Esophageal perforation: Continuing challenge to treatment

AbstractEsophageal perforation carries with it a high morbidity and mortality if not treated appropriately and aggressively. Three approaches are available for the treatment of esophageal perforation: conservative, endotherapy, and surgery. The location viz. cervical, thoracic, or abdominal portions of the esophagus and size of the perforation influence treatment choice. Cervical perforations are usually small and can be treated conservatively as the perforation or leak is also contained within the triangle of Killian in the neck. Most cervical perforations have a good outcome with conservative treatment with intravenous antibiotics and nil by mouth. Treatment of thoracic perforations depends very much on the size of the perforation. Small perforations due to sclerotherapy injection, for example, can be treated conservatively. Endotherapy can help avoid surgery in other cases: small tears from endoscopic insertion can be clipped and esophageal fistulae can be injected with fibrin glue. Larger perforations can be treated with stent placement if the dehiscence of the lumen circumference does not exceed 70%. Stent placement with self-expandable fully-covered plastic and metallic stents or partially-covered metallic stents has been used with fairly good success. One of the problems with stent placement is the migration of these stents. Perforation of the intra-abdominal portion of the esophagus often results in a very rapid development of peritonitis and sepsis and surgery is usually recommended. Surgery is mandatory in any part of the esophagus when the perforation is large or when patients do not improve with conservative or endoscopic treatment. In very ill patients, esophageal exclusion surgery can be carried out until the patient’s general condition stabilizes. In cases of a diseased esophagus such as corrosive injury related perforations or cancer of the esophagus, esophageal replacement surgery should be contemplated with total esophagectomy and gastric pull-up surgery or creation of a neoesophagus with colonic interposition