal fistulas. Endoscopic gluing of EP has
codified, thanks to the contribution of Altorjay et al. [30] been reported rarely, mostly as clinical case reports. Rabago
(Table 2). A delay in management greater than 24 hours has et al. [43] reported a successful closure with this treatment
now become a relative contraindication as several series for a 2 mm EP seen early after endoscopic extraction of food
have recently shown that this treatment modality can be impaction. Fischer et al. [44] successfully completed a clip
successful in this setting [31—33]. Presently, medical treat- closure of a large iatrogenic EP with injection of glue.
ment failure, requiring interventional treatment, can occur
in approximately 20% of cases [30]. Surgical treatment
Conservative interventional treatment The choice of surgical treatment depends on the localization
of the perforation, its size, the viability of the esophageal
Nonoperative management walls, the degree of local sepsis and the presence or not of
Vogel et al. [34] recently reported their results after underlying esophageal pathology.
‘‘aggressive nonoperative treatment’’ in 47 spontaneous
and iatrogenic EP, based on repeated clinical and radiologic Conservative surgical treatment
evaluation and multiple percutaneous drainages. Surgery
was avoided in 68% of these patients. None of these patients Conservative surgical treatment includes debridement of
sustained an esocutaneous fistula. Overall mortality was 6%. infected and necrotic tissues, suture of the perforation
whenever possible, drainage, treatment of distal obsta-
Endoscopic management cles and parenteral or enteral hypercaloric alimentation.
The nutritional status of the patient as well as the delay
This treatment modality, the goal of which is to arrest the
before eating is allowed may indicate the need for a feed-
source of septic contamination, is under evaluation [35—41].
ing jejunostomy. Effective analgesia as well as motor and
Endoscopic treatment can be combined with percutaneous
respiratory rehabilitation are indispensible as for all major
or surgical drainage of septic collections. By virtue of its mini
esophageal surgery. The surgical approach is through a left
invasive character, this modality is an appealing alternative
cervicotomy for cervical EP and median laparotomy for
to open surgery.
abdominal EP. For thoracic EP, the side of the thoracotomy
Endoprostheses is dictated by the location of the EP (right thoracotomy for
cervical and upper and middle thirds of thoracic EP, left tho-
The goal of endoscopic insertion of endoprotheses covering racotomy for the lower third of the thoracic esophagus) and
the EP opening is to prevent continuing septic contamina- by the predominant side of associated pleural effusion.
tion, to guide the re-epithelialization of the mucosal gap
and allow early feeding (Fig. 3). Most prostheses used in this
indication are coated and extractible. Extirpation should be Debridement and pleural decortication
performed between four and six weeks after insertion to Whatever repair technique is used, all infected and necrotic
avoid re-EP, hemorrhage or impaction of the stent. tissues must be debrided. Pleural decortication is indicated
At present, the best indications of endoprotheses are in the case of purulent pleurisy. This is the only means of
small iatrogenic perforations diagnosed early. Cervical and obtaining full lung expansion, which can bridge the gap much
 e122
Table 3 Treatment of esophageal perforations with endoprostheses. Analysis of the literature.
References (year) Siersema et Gelbmann Johnson et Fischer et Tuebergen Salminen et Kim et al.
al. [41] et al. [40] al. [38] al. [39] et al. [37] al. [36] [35] 2009
(2003) (2004) (2005) (2006) (2008) (2009)
Patients (n) 11 9 22 15 32 10 17
Anastomotic fistula (n) 3 5 2 0 22 2 11
Perforations (n) 8 4 20 15 10 8 6
Localization of the perforation (n)
Cervical 0 0 0 0 0 0 NS
Thoracic 11 9 22 15 32 10 NS
Abdominal 0 0 0 0 0 0 NS
Delay before management (d) 3 (1—28) 7.7 (2—10) 11 < 1 0.5 (30—13) 14 (0—611) 13 (2h—48) 6.5 (1—65)
(range)
Type of endoprosthesis Flamingo® /UltraflexPolyflex
® ®
Ultraflex ®
Ultraflex® / Ultraflex® ULtraflex® Mongomery®
Niti-S-
Stent®
Technically successful insertion of 100 100 95 100 100 100 100
endoprothesis (%)
Morbidity (%) NS 33 12.5 13 28 20 59
Migration of endoprotheses (%) 9 30 14 NS 6 10 35
Mortality (%) 0 33 23 7 15 30 6
Extraction of endoprotheses (%) 64 67 77 80 70 90 88
Interval before extraction of 49 (42—98) 135 21 28 (10—56) 45 (4—426) 70 36.5
endoprotheses (d) (range) (32—242) (21—112) (1—109)
Recovery (%) 93 66 77 93 81 70 88
NS: not specified.

M. Chirica et al.
Esophageal perforations e123

Figure 3. Endoscopic treatment of endoscopic esophageal perforation. (A) Endoscopic view: perforation middle third of esophagus (arrow).
(B) Endoscopic view: stent in place. (C) X-ray after placement of prosthesis (arrows).

like a patch and avoid pleural spaces, source of local infec- • at the level of the cervical esophagus, a sternocleidomas-
tion and leakage. toid flap is the most widely used technique. The sternal
chef is divided as distally as possible near its insertion and
Suture of the perforation separated from the clavicular fascicule, long enough to
reach and cover the suture to which it is affixed with indi-
Identification of the perforation is not always easy. Explo- vidual sutures. The myocutaneous pectoris maximus flap
ration must be performed cautiously, not to increase is used more rarely. Interposition of a flap between the
esophageal wall damage. Instillation of methylene blue tracheal suture and the esophageal suture is indispensable
through an esophageal tube can help locate the fistula in dif- when tracheal and esophageal rents are associated [11].
ficult cases. Longitudinal myotomy can be performed at both Weiman et al. [11] successfully treated 12 such patients,
ends of the perforation to best expose the mucosal edges; nine of whom had associated tracheal fistulas. Mortality
this is particularly important in the case of spontaneous rup- was nil and the residual esotracheal fistula rate was 8%;
ture of the esophagus, a situation in which the mucosal • at the level of the thoracic and abdominal esophagus,
rent is longer than the muscular tear [22]. The edges of several reinforcement techniques have been described.
the perforation are trimmed and sutured, in two layers Parietal or mediastinal pleural flaps are the easiest to
whenever possible [45]. In thoracic and abdominal perfo- perform. At the level of the perforation, a ‘‘U’’ shaped
rations, an endolumenal suction tube can be placed under incision is made in the pleura, in front of the azygos vein
digital guidance near the suture line. Appropriate position- on the right, and in front of the aorta, on the left. The
ing of the drain near the oesophageal suture, may avoid survival rate was 100% in the series reported by Gouge
re-operation in case of suture leakage. Whenever the per- et al. [54], who observed refistulization in 14% of the 14
foration is identified, suture is the technique recommended patients, eight of whom had undergone operation more
by most authors [23,31,32,46—53]. More than the time inter- than 24 h after the perforation. The intercostal flap, on
val between the perforation and the closure, viability of the the other hand, must be anticipated and prepared before
perforation edges and its corollary, the magnitude of the placing the intercostal retractor. The muscle is disinserted
loss of substance after debridement, condition the use of from the periosteum along its entire length, caution being
this technique [33,49]. The risk of suture breakdown ranges exercised not to damage the vasculonervous bundle. The
from 25 to 50% [4]. Iterative fistulization increases morbidity omental flap, and preferentially the fundus flap, easy to
and hospital stay, but does not increase mortality [47]. perform, should be used as often as possible to rein-
force sutures of abdominal and lower thoracic EP. Last,
Reinforcement flaps diaphragmatic flaps and extrathoracic muscular flaps have
In order to limit the risk of refistulization, several reinforce- been used successfully to bridge large losses of substance
ment techniques have been described: seen late and for which simple suture is not possible [55].
e124 M. Chirica et al.

Simple drainage Table 4 Mortality of esophageal perforations according

Whenever suture is not possible or whenever the perforation to time interval before management.
is not visible, simple drainage with or without associated
References (year) < 24 h (%) > 24 h (%)
irrigation-suction, can be used. This modality allows direct-
ing the perforation and limits extension of contamination. Sung et al. [63] (2002) 0 7
While this technique is acceptable in cervical perforations, Jougon et al. [49] (2004) 44 13
it is not recommended in thoracic or abdominal perforations Braghetto et al. [52] (2004) 15 28
because the technique does not prevent further dissemina- Brinster et al. [4] (2004) 14 28
tion of infection [4]. Linden et al. [56] (2007) 5 8.7
Eroglu et al. [32] (2009) 3 36
T-tube drainage Griffith et al. [23] (2009) 18.2 37.5
Vallbohmer et al. [46] (2009) 0 19
T-tube drainage, enhancing directed fistulization of the per- Wang et al. [33] (2009) 0 33
foration, is used essentially in perforations of the thoracic Abbas et al. [31] (2009) 8 25
esophagus when all other repair attempts seem to be illusory
because of the magnitude of esophageal damage. The perfo-
ration is sutured around a large caliber T-tube inserted into
the perforation. Opacification of the T-tube is performed (caustic burn, peptic ulcer, tumor) or in major destruction
before removing the drain 4 to 6 weeks later. In 2007, Linden [50].
et al. [56] reported a 9% mortality rate and a 30% reoper-
ation rate in their series of 17 patients. In our center, we
have abandoned this technique because the control of pleu- Prognosis
ral contamination is suboptimal and reoperation has been
necessary in all cases. The main prognostic factor remains the time interval
between the perforation and treatment. Mortality increases
Esophageal exclusion two-fold when this delay is greater than 24 h (Table 4).
Esophageal exclusion was proposed by Urschell et al. [57] Prognosis varies also according to the localization of the
for the treatment of patients whose general health was EP (Table 5). The prognosis of cervical perforations is in
judged too precarious for major surgery. Associated with general satisfactory because the perforation remains con-
debridement and drainage, the esophagus is excluded by a fined in a closed space as the fascial attachments between
cervical esophagostomy or stapling. Stapling the cardia or the esophagus and the prevertebral fascia limit the lat-
gastrostomy completes the bipolar exclusion. The limits of eral diffusion of infection. The perforation becomes life
this technique are the unforeseeable character of return of threatening when the superior mediastinum is involved.
staple line patency (between 8 days and 1 month) and the The severity of thoracic perforations is related to exten-
risk of stricture which has led most authors to abandon the sive mediastinitis, pleural rupture and consequent purulent
technique [57]. pleurisy. Contained perforations within sclerotic mediasti-
nal tissues such as perforation after dilation of a caustic
burn stricture are rarely life threatening. Perforation of
Nonconservative surgery: esophagectomy the abdominal esophagus into the peritoneal cavity gives
The transthoracic route allows for better control of sep- rise to diffuse peritonitis and can be rapidly highly sep-
sis than the transhiatal route when pleural contamination tic.
and extensive mediastinal involvement are associated, at The cause of the perforation also has a role in prognosis
the price of greater impingement on the respiratory func- (Table 6): prognosis is better after instrumental perfora-
tion. Immediate restoration of digestive tract continuity by tion recognized and treated early. Last, mortality differs
gastroplasty is recommended by some authors for perfora- greatly according to the type of treatment performed, also
tions seen early [58]. This policy seems debatable in our related to the above-mentioned factors and patient status.
opinion because it can worsen outcome. Total esophagec- In a series of 726 patients collected by Brinster et al. [4],
tomy is indicated after failure of conservative treatments, in mortality was 17% (0 to 33%) after medical treatment, 12%
the setting of perforation complicating a diseased esophagus (0 to 31%) after suture, 36% (0 to 47%) after simple drainage,

Table 5 Mortality for esophageal perforations related to location of the perforation.

References (year) Cervical (%) Thoracic (%) Abdominal (%)
Okten et al. [51] (2001) 20 36 0
Gupta et Kaman [50] (2004) 17 14 0
Braghetto et al. [52] (2004) 0 42 22
Brinster et al. [4] (2004) 6 27 21
Vogel et al. [34] (2005) 0 5.4 —
Erdogan et al. [48] (2007) 0 12 —
Abbas et al. [31] (2009) 8 18 3
Eroglu et al. [32] (2009) 0 16.7 16.7
Griffith et al. [23] (2009) 0 26 20
Vallbohmer et al. [46] (2009) 0 9 0
Esophageal perforations e125

Table 6 Mortality of esophageal perforations according to cause.

References (year) Boerhaave (%) Endoscopic (%) Foreign body (%) Trauma (%) Surgery (%)
Gouge et al. [54] (1988) 25 25 — 0 0
Brinster et al. [4] (2004) 36 19 — 7 —
Sung et al. [63] (2002) 14 0 0 — —
Kollmar et al. [60] (2003) 35 — — — —
Gupta et Kaman [50] (2004) 66 5 25 0 33
Jougon et al. [49] (2004) 24 — — — —
Braghetto et al. [52] (2005) 44 9 0 — —
Vogel et al. [34] (2006) 7 4 — 0 0
Erdogan et al. [48] (2007) 67 8 — 0 0
Eroglu et al. [32] (2009) 0 11 11 16 —
Griffith et al. [23] (2009) 26 27 0 0 —
Abbas et al. [31] (2009) 11 14 — — —
Wang et al. [33] (2009) 28 — — — —
Vallbohmer et al. [46] (2009) 11 7 — 0 —

24% (0 to 80%) after esophageal exclusion and 17% (0 to 43%) perforation in two layers, eventually reinforced by a flap,
after esophagectomy. indispensable when tracheal perforation is associated, and
drainage. Simple drainage is acceptable when esophageal
damage is important or when the perforation cannot be
The most frequent situations identified.

The goal of this chapter is to propose a management scheme

adapted to the most frequently encountered situations. A
therapeutic algorithm is proposed (Fig. 4). Perforations of the thoracic esophagus

Perforations of the cervical esophagus Iatrogenic perforations

Usually small, diagnosed early, these perforations are the
Nonoperative treatment can be attempted for small con- ideal indication for nonoperative management. Treatment
tained perforations, most often iatrogenic, as long as close consists of close monitoring, strict fasting, broad-spectrum
surveillance can be ensured. Endolumenal clipping is pos- antibiotics and possibly endolumenal clips or stenting,
sible if the perforation is seen early. Currently, there is ideally performed at the same time, and percutaneous
no indication for endoprotheses in this location because drainage as needed. If loss of substance is present,
of difficulty in positioning the prosthesis and the risk of or if diagnosis is late or initial treatment fails, the
migration [59]. Surgical treatment, necessary in 70 to 80% prognosis is similar to that of spontaneous perfora-
of patients [4], consists of left cervicotomy, suturing the tions.

Figure 4. Treatment of esophageal perforations: therapeutic algorithm.

e126 M. Chirica et al.

Spontaneous perforations
ESSENTIAL POINTS
Initial treatment is based on primary suture, with or with-
out reinforcement, debridement with pleural decortication, • Most esophageal perforations today are
associated with drainage, irrespective of the time interval iatrogenic.
between the perforation and management [60]. Nonopera- • Initial diagnosis is incorrect 50% of the time,
tive management, T-tube drainage or esophageal exclusion because of atypical clinical presentation.
have always been ineffective and dangerous in our experi- • Computed tomography with upper GI opacification
ence. We believe that insertion of an endoprosthesis is a is the key to diagnosis and workup.
therapeutic error because it delays and risks compromising • Nonoperative management can be considered in
successful surgery, which is the mainstay of treatment. Pros- selected patients.
thesis insertion may be an option, however, in the case of • Reinforced suture of the perforation is the major
suture leakage after initial surgical treatment [59]. treatment option.
• Endoscopic treatment constitutes an attractive
alternative to surgery but is still under evaluation.
Perforations of the abdominal esophagus • Overall mortality of esophageal perforations is
close to 20%.
Perforation of the abdominal esophagus usually occurs in • Poor prognostic factors include:
patients with underlying esophageal disease. Treatment of - Time interval before treatment greater than
any distal obstacle at the same time is an essential part 24 h.
of the therapeutic scheme [4]. Suture of EP after dila- - Spontaneous character of the perforation.
tion for achalasia should be associated with seromyotomy - Thoracic and abdominal location.
contralateral to the perforation and covered with a par- - Underlying esophageal disease.
tial fundoplication wrap, operation which can be performed • Interventional endoscopy is still under evaluation
laparoscopically. When perforation occurs in hiatal her- in this indication. To this day, no controlled trial
nia, fundoplication covering the sutures treats GERD at the has been able to show improved survival with its
same time. When EP occurs during laparoscopic surgery for use.
achalasia or GERD, the operation can be continued laparo-
scopically as long as the perforation is diagnosed during the
operation and repair is judged to be satisfactory [61].
Conflict of interest statement
Tumor perforations No conflicts of interest are to be reported.

Total esophagectomy has been recommended in this setting

because this modality treats the source of contamination Acknowledgements
and the tumor at the same time [58]. This attitude was
questioned recently by Di Franco et al. [62] who treated Our thanks to professor Frédéric Prat of Cochin Hospital
48 patients with iatrogenic perforation by esophagectomy for providing us with the endoscopic images illustrating this
(n = 16) or nonoperatively (n = 32), most often by stenting. update.
Immediate mortality was similar between the two groups (0
vs. 9%, P = 0.54). All patients undergoing resection died of
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