Return to: Head and Neck

See also: Zenker's Diverticulectomy

Note: last updated before 2013

GENERAL

1. This protocol is designed to aid in the management of identified or suspected esophageal perforations that can occur secondary to penetrating trauma; during esophageal, neck, or chest procedures; or are created by the placement of esophageal or endotracheal tubes. This is in contrast to the spontaneous esophageal rupture or Boerhaave's syndrome, as well as ruptures induced by tumor or foreign-body ingestion.
2. Cervical esophageal perforation and thoracic esophageal perforation require a slightly different approach to diagnosis and management. 
3. Risk factors:
   1. Prior radiation therapy, esophageal perforation, or esophageal surgery
   2. Strictures, particularly malignant strictures
   3. Esophageal diverticula
   4. Severe esophagitis
   5. Inexperienced operator

ESOPHAGEAL PERFORATION DIAGNOSIS AND INITIAL MANAGEMENT

1. Cervical Esophagus
   1. Suspected esophageal perforation (trauma, traumatic endoscopy, nasogastric tube placement, cervical surgery)
      1. When the patient is in the operating room
         1. If the neck is closed, pharyngoesophagoscopy is needed.
         2. If the neck is open, begin with gentle inspection of the pharyngoesophageal region.
         3. If no perforation is found, instillation of saline with a 150 cc Aseptoe syringe through the oral cavity into the pharynx to balloon out piriform sinuses and upper esophagus may reveal the leak.
      2. When the patient is out of the operating room
         1. Admit to ward
         2. Keep NPO
         3. Check chest x-ray, soft tissue neck film, look for free air
         4. Monitor for fever, tachycardia, dyspnea, dysphagia,
         5. Monitor for back and chest pain
         6. Monitor for cervical or chest wall crepitus
         7. Listen for a a crunching sound synchronous with heartbeat when performing cardiac auscultation (Hamman's sign) indicating pneumomediastinum.
         8. Begin antibiotic coverage (broad spectrum)
            1. Ampicillin/sulbactam OR ticarcillin/clavulanate +/- clindamycin (oral anaerobes)
            2. Penicillin allergy: clindamycin/ gentamicin
         9. Begin IV proton-pump inhibitor or antihistamine
         10. Contrast esophagram (water soluble, eg, Gastrografin)
             1. Negative esophagram: False negative possible, CT scan may add information if clinical suspicion is high
      3. If initial evaluation is negative (i.e. NO perforation and clinical suspicion is low)
         1. Monitor patient for 8 hours
         2. Begin clear liquids
         3. Monitor for 24 hours; if symptoms appear, make the patient NPO and repeat the esophagram
   2. Known esophageal perforation
      1. Identify and document extent of tear
         1. Superior and inferior extent (cervical versus cervicothoracic esophagus)
         2. Depth of tear: mucosal, submucosal (intramural), transmuscular
         3. Cause of perforation; rigid scope, flexible scope, NG tube
         4. Condition of patient at time of perforation (diabetic, etc)
         5. Time since perforation event
         6. Extent of possible food or liquid contamination of perforation site
      2. Initial treatment
         1. If the patient is in the operating room
            1. Complete exploration and primary closure
            2. Place a passive neck drain
         2. When out of the operating room and after primary closure
            1. Admit to ward
            2. NPO
            3. Chest x-ray, soft tissue neck film, look for free air
            4. Monitor for fever, tachycardia, dyspnea, dysphagia, abdominal rigidity, back and chest pain
            5. Monitor for cervical or chest wall crepitus
            6. Begin antibiotic coverage (broad spectrum)
               1. Ampicillin/sulbactam OR ticarcillin/clavulanate +/- clindamycin (oral anerobes)
               2. Penicillin allergy: clindamycin/gentamicin
            7. Begin IV proton-pump inhibitor or antihistamine
            8. Contrast esophagram (water soluble, eg, Gastrografin) false negative esophagram is possible
            9. CT scan may add information if clinical suspicion high
2. Thoracic Esophagus
   1. Consult cardiothoracic surgery service.
   2. If an esophageal perforation is suspected at the time of endoscopy, the patient should remain in the operating room and be evaluated by intraoperative exploration and endoscopy.
   3. Consider endoscopic placement of stent
   4. When the patient is outside the operating room the investigation includes
      1. Chest x-ray
      2. Contrast esophagram
      3. Chest CT scan
   5. If no perforation is identified, the patient should be observed closely for at least 24 hours prior to the return of oral feeding with continued close observation.
   6. If the perforation is identified, then treatment plans are made and followed

TREATMENT

1. General
   1. Controversy remains as to the best approach to treating esophageal perforations, OPEN surgical vs CLOSED medical. Treatment decisions will be affected by:
      1. Mechanism of the perforation
      2. Time interval between perforation event and treatment (<24 hours favors medical management)
      3. Patient's overall condition
      4. Patient's response to the perforation
      5. The status of the esophagus at the time of the perforation (eg, esophageal or paraesophageal cancer, esophageal stenosis, prior esophageal injury or surgery)
      6. Location of perforation (cervical favors medical management)
      7. Size of perforation
   2. All perforations require at the least:
      1. Broad spectrum antibiotic coverage
      2. PPI/antihistamine therapy
      3. NPO for 7 days, depending on clinical status of patient
      4. Intravenous nutrition
      5. Close observation and clinical examination
2. Cervical Esophageal Perforation
   1. Small cervical perforation
      1. May be treated with nonsurgical closed management with repeat esophagram in 5 to 7 days.
      2. Exploration of the neck with repair and drainage is usually a low-risk procedure, which may prevent later potential complication.
   2. Large cervical perforation
      1. Operative closure and transcervical drainage, followed by:
         1. Drain management
         2. Repeat esophagram in 5 to 7 days
      2. Occasionally cervical perforation will require salivary diversion.
      3. Flap reconstruction maybe required in certain cases.
      4. Consider endoscopic placement of stent for low cervical perforations (see management of thoracic perforations below).
3. Thoracic Esophageal Perforation
   1. General
      1. Thoracic esophageal perforation management is complicated by the increased risk of mediastinal and thoracic infections, which has to be balanced against the risks and long-term side effects of surgical intervention.
   2. Small thoracic perforation
      1. Admit to ICU.
      2. Consider nonsurgical management, which may be possible if the esophagus and patient are otherwise in good health, and spontaneous healing can be anticipated.
      3. Esophageal stent may be placed endoscopically by a highly skilled operator
         1. Obtain repeat esophagram in 2-3 days following stent placement to asses for seal before advancing to clear liquids.
         2. Remove stent within 6 weeks.
      4. Surgical therapy may be required to control and drain secondary abscess formation even if primary healing of the esophagus occurs.
      5. Obtain repeat CXRs to assess for pneumomediastinum and pleural effusions
   3. Large thoracic perforation
      1. Surgery management for early well-confined perforations would consist of identification and debridement of nonviable tissue, followed by multilayered closure: mucosa, muscle, and then additional nearby tissues (pleura, pericardium, etc). This is followed by drainage and closure. Repeat radiology studies in 7 to 10 days if no signs of closure failure are identified in the interim.
      2. Large and extensive perforations could require drainage and diversion procedures, cervical esophagostomy, distal esophageal closure, and feeding gastrostomy or jejunostomy. Late repair or possible replacement procedures would follow.
      3. When patients present late or have other complicating issues a nonsurgical approach may be utilized if the perforation cavity is confined to the mediastinum and drains well into esophagus. These patients require close observation for progression of symptoms, frequent CXR, and normalized swallow studies prior to the initiation of PO intake. 
      4. Pleural effusions may occur due to relatively lower intrathoracic pressures.
         1. Enlarging pleural effusions require chest tube or CT-guided catheter placement for drainage.
4. Follow-Up
   1. After confirmed closure of perforation on repeat esophagram, begin a clear liquid diet and advance to full diet over 1 to 2 weeks.
   2. Complete a total 7-14 day course of broad spectrum antibiotics.
   3. A healed perforation may create a site of stricture with secondary dysphagia.

REFERENCES

Murphy DW, Roufail WM. Rupture and perforation. In: Castell DO, ed. The Esophagus. 2nd ed. Boston, Mass: Little Brown and Co; 1995.

Pasricha, PJ, Ravich WJ. Complications of flexible esophagoscopy. In: Eisele DW, ed. Complications in Head and Neck Surgery. St. Louis, Mo: Mosby; 1993.

Hernandez LV, Jacobson JW, Harris MS, Hernandez LJ.  Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures.  Gastrointest Endosc. 2000;51(4 Pt 1):460.

Medical management of esophageal perforations.  Curr Treat Options Gastroenterol. 2008 Feb;11(1):54-63.

Jones WG, Ginsberg RJ.  Esophageal perforation: A continuing challenge.  Ann Thorac Surg 1992;53:534-543