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: pierre.cattan@sls.aphp.fr (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
Foreign bodies
Ingested foreign bodies are responsible for 80% of cervical
perforations [4]. The foreign body usually impacts in the
esophageal wall at the level of the physiological, narrow
portion of the esophagus (cf. supra). Prolonged impaction
can lead to extralumenal migration which can perforate
nearby organs such as the trachea or the aorta with often
fatal outcome [20]. The foreign bodies most often incrimi-
nated include dental prostheses and bones. The risk of EP
during endoscopic extraction of ingested foreign bodies is
estimated at 0.25% [21].
Spontaneous perforations
Boerhaave’s syndrome is a spontaneous barotraumatic rup-
ture of the lower third of the esophagus secondary to
an abrupt increase in intraesophageal pressure (up to
290 mmHg) during vomiting, associated with absence of
relaxation of the superior sphincter of the esophagus [22].
By extension, most authors regroup under the name of
Boerhaave’s syndrome, all spontaneous perforations of an
otherwise healthy esophagus, whether secondary to vomit-
ing or not. They represent 8 to 56% of perforations in recent
series (Table 1). The perforation is located most often (80%)
on the left border of the lower third of the thoracic esoph-
agus and measures 3 to 6 cm on the average [22]. Iterative
spontaneous perforations, occurring several months or years
afterwards, have also been reported [23,24].
Perforations occurring on diseased esophagus
EP can occur in people with conditions such as esophageal
diverticules, Barrett’s esophagus, infective esophagitis (in
the immunocompromised patient), even in the absence of
instrumental maneuvers [4]. EP complicates 5 to 8% of
esophageal cancers treated with palliative intent; one out
of four are fatal [25]. Fistulas between a tumor of the
esophagus and the tracheobroncheal tree are found in 4.9%
of patients with esophageal cancer. These fistulas develop
because of tumoral invasion or are secondary to radiation
therapy or after insertion of an endoprosthesis [25].
Diagnosis
Clinical presentation
The mean age of patients with EP is 60 years. The clinical
expression of EP is extremely variable and initial diagno-
sis is wrong in one out of two cases and 60% of the time,
the time interval to diagnosis is longer than 24 hours [23].
The initial symptoms are often suggestive of myocardial
infarction, perforated ulcer, acute pancreatitis, aortic dis-
section, spontaneous pneumothorax or pulmonary disease.
This underlines the importance of always keeping this diag-
nosis in mind and defining the circumstances surrounding
the appearance of clinical signs. In fine, onset of any symp-
tom after digestive endoscopy or vomiting should lead to
suspicion of EP.
The clinical expression of perforation depends on the
location of the perforation and the delay between the
perforation and presentation. Cervical perforations occur
most often during upper GI endoscopy and, in general, the
diagnosis is obvious. The most frequent clinical signs are
subcutaneous emphysema (95%) and cervical pain (90%),
e119
sometimes associated with dysphagia, dysphonia or fever
[4]. The diagnosis of thoracic EPs is particularly difficult.
In case of spontaneous perforation, the clinical signs most
often observed are, by decreasing order of frequency, vom-
iting (84%), thoracic pain (79%), dyspnea (53%), epigastric
pain (47%), or dysphagia (21%) [23]. Mackler’s triad (thoracic
pain, vomiting and emphysema), although highly suggestive
of the diagnosis, is found in less than one third of cases
[23]. In case of delayed diagnosis, sepsis is dominant. When
the perforation is abdominal, guarding or rigidity can be
associated with mediastinal or pleural signs. The inaugural
picture associates dorsal pain, exacerbated by dorsal decu-
bitus, or epigastric pain irradiating to the scapula, due to
diaphragmatic irradiation, followed rapidly by septic shock.
Complementary investigations
Conventional radiology
Lateral cervical X-rays can show prevertebral free air in
cervical EPs. In thoracic EPs, the standard lung X-ray is
abnormal in 90% of cases [4] showing pleural effusion,
pneumothorax or hydropneumothorax, pneumoperitoneum
or retropneumoperitoneum. Pneumomediastinum or subcu-
taneous emphysema require at least one hour to appear
after perforation occurs explaining why X-rays performed
too early can be falsely reassuring [26].
Cervicothoracoabdominal CT scans
GI contrast enhanced CT is currently the initial investiga-
tion of choice because sensitivity (92 to 100%) is better than
that for esogastroduodenal follow-through [27]. Moreover,
contrast-enhanced CT can help delineate extension to adja-
cent structures (mediastinitis, pleural effusion, subpleural
abscess, intraperitoneal effusion) and thus guide therapy
(Fig. 1). Last, when EP is not confirmed by CT, other diag-
noses such as aortic dissection, duodenal ulcer perforation
or pancreatitis can be made [4].
Esogastroduodenal follow-through (EGDFT)
EGDFT has a 50% sensitivity for the detection of cervical
EP and 75—80% for the detection of thoracic EP [4]. This
investigation provides a good idea of the location of the EP,
indicates the importance of the extravasation and whether
the leak is contained or not (Fig. 2). Barium opacification is
more sensitive (60% for cervical and up to 90% for thoracic
EP) than hydrosolubles but should be reserved for suspected
esotracheal fistula because of the toxicity of hydrosolubles
for the lung. When the first opacification is negative but
there are strong clinical reasons to suspect the fistula, a
second opacification is advised in the hours that follow [4].
Esophageal endoscopy
The sensitivity of endoscopy is nearly 100% and the speci-
ficity 83% for the detection of EP [28]. However, the only
truly diagnostic indication for endoscopy is the routine
search for EP in penetrating trauma. This investigation is not
recommended for any other situation because insufflation
is capable of enlargement of a minimal transmural opening
thus compromising the possibility of conservative treatment
[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-

There are several possible therapeutic strategies rang-
ing from medical treatment to the most aggressive,
esophagectomy. Somewhere between these two extremes,
one finds the mini-invasive techniques, including interven-
tional endoscopy, eventually associated with surgical or
radiological drainage, but these modalities have not yet
been validated. The chances of preserving the native esoph-
agus and of patient survival depend on the success of initial
treatment. The principal objectives of treatment are to
treat infection, prevent continuing septic contamination,
tinuity.
Medical treatment
Strict fasting is prescribed until performing a radiologic con-
trol (EGDFT or CT scan) on day 7. Total parenteral nutrition,
broad-spectrum antibiotic prophylaxis directed against aer-
obic and anaerobic germs (14 to 21 days) as well as proton
pump inhibitors to check associated acid reflux are the basis
for treatment. Close monitoring is necessary to detect per-
sistence or reappearance of symptoms, especially septic.
Esophageal perforations
Table 2 Indications for exclusive medical treatment of
esophageal perforations.
Delay before management
Early: less than 24 h
Clinical
Absence of marked infective syndrome
Radiologic
Cervical or thoracic location of the perforation
Contained perforation
Intramural perforation
Limited extravasation of contrast material, into the
esophageal lumen
Absence of extravasation into the pleura
Patient characteristics
Non tumoral perforation
Absence of downstream obstacle
Other
Possibility of clinical and radiologic surveillance by a
team used to medicosurgery management of
esophageal disease
Repeat CT is useful to guide changes in therapeutic poli-
cies.
The initial attempts at medical treatment were reported
by Mengold and Klassen in 1965: mortality was 6% in their
series of 18 patients [29]. Indications are presently well
codified, thanks to the contribution of Altorjay et al. [30]
(Table 2). A delay in management greater than 24 hours has
now become a relative contraindication as several series
have recently shown that this treatment modality can be
successful in this setting [31—33]. Presently, medical treat-
ment failure, requiring interventional treatment, can occur
in approximately 20% of cases [30].
Conservative interventional treatment
Nonoperative management
Vogel et al. [34] recently reported their results after
‘‘aggressive nonoperative treatment’’ in 47 spontaneous
and iatrogenic EP, based on repeated clinical and radiologic
evaluation and multiple percutaneous drainages. Surgery
was avoided in 68% of these patients. None of these patients
sustained an esocutaneous fistula. Overall mortality was 6%.
Endoscopic management
This treatment modality, the goal of which is to arrest the
source of septic contamination, is under evaluation [35—41].
Endoscopic treatment can be combined with percutaneous
or surgical drainage of septic collections. By virtue of its mini
invasive character, this modality is an appealing alternative
to open surgery.
Endoprostheses
The goal of endoscopic insertion of endoprotheses covering
the EP opening is to prevent continuing septic contamina-
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
performed between four and six weeks after insertion to
avoid re-EP, hemorrhage or impaction of the stent.
At present, the best indications of endoprotheses are
small iatrogenic perforations diagnosed early. Cervical and
e121
abdominal EP are relative contraindications, because of the
high risk of migration in these locations. The success rates in
the principal series in the literature [35—41] range from 92
to 100%, the healing rates of the perforation range from 13
to 69% and mortality, from 0 to 33% (Table 3). Stent migration
is the main complication (6 to 35%).
Endoscopic clipping
The idea of closing EP with hemostatic clips came from the
experience of endoscopic closure of gastric and colonic per-
forations [42]. The relatively limited opening gap of clips
(< 11 mm) only allows approximation of the mucosal edges.
The technique consists of placing the clips on the breach
from one extremity to the other. This technique can be used
for small EP because of the technical constraints and for per-
forations diagnosed early, before advanced contamination of
the mediastinum sets in. The ideal indication is iatrogenic
endoscopic EP, occurring during mucosal resection or dur-
ing submucosal dissection. In 17 selected patients (average
size of perforation: 9 mm; range: 6 to 12 mm, time interval
before management: 2 days [range 0 to 40 days]), Qaader et
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.
Endoscopic gluing
The use of fibrin glue was initially proposed for manage-
ment of esophageal fistulas. Endoscopic gluing of EP has
been reported rarely, mostly as clinical case reports. Rabago
et al. [43] reported a successful closure with this treatment
for a 2 mm EP seen early after endoscopic extraction of food
impaction. Fischer et al. [44] successfully completed a clip
closure of a large iatrogenic EP with injection of glue.
Surgical treatment
The choice of surgical treatment depends on the localization
of the perforation, its size, the viability of the esophageal
walls, the degree of local sepsis and the presence or not of
underlying esophageal pathology.
Conservative surgical treatment
Conservative surgical treatment includes debridement of
infected and necrotic tissues, suture of the perforation
whenever possible, drainage, treatment of distal obsta-
cles and parenteral or enteral hypercaloric alimentation.
The nutritional status of the patient as well as the delay
before eating is allowed may indicate the need for a feed-
ing jejunostomy. Effective analgesia as well as motor and
respiratory rehabilitation are indispensible as for all major
esophageal surgery. The surgical approach is through a left
cervicotomy for cervical EP and median laparotomy for
abdominal EP. For thoracic EP, the side of the thoracotomy
is dictated by the location of the EP (right thoracotomy for
cervical and upper and middle thirds of thoracic EP, left tho-
racotomy for the lower third of the thoracic esophagus) and
by the predominant side of associated pleural effusion.
Debridement and pleural decortication
Whatever repair technique is used, all infected and necrotic
tissues must be debrided. Pleural decortication is indicated
in the case of purulent pleurisy. This is the only means of
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
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-
tion and leakage.
Suture of the perforation
Identification of the perforation is not always easy. Explo-
ration must be performed cautiously, not to increase
esophageal wall damage. Instillation of methylene blue
through an esophageal tube can help locate the fistula in dif-
ficult cases. Longitudinal myotomy can be performed at both
ends of the perforation to best expose the mucosal edges;
this is particularly important in the case of spontaneous rup-
ture of the esophagus, a situation in which the mucosal
rent is longer than the muscular tear [22]. The edges of
the perforation are trimmed and sutured, in two layers
whenever possible [45]. In thoracic and abdominal perfo-
rations, an endolumenal suction tube can be placed under
digital guidance near the suture line. Appropriate position-
ing of the drain near the oesophageal suture, may avoid
re-operation in case of suture leakage. Whenever the per-
foration is identified, suture is the technique recommended
by most authors [23,31,32,46—53]. More than the time inter-
val between the perforation and the closure, viability of the
perforation edges and its corollary, the magnitude of the
loss of substance after debridement, condition the use of
this technique [33,49]. The risk of suture breakdown ranges
from 25 to 50% [4]. Iterative fistulization increases morbidity
and hospital stay, but does not increase mortality [47].
Reinforcement flaps
In order to limit the risk of refistulization, several reinforce-
ment techniques have been described:
e123
• at the level of the cervical esophagus, a sternocleidomas-
toid flap is the most widely used technique. The sternal
chef is divided as distally as possible near its insertion and
separated from the clavicular fascicule, long enough to
reach and cover the suture to which it is affixed with indi-
vidual sutures. The myocutaneous pectoris maximus flap
is used more rarely. Interposition of a flap between the
tracheal suture and the esophageal suture is indispensable
when tracheal and esophageal rents are associated [11].
Weiman et al. [11] successfully treated 12 such patients,
nine of whom had associated tracheal fistulas. Mortality
was nil and the residual esotracheal fistula rate was 8%;
• at the level of the thoracic and abdominal esophagus,
several reinforcement techniques have been described.
Parietal or mediastinal pleural flaps are the easiest to
perform. At the level of the perforation, a ‘‘U’’ shaped
incision is made in the pleura, in front of the azygos vein
on the right, and in front of the aorta, on the left. The
survival rate was 100% in the series reported by Gouge
et al. [54], who observed refistulization in 14% of the 14
patients, eight of whom had undergone operation more
than 24 h after the perforation. The intercostal flap, on
the other hand, must be anticipated and prepared before
placing the intercostal retractor. The muscle is disinserted
from the periosteum along its entire length, caution being
exercised not to damage the vasculonervous bundle. The
omental flap, and preferentially the fundus flap, easy to
perform, should be used as often as possible to rein-
force sutures of abdominal and lower thoracic EP. Last,
diaphragmatic flaps and extrathoracic muscular flaps have
been used successfully to bridge large losses of substance
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

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

Figure 4. Treatment of esophageal perforations: therapeutic algorithm.

e126
Spontaneous perforations
Initial treatment is based on primary suture, with or with-
out reinforcement, debridement with pleural decortication,
associated with drainage, irrespective of the time interval
between the perforation and management [60]. Nonopera-
tive management, T-tube drainage or esophageal exclusion
have always been ineffective and dangerous in our experi-
ence. We believe that insertion of an endoprosthesis is a
therapeutic error because it delays and risks compromising
successful surgery, which is the mainstay of treatment. Pros-
thesis insertion may be an option, however, in the case of
suture leakage after initial surgical treatment [59].
Perforations of the abdominal esophagus
Perforation of the abdominal esophagus usually occurs in
patients with underlying esophageal disease. Treatment of
any distal obstacle at the same time is an essential part
of the therapeutic scheme [4]. Suture of EP after dila-
tion for achalasia should be associated with seromyotomy
contralateral to the perforation and covered with a par-
tial fundoplication wrap, operation which can be performed
laparoscopically. When perforation occurs in hiatal her-
nia, fundoplication covering the sutures treats GERD at the
same time. When EP occurs during laparoscopic surgery for
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].
Tumor perforations
Total esophagectomy has been recommended in this setting
because this modality treats the source of contamination
and the tumor at the same time [58]. This attitude was
questioned recently by Di Franco et al. [62] who treated
48 patients with iatrogenic perforation by esophagectomy
(n = 16) or nonoperatively (n = 32), most often by stenting.
Immediate mortality was similar between the two groups (0
vs. 9%, P = 0.54). All patients undergoing resection died of
tumor recurrence, nine during the first postoperative year;
median survival did not differ between the two groups (9.8
months vs. 6.9 months, P = 0.315). This study questions the
value of esophagectomy for cancer perforation since sur-
vival was not improved by resection. The authors underscore
the importance of avoiding perforation during endoscopic
maneuvers in patients for whom curative treatment is pos-
sible.
Conclusion
Several clinicopathological entities with very different prog-
nosis and treatment modalities are grouped under the same
generic term of EP. EPs are fatal in one out of five cases.
Early diagnosis and appropriate management can improve
the dismal prognosis. Suture, reinforced whenever applica-
ble, and treatment of underlying causes remain the mainstay
of treatment. However, nonsurgical treatment associat-
ing medical treatment, endoprostheses and radiological
drainage can be proposed in selected patients. When major
esophageal damage is found or when conservative treatment
fails, esophagectomy must not be delayed because patient
survival may be jeopardized.
M. Chirica et al.
ESSENTIAL POINTS
• Most esophageal perforations today are
iatrogenic.
• Initial diagnosis is incorrect 50% of the time,
because of atypical clinical presentation.
• Computed tomography with upper GI opacification
is the key to diagnosis and workup.
• Nonoperative management can be considered in
selected patients.
• Reinforced suture of the perforation is the major
treatment option.
• Endoscopic treatment constitutes an attractive
alternative to surgery but is still under evaluation.
• Overall mortality of esophageal perforations is
close to 20%.
• Poor prognostic factors include:
- Time interval before treatment greater than
24 h.
- Spontaneous character of the perforation.
- Thoracic and abdominal location.
- Underlying esophageal disease.
• Interventional endoscopy is still under evaluation
in this indication. To this day, no controlled trial
has been able to show improved survival with its
use.
Conflict of interest statement
No conflicts of interest are to be reported.
Acknowledgements
Our thanks to professor Frédéric Prat of Cochin Hospital
for providing us with the endoscopic images illustrating this
update.
References
[1] Derbes VJ, Mitchell Jr RE. Hermann Boerhaave’s Atrocis,
nec descripti prius, morbi historia, the first translation
of the classic case report of rupture of the esopha-
gus, with annotations. Bull Med Libr Assoc 1955;43(2):
217—40.
[2] Barrett NR, Franklin RH. Concerning the unfavourable late
results of certain operations performed in the treatment of
cardiospasm. Br J Surg 1949;37(146):194—202 [illust].
[3] Olson A, Clagett OT. Spontaneous rupture of the esophagus.
Report of a case with immediate diagnosis and succesful surgi-
cal repair. Postgrad Med 1947;2:417—9.
[4] Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kuchar-
czuk JC. Evolving options in the management of esophageal
perforation. Ann Thorac Surg 2004;77(4):1475—83.
[5] Scatton O, Gaudric M, Massault PP, Chaussade S, Houssin D,
Dousset B. [Conservative management of esophageal perfora-
tion after pneumatic dilatation for achalasia]. Gastroenterol
Clin Biol 2002;26(10):883—7.
[6] Slater G, Sicular AA. Esophageal perforations after forceful
dilatation in achalasia. Ann Surg 1982;195(2):186—8.
[7] Kavic SM, Basson MD. Complications of endoscopy. Am J Surg
2001;181(4):319—32.
[8] Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook
H, Rapier R, et al. Randomized trial of emergency endo-
scopic sclerotherapy versus emergency portacaval shunt for
Esophageal perforations
acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg
2009;209(1):25—40.
[9] Vrouenraets BC, Been HD, Brouwer-Mladin R, Bruno M, van Lan-
schot JJ. Esophageal perforation associated with cervical spine
surgery: report of two cases and review of the literature. Dig
Surg 2004;21(3):246—9.
[10] Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstat-
ter M, Lin F, et al. Endoscopic and surgical treatments for
achalasia: a systematic review and meta-analysis. Ann Surg
2009;249(1):45—57.
[11] Weiman DS, Walker WA, Brosnan KM, Pate JW, Fabian
TC. Noniatrogenic esophageal trauma. Ann Thorac Surg
1995;59(4):845—9, discussion 9-50.
[12] Beal SL, Pottmeyer EW, Spisso JM. Esophageal perforation fol-
lowing external blunt trauma. J Trauma 1988;28(10):1425—32.
[13] Cumberbatch GL, Reichl M. Oesophageal perforation: a rare
complication of minor blunt trauma. J Accid Emerg Med
1996;13(4):295—6.
[14] Jaspersen D. Drug-induced oesophageal disorders: patho-
genesis, incidence, prevention and management. Drug Saf
2000;22(3):237—49.
[15] Al-Mofarreh MA, Al Mofleh IA. Esophageal ulceration
complicating doxycycline therapy. World J Gastroenterol
2003;9(3):609—11.
[16] Jougon J, Cantini O, Delcambre F, Minniti A, Velly JF.
Esophageal perforation: life threatening complication of endo-
tracheal intubation. Eur J Cardiothorac Surg 2001;20(1):7—10
[discussion -1].
[17] Jougon JB, Gallon P, MacBride T, Dubrez J, Velly JF. Esophageal
perforation after transesophageal echocardiography. Eur J Car-
diothorac Surg 1999;16(6):686—7.
[18] de Dominicis F, Rekik R, Merlusca G, Deguines JB, Gamain J,
Berna P. Perforation par sonde nasogastrique avec arc aortique
droit et aorte descendante à droite. J Chir 2009;146:499—502.
[19] Lee JG, Lieberman DA. Complications related to endo-
scopic hemostasis techniques. Gastrointest Endosc Clin N Am
1996;6(2):305—21.
[20] Champault A, Cattan P. [Aortic rupture due to a swallowed
medical needle]. J Chir (Paris) 2009;146(4):442—3.
[21] Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Manage-
ment of esophageal foreign bodies: a retrospective review of
400 cases. Eur J Cardiothorac Surg 2002;21(4):653—6.
[22] Korn O, Onate JC, Lopez R. Anatomy of the Boerhaave syn-
drome. Surgery 2007;141(2):222—8.
[23] Griffiths EA, Yap N, Poulter J, Hendrickse MT, Khurshid
M. Thirty-four cases of esophageal perforation: the experi-
ence of a district general hospital in the UK. Dis Esophagus
2009;22(7):616—25.
[24] Khan OA, Barlow CW, Weeden DF, Amer KM. Recurrent
spontaneous esophageal rupture. Eur J Cardiothorac Surg
2005;28(1):178—9.
[25] Morgan RA, Ellul JP, Denton ER, Glynos M, Mason RC, Adam
A. Malignant esophageal fistulas and perforations: manage-
ment with plastic-covered metallic endoprostheses. Radiology
1997;204(2):527—32.
[26] Han SY, McElvein RB, Aldrete JS, Tishler JM. Perforation of
the esophagus: correlation of site and cause with plain film
findings. AJR Am J Roentgenol 1985;145(3):537—40.
[27] de Lutio di Castelguidone E, Merola S, Pinto A, Raissaki
M, Gagliardi N, Romano L. Esophageal injuries: spectrum
of multidetector row CT findings. Eur J Radiol 2006;59(3):
344—8.
[28] Horwitz B, Krevsky B, Buckman Jr RF, Fisher RS, Dabezies MA.
Endoscopic evaluation of penetrating esophageal injuries. Am
J Gastroenterol 1993;88(8):1249—53.
[29] Mengold L, Klassen KP. Conservative management of
esophageal perforation. Arch Surg 1965;91:232—40.
[30] Altorjay A, Kiss J, Voros A, Bohak A. Nonoperative manage-
ment of esophageal perforations. Is it justified? Ann Surg
1997;225(4):415—21.
[31] Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landre-
neau J, Luketich JD, et al. Contemporaneous management of
e127
esophageal perforation. Surgery 2009;146(4):749—55 [discus-
sion 55—6].
[32] Eroglu A, Turkyilmaz A, Aydin Y, Yekeler E, Karaoglanoglu N.
Current management of esophageal perforation: 20 years expe-
rience. Dis Esophagus 2009;22(4):374—80.
[33] Wang Y, Zhang R, Zhou Y, Li X, Cheng Q, Liu K, et al. Our
experience on management of Boerhaave’s syndrome with late
presentation. Dis Esophagus 2009;22(1):62—7.
[34] Vogel SB, Rout WR, Martin TD, Abbitt PL. Esophageal perfo-
ration in adults: aggressive, conservative treatment lowers
morbidity and mortality. Ann Surg 2005;241(6):1016—21 [dis-
cussion 21—3].
[35] Kim AW, Liptay MJ, Snow N, Donahue P, Warren WH. Util-
ity of silicone esophageal bypass stents in the management
of delayed complex esophageal disruptions. Ann Thorac Surg
2008;85(6):1962—7 [discussion 7].
[36] Salminen P, Gullichsen R, Laine S. Use of self-expandable metal
stents for the treatment of esophageal perforations and anas-
tomotic leaks. Surg Endosc 2009;23(7):1526—30.
[37] Tuebergen D, Rijcken E, Mennigen R, Hopkins AM, Senninger
N, Bruewer M. Treatment of thoracic esophageal anasto-
motic leaks and esophageal perforations with endoluminal
stents: efficacy and current limitations. J Gastrointest Surg
2008;12(7):1168—76.
[38] Johnsson E, Lundell L, Liedman B. Sealing of esophageal
perforation or ruptures with expandable metallic stents: a
prospective controlled study on treatment efficacy and limi-
tations. Dis Esophagus 2005;18(4):262—6.
[39] Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt
UT. Nonoperative treatment of 15 benign esophageal perfora-
tions with self-expandable covered metal stents. Ann Thorac
Surg 2006;81(2):467—72.
[40] Gelbmann CM, Ratiu NL, Rath HC, Rogler G, Lock G,
Scholmerich J, et al. Use of self-expandable plastic stents
for the treatment of esophageal perforations and symptomatic
anastomotic leaks. Endoscopy 2004;36(8):695—9.
[41] Siersema PD, Homs MY, Haringsma J, Tilanus HW, Kuipers EJ.
Use of large-diameter metallic stents to seal traumatic non-
malignant perforations of the esophagus. Gastrointest Endosc
2003;58(3):356—61.
[42] Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW. Endo-
scopic clips for closing esophageal perforations: case report
and pooled analysis. Gastrointest Endosc 2007;66(3):605—11.
[43] Rabago LR, Castro JL, Joya D, Herrera N, Gea F, Mora P, et al.
[Esophageal perforation and postoperative fistulae of the upper
digestive tract treated endoscopically with the application of
Tissucol]. Gastroenterol Hepatol 2000;23(2):82—6.
[44] Fischer A, Schrag HJ, Goos M, von Dobschuetz E, Hopt UT.
Nonoperative treatment of four esophageal perforations with
hemostatic clips. Dis Esophagus 2007;20(5):444—8.
[45] Yeginsu A, Ergin M, Erkorkmaz U. Strength of esophageal clo-
sure techniques with and without tissue reinforcement. World
J Surg 2007;31(7):1445—8.
[46] Vallböhmer D, Hölscher AH, Hölscher M, Bludau M, Gutschow
C, Stippel D, et al. Options in the management of esophageal
perforation: analysis over a 12-year period. Dis Esophagus
2010;23(3):185—90.
[47] Cho S, Jheon S, Ryu KM, Lee EB. Primary esophageal repair in
Boerhaave’s syndrome. Dis Esophagus 2008;21(7):660—3.
[48] Erdogan A, Gurses G, Keskin H, Demircan A. The sealing effect
of a fibrin tissue patch on the esophageal perforation area in
primary repair. World J Surg 2007;31(11):2199—203.
[49] Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF. Pri-
mary esophageal repair for Boerhaave’s syndrome whatever
the free interval between perforation and treatment. Eur J
Cardiothorac Surg 2004;25(4):475—9.
[50] Gupta NM, Kaman L. Personal management of 57 con-
secutive patients with esophageal perforation. Am J Surg
2004;187(1):58—63.
[51] Okten I, Cangir AK, Ozdemir N, Kavukcu S, Akay H,
Yavuzer S. Management of esophageal perforation. Surg Today
2001;31(1):36—9.
e128
[52] Braghetto I, Rodriguez A, Csendes A, Korn O. [An update on
esophageal perforation]. Rev Med Chil 2005;133(10):1233—41.
[53] Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic
esophageal perforations: a decade of experience. Ann Thorac
Surg 2003;75(4):1071—4.
[54] Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo
pleural wrap procedure in 18 patients with perforation of the
thoracic esophagus. Ann Surg 1989;209(5):612—7 [discussion
7—9].
[55] Kotzampassakis N, Christodoulou M, Krueger T, Demartines N,
Vuillemier H, Cheng C, et al. Esophageal leaks repaired by a
muscle onlay approach in the presence of mediastinal sepsis.
Ann Thorac Surg 2009;88(3):966—72.
[56] Linden PA, Bueno R, Mentzer SJ, Zellos L, Lebenthal A, Colson
YL, et al. Modified T-tube repair of delayed esophageal perfo-
ration results in a low mortality rate similar to that seen with
acute perforations. Ann Thorac Surg 2007;83(3):1129—33.
[57] Urschel Jr HC, Razzuk MA, Wood RE, Galbraith N, Pockey
M, Paulson DL. Improved management of esophageal per-
foration: exclusion and diversion in continuity. Ann Surg
1974;179(5):587—91.
M. Chirica et al.
[58] Orringer MB, Stirling MC. Esophagectomy for esophageal dis-
ruption. Ann Thorac Surg 1990;49(1):35—42 [discussion —3].
[59] Freeman RK, Ascioti AJ, Wozniak TC. Postoperative esophageal
leak management with the Polyflex esophageal stent. J Thorac
Cardiovasc Surg 2007;133(2):333—8.
[60] Kollmar O, Lindemann W, Richter S, Steffen I, Pis-
torius G, Schilling MK. Boerhaave’s syndrome: primary
repair vs. esophageal resection–case reports and meta-
analysis of the literature. J Gastrointest Surg 2003;7(6):
726—34.
[61] Sanchez-Pernaute A, Aguirre EP, Talavera P, Valladares
LD, de la Serna JP, Mantilla CS, et al. Laparoscopic
approach to esophageal perforation secondary to pneu-
matic dilation for achalasia. Surg Endosc 2009;23(5):
1106—9.
[62] Di Franco F, Lamb PJ, Karat D, Hayes N, Griffin SM. Iatro-
genic perforation of localized oesophageal cancer. Br J Surg
2008;95(7):837—9.
[63] Sung SW, Park JJ, Kim YT, Kim JH. Surgery in thoracic
esophageal perforation: primary repair is feasible. Dis Esopha-
gus 2002;15(3):204—9.