Medical management of iatrogenic esophageal perforations

Opinion statement

Esophageal perforation is an uncommon, potentially disastrous occurrence with high mortality rates even when managed with surgery. Over the past few decades, several case series have shown that nonoperative management is a feasible option in some patients, although the criteria for selecting such patients are neither firmly established nor accepted by all those who manage these critical patients. The decision to manage a patient without surgery should be made collaboratively with a surgeon. No single criterion, with the possible exception of sepsis and shock, mandates surgical management. Randomized, prospective studies comparing surgical and nonsurgical therapy have not been performed. Factors that can affect the decision to proceed nonoperatively include the perforation’s site and size, the patient’s underlying comorbidities, and the patient’s hemodynamic status on presentation. Healthy patients with small, contained perforations who present without sepsis tend to be the best candidates for nonoperative management. Intravenous antibiotics and cessation of oral intake should be instituted immediately, even before confirming the diagnosis. Mediastinal fluid collections and pleural effusions often coexist with esophageal perforations and must be managed concomitantly. Percutaneously placed drains are an important adjunct to therapy when collections are identified. Endoscopic stenting has been introduced as a means to seal the perforation. After embarking on a nonoperative course, patients still may deteriorate and require surgery, so close follow-up is warranted for every patient. When proper nonoperative management strategies are followed, outcomes have been shown to be at least equivalent to those of surgical management in most series. In this review, the principles of patient selection and medical therapy for iatrogenic esophageal perforations are discussed.