World Journal of Surgery

, Volume 38, Issue 5, pp 1093–1099 | Cite as

Management of Thoracic Esophageal Perforation

  • Yidan Lin
  • Guangliang Jiang
  • Lunxu Liu
  • Jack Xiwen Jiang
  • Longqi Chen
  • Yongfan Zhao
  • Junjie Yang



The aim of this study was to characterize an optimal strategy in managing thoracic esophageal perforation, focusing on the differential diagnosis and treatment of patients with contained versus noncontained perforations and on the importance of the time interval between injury and repair and how that affects the outcome of a primary repair.


A retrospective study was conducted. A strict definition of contained or noncontained perforation was based on a combination of esophagography, chest CT scan, and endoscopy as well as monitoring systemic symptoms. Management options for our cohort included conservative therapy, primary repair and debridement, esophagectomy, and mesh-covered stents. Patients were stratified into two groups according to the time interval after injury: ≤48-h group and >48-h group.


Between January 1997 and January 2013, a total of 66 consecutive patients (47 males and 19 females, mean age = 49.1 ± 16.2 years) were treated for thoracic esophageal perforation. Perforation was confirmed by esophagography in 51 patients and by endoscopy in 15 patients. Eighteen patients were assigned to the contained perforation group. All these patients were successfully cured without surgery. The noncontained group included 48 patients; its mortality rate was 7.7 % (3/39) with surgery and 55.6 % (5/9) with stent placement. Compared with the contained group, the noncontained group had a significantly longer length of stay (LOS) (16 ± 3.2 vs. 26.3 ± 18.7 days; p < 0.05) and a higher mortality rate (0 vs. 22.9 %, p < 0.05). In the two time-interval groups, patient characteristics, including age, gender, and comorbidities, etiologic cause, length and location of the perforation, and the incidence of using tissue buttress were similar (p > 0.05). The incidence of postoperative leak was significantly higher in >48-h group (0 in ≤48-h group vs. 37.5 % in >48-h group; p < 0.01). In addition, the >48-h group had a significantly longer LOS (18.0 ± 9.1 days in ≤48-h group vs. 31.5 ± 18.6 days in >48-h group; p < 0.01). The two deaths occurred in the >48-h group (0 in ≤48-h group vs. 12.5 % in >48-h group; p > 0.05) due to postoperative leaks.


Contained or noncontained perforation should be rigorously differentiated. Then, for a contained perforation, conservative therapy coupled with repeated imaging is reasonable treatment. For a noncontained perforation, a primary repair can be safely performed within 48 h after injury. After that, a primary repair is still reasonable but is associated with an increased risk of postoperative leaks.


  1. 1.
    Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC (2004) Evolving options in the management of esophageal perforation. Ann Thorac Surg 77(4):1475–1483PubMedCrossRefGoogle Scholar
  2. 2.
    Eroglu A, Can Kurkcuogu I, Karaoganogu N, Tekinbas C, Yimaz O, Basog M (2004) Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus 17(1):91–94PubMedCrossRefGoogle Scholar
  3. 3.
    Vallbohmer D, Holscher AH, Holscher M, Bludau M, Gutschow C, Stippel D, Bollschweiler E, Schroder W (2010) Options in the management of esophageal perforation: analysis over a 12-year period. Dis Esophagus 23(3):185–190PubMedCrossRefGoogle Scholar
  4. 4.
    Bladergroen MR, Lowe JE, Postlethwait RW (1986) Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 42(3):235–239PubMedCrossRefGoogle Scholar
  5. 5.
    Zhu ZJ, Zhao YF, Chen LQ, Hu Y, Liu LX, Wang Y, Kou YL (2008) Clinical application of layered anastomosis during esophagogastrostomy. World J Surg 32(4):583–588. doi:10.1007/s00268-007-9396-5 Google Scholar
  6. 6.
    Foley MJ, Ghahremani GG, Rogers LF (1982) Reappraisal of contrast media used to detect upper gastrointestinal perforations: comparison of ionic water-soluble media with barium sulfate. Radiology 144(2):231–237PubMedGoogle Scholar
  7. 7.
    Backer CL, LoCicero J III, Hartz RS, Donaldson JS, Shields T (1990) Computed tomography in patients with esophageal perforation. Chest 98(5):1078–1080PubMedCrossRefGoogle Scholar
  8. 8.
    Horwitz B, Krevsky B, Buckman RF Jr, Fisher RS, Dabezies MA (1993) Endoscopic evaluation of penetrating esophageal injuries. Am J Gastroenterol 88(8):1249–1253PubMedGoogle Scholar
  9. 9.
    Minnich DJ, Yu P, Bryant AS, Jarrar D, Cerfolio RJ (2011) Management of thoracic esophageal perforations. Eur J Cardiothorac Surg 40(4):931–937PubMedGoogle Scholar
  10. 10.
    Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK (2003) Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 75(4):1071–1074PubMedCrossRefGoogle Scholar
  11. 11.
    Sung SW, Park JJ, Kim YT, Kim JH (2002) Surgery in thoracic esophageal perforation: primary repair is feasible. Dis Esophagus 15(3):204–209PubMedCrossRefGoogle Scholar
  12. 12.
    Freeman RK, Ascioti AJ (2011) Esophageal stent placement for the treatment of perforation, fistula, or anastomotic leak. Semin Thorac Cardiovasc Surg 23(2):154–158PubMedCrossRefGoogle Scholar
  13. 13.
    Altorjay A, Kiss J, Voros A, Sziranyi E (1998) The role of esophagectomy in the management of esophageal perforations. Ann Thorac Surg 65(5):1433–1436PubMedCrossRefGoogle Scholar
  14. 14.
    Skinner DB, Little AG, DeMeester TR (1980) Management of esophageal perforation. Am J Surg 139(6):760–764PubMedCrossRefGoogle Scholar
  15. 15.
    Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS (1990) Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 50(1):45–49 discussion 50–41PubMedCrossRefGoogle Scholar
  16. 16.
    Flynn AE, Verrier ED, Way LW, Thomas AN, Pellegrini CA (1989) Esophageal perforation. Arch Surg 124(10):1211–1214 discussion 1214–1215PubMedCrossRefGoogle Scholar
  17. 17.
    Whyte RI, Iannettoni MD, Orringer MB (1995) Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg 109(1):140–144 discussion 144–146PubMedCrossRefGoogle Scholar
  18. 18.
    Hendren WH, Henderson BM (1968) Immediate esophagectomy for instrumental perforation of the thoracic esophagus. Ann Surg 168(6):997–1003PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Jones WG II, Ginsberg RJ (1992) Esophageal perforation: a continuing challenge. Ann Thorac Surg 53(3):534–543PubMedCrossRefGoogle Scholar
  20. 20.
    Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT (2006) Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 81(2):467–473PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Yidan Lin
    • 1
  • Guangliang Jiang
    • 1
  • Lunxu Liu
    • 1
  • Jack Xiwen Jiang
    • 2
  • Longqi Chen
    • 1
  • Yongfan Zhao
    • 1
  • Junjie Yang
    • 1
  1. 1.Department of Thoracic Surgery, West China HospitalWest China Medical School of Sichuan UniversityChengduChina
  2. 2.Division of Thoracic Surgery, Perelman School of Medicine University of PennsylvaniaPhiladelphiaUSA

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