Skip to main content

Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort



Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.


Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.


Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).


Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004 77(4):1475-83.

    Article  PubMed  Google Scholar 

  2. Lampridis S, Mitsos S, Hayward M, Lawrence D, Panagiotopoulos N. The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions. J Thorac Dis. 2020 12(5):2724-2734.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nesbitt JC, Sawyers JL. Surgical management of esophageal perforation . Am Surg. 1987;53:183-191.

    CAS  PubMed  Google Scholar 

  4. Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intratho-racic esophageal disruptions. Ann Thorac Surg 1979;27:404-8.

    Article  CAS  PubMed  Google Scholar 

  5. Sohda M, Kuwano H, Sakai M, Miyazaki T, Kakeji Y, Toh Y, Matsubara H. A national survey on esophageal perforation: study of cases at accredited institutions by the Japanese Esophagus Society. Esophagus. 2020 17(3):230-238. Epub 2020 May 15.

    Article  PubMed  Google Scholar 

  6. Skinner DB, Little AG, DeMeester TR. Management of esophageal perforation . Am J Surg. 1980;139:760-764.

    Article  CAS  PubMed  Google Scholar 

  7. Freeman RK, Ascioti AJ, Giannini T, Mahidhara RJ. Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak. Ann Thorac Surg. 2012; 94(3):959-64;

    Article  PubMed  Google Scholar 

  8. Raff LA, Schinnerer EA, Maine RG, Jansen J, Noorbakhsh MR, Spigel Z, Campion E, Coleman J, Saquib S, Carroll JT, Jacobson LE, Williams J, Young AJ, Pascual J, Burruss S, Gordon D, Robinson BRH, Nahmias J, Kutcher ME, Bugaev N, Jeyamurugan K, Bosarge P. Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study. J Trauma Acute Care Surg. 2020 89(4):691-697.

    Article  PubMed  Google Scholar 

  9. Sdralis EIK, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Dis Esophagus. 2017;30(8):1-6.

    Article  PubMed  Google Scholar 

  10. Herrera A, Freeman RK. The Evolution and Current Utility of Esophageal Stent Placement for the Treatment of Acute Esophageal Perforation. Thorac Surg Clin. 2016 26(3):305-14

    Article  PubMed  Google Scholar 

  11. Thornblade LW, Cheng AM, Wood DE, et al. A Nationwide Rise in the Use of Stents for Benign Esophageal Perforation. Ann Thorac Surg. 2017;104(1):227-233.

    Article  PubMed  PubMed Central  Google Scholar 

  12. David EA, Kim MP, Blackmon SH.Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage. Am J Surg. 2011 202(6):796-801

    Article  PubMed  Google Scholar 

  13. Dickinson KJ, Buttar N, Wong Kee Song LM, Gostout CJ, Cassivi SD, Allen MS, Nichols FC, Shen KR, Wigle DA, Blackmon SH.Utility of endoscopic therapy in the management of Boerhaave syndrome. Endosc Int Open. 2016 4(11):E1146-E1150

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Eroglu A, Turkyilmaz A, Aydin Y, Yekeler E, Karaoglanoglu N. Current management of esophageal perforation: 20 years experience. Dis Esophagus. 2009;22(4):374-380.

    Article  CAS  PubMed  Google Scholar 

  15. Ceppa DP, Rosati CM, Chabtini L, et al. Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies. Ann Thorac Surg. 2017;104(3):1054-1061.

    Article  PubMed  Google Scholar 

  16. Connelly CL, Lamb PJ, Paterson-Brown S. Outcomes following Boerhaave's syndrome. Ann R Coll Surg Engl. 2013;95(8):557-560.

    CAS  PubMed  PubMed Central  Google Scholar 

  17. Axtell AL, Gaissert HA, Morse CR, Premkumar A, Schumacher L, Muniappan A, Ott H, Allan JS, Lanuti M, Mathisen DJ, Wright CD. Management and outcomes of esophageal perforation. Dis Esophagus. 2022.

  18. Amir AI, van Dullemen H, Plukker JT. Selective approach in the treatment of esophageal perforations. Scand J Gastroenterol. 2004;39(5):418-422.

    Article  CAS  PubMed  Google Scholar 

  19. Huu Vinh V, Viet Dang Quang N, Van Khoi N. Surgical management of esophageal perforation: role of primary closure. Asian Cardiovasc Thorac Ann. 2019;27(3):192-198. Epub 2019 Jan 21.

    Article  PubMed  Google Scholar 

  20. Muir AD, White J, McGuigan JA, McManus KG, Graham AN. Treatment and outcomes of oesophageal perforation in a tertiary referral centre. Eur J Cardiothorac Surg. 2003;23(5):799-804; discussion 804.

    Article  CAS  PubMed  Google Scholar 

  21. Markar SR, Mackenzie H, Wiggins T, et al. Management and Outcomes of Esophageal Perforation: A National Study of 2,564 Patients in England. Am J Gastroenterol. 2015;110(11):1559-1566.

    Article  PubMed  Google Scholar 

  22. Horwitz B, Krevsky B, Buckman RF, Fisher RS, Dabezies MA. Endoscopic evaluation of penetrating esophageal injuries. Am J Gastroenterol. 1993;88(8):1249-1253.

    CAS  PubMed  Google Scholar 

  23. Sudarshan M, Elharram M, Spicer J, Mulder D, Ferri LE. Management of esophageal perforation in the endoscopic era: Is operative repair still relevant? Surgery. 2016;160(4):1104-1110.

    Article  PubMed  Google Scholar 

Download references


American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Lye-Yeng Wong.

Ethics declarations

Conflicts of Interest

The authors have no conflicts of interest or funding sources related to this manuscript. All listed authors contributed substantially to the design, drafting, approval, and accountability of this work. Word count: 4,737

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This project has been presented as a poster at the General Thoracic Surgical Club’s 34th Annual Meeting, Bonita Springs, FL, March 10-13, 2022

Supplementary information


(DOCX 13 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wong, LY., Leipzig, M., Liou, D.Z. et al. Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort. J Gastrointest Surg 27, 1757–1765 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: