Esophageal Obstruction and Perforation: Incidence, Etiologies, Presentation, and Management

  • Mia DeBarrosEmail author
  • Daniel G. Cuadrado


Esophageal perforation or obstruction is overall a rare but serious entity with mortality rates as high as 30%. Often discussed but rarely encountered, it requires correct and complex decision-making to ensure an optimal outcome for the patient. Throughout the literature, it is difficult to find all-encompassing discussions on esophageal perforation or obstruction and its management. Esophageal obstruction is broadly divided into benign and malignant etiologies. Overall, the most common etiology is for benign causes such as caustic ingestions, foreign body impactions, strictures, dysmotility, and hernias. Perforation is most commonly iatrogenic occurring during instrumentation of the esophagus; however there is typically an underlying associated pathology.

The acute management of esophageal perforation is dictated by location of the injury, underlying comorbid conditions, and the level of physiologic derangement. Presentation of perforation is varied, non-specific, and dependent on location. The gold standard for imaging is thin barium esophagram, but CT chest is an excellent alternative. Surgical repair of perforation involves circumferential dissection and mobilization with full exposure of the perforation via myotomy. The approach depends on the level of perforation. The repair should be buttressed with tissue such as muscle flap, pericardial fat pad, or pleura. Perforations secondary to malignancy should be approached with caution, and definitive oncological resection should not be undertaken in the same procedure; instead temporizing measures are preferred. Esophageal diversion is becoming less common. In hemodynamically unstable patients, with a large defect or nonviable esophageal tissue, diversion or resection with discontinuity may serve as a damage control option.

Obstructions are initially managed with securing the airway and then using diagnostic imaging to determine the cause. Food impaction is managed endoscopically or pharmacologically. Malignant obstruction management requires a multimodal approach, and primary resection should not to be undertaken in the acute care setting due to frailty in the majority of this patient population. Chronic obstructive pathology such as strictures and dysmotility disorders is primarily managed with endoscopy with surgical intervention reserved for young, fit patients or those who fail endoscopic therapy.

The purpose of this chapter is to provide a discussion on basic anatomy and physiology of the esophagus and the etiology of obstruction and perforation. The presentation of acute and chronic esophageal perforations and obstruction, as well as the management of each entity, will also be discussed.


Esophageal perforation Esophageal obstruction Esophageal trauma Esophageal dysmotility Strictures 


  1. 1.
    Oezcelik A, DeMeester SR. General anatomy of the esophagus. Thorac Surg Clin. 2011;21(2):289–97. xPubMedCrossRefGoogle Scholar
  2. 2.
    Patel D, Vaezi MF. Normal esophageal physiology and laryngopharyngeal reflux. Otolaryngol Clin N Am. 2013;46(6):1023–41.CrossRefGoogle Scholar
  3. 3.
    Rice TW, Bronner MP. The esophageal wall. Thorac Surg Clin. 2011;21(2):299–305, x.PubMedCrossRefGoogle Scholar
  4. 4.
    Torre LA, Siegel RL, Ward EM, Jemal A. Global cancer incidence and mortality rates and trends – an update. Cancer Epidemiol Biomark Prev. 2016;25(1):16–27.CrossRefGoogle Scholar
  5. 5.
    Lagergren J, Smyth E, Cunningham D, Lagergren P. Oesophageal cancer. Lancet. 2017;390(10110):2383–96.PubMedCrossRefGoogle Scholar
  6. 6.
    Bharat A, Crabtree T. Management of advanced-stage operable esophageal cancer. Surg Clin North Am. 2012;92(5):1179–97.PubMedCrossRefGoogle Scholar
  7. 7.
    Smith CD. Esophageal strictures and diverticula. Surg Clin North Am. 2015;95(3):669–81.PubMedCrossRefGoogle Scholar
  8. 8.
    Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th annual report. Clin Toxicol (Phila). 2017;55(10):1072–252.CrossRefGoogle Scholar
  9. 9.
    Kurowski JA, Kay M. Caustic ingestions and foreign bodies ingestions in pediatric patients. Pediatr Clin N Am. 2017;64(3):507–24.CrossRefGoogle Scholar
  10. 10.
    Triadafilopoulos G, Roorda A, Akiyama J. Update on foreign bodies in the esophagus: diagnosis and management. Curr Gastroenterol Rep. 2013;15(4):317.PubMedCrossRefGoogle Scholar
  11. 11.
    Stavropoulos SN, Friedel D, Modayil R, Parkman HP. Diagnosis and management of esophageal achalasia. BMJ. 2016;354:i2785.PubMedCrossRefGoogle Scholar
  12. 12.
    Uppal DS, Wang AY. Update on the endoscopic treatments for achalasia. World J Gastroenterol. 2016;22(39):8670–83.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Bowers SP. Esophageal motility disorders. Surg Clin North Am. 2015;95(3):467–82.PubMedCrossRefGoogle Scholar
  14. 14.
    Pregun I, Hritz I, Tulassay Z, Herszenyi L. Peptic esophageal stricture: medical treatment. Dig Dis. 2009;27(1):31–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Andolfi C, Jalilvand A, Plana A, Fisichella PM. Surgical treatment of paraesophageal hernias: a review. J Laparoendosc Adv Surg Tech A. 2016;26(10):778–83.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Schieman C, Grondin SC. Paraesophageal hernia: clinical presentation, evaluation, and management controversies. Thorac Surg Clin. 2009;19(4):473–84.PubMedCrossRefGoogle Scholar
  17. 17.
    Rashid F, Thangarajah T, Mulvey D, Larvin M, Iftikhar SY. A review article on gastric volvulus: a challenge to diagnosis and management. Int J Surg. 2010;8(1):18–24.PubMedCrossRefGoogle Scholar
  18. 18.
    Muller M, Gockel I, Hedwig P, Eckardt AJ, Kuhr K, Konig J, et al. Is the Schatzki ring a unique esophageal entity? World J Gastroenterol. 2011;17(23):2838–43.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Furuta GT, Katzka DA. Eosinophilic esophagitis. N Engl J Med. 2015;373(17):1640–8.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Hiremath GS, Hameed F, Pacheco A, Olive A, Davis CM, Shulman RJ. Esophageal food impaction and eosinophilic esophagitis: a retrospective study, systematic review, and meta-analysis. Dig Dis Sci. 2015;60(11):3181–93.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin N Am. 2014;43(2):201–18.CrossRefGoogle Scholar
  22. 22.
    Polguj M, Chrzanowski L, Kasprzak JD, Stefanczyk L, Topol M, Majos A. The aberrant right subclavian artery (arteria lusoria): the morphological and clinical aspects of one of the most important variations – a systematic study of 141 reports. Sci World J. 2014;2014:292734.CrossRefGoogle Scholar
  23. 23.
    Okumus M, Ozkan F, Bozkurt S, Dogan M, Tokur M, Kapci M. Arteria lusoria: a very rare cause of esophageal obstruction in a hypoxemic patient. Turk J Gastroenterol. 2014;25(4):433–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Petrone P, Kassimi K, Jimenez-Gomez M, Betancourt A, Axelrad A, Marini CP. Management of esophageal injuries secondary to trauma. Injury. 2017;48(8):1735–42.PubMedCrossRefGoogle Scholar
  25. 25.
    Kaman L, Iqbal J, Kundil B, Kochhar R. Management of Esophageal Perforation in adults. Gastroenterology Res. 2010;3(6):235–44.PubMedPubMedCentralGoogle Scholar
  26. 26.
    de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave’s syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009;26(1):1–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Aiolfi A, Inaba K, Recinos G, Khor D, Benjamin ER, Lam L, et al. Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank. World J Emerg Surg. 2017;12:19.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Hurtgen M, Herber SC. Treatment of malignant tracheoesophageal fistula. Thorac Surg Clin. 2014;24(1):117–27.PubMedCrossRefGoogle Scholar
  29. 29.
    Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am. 2003;13(2):271–89.PubMedCrossRefGoogle Scholar
  30. 30.
    Zhou C, Hu Y, Xiao Y, Yin W. Current treatment of tracheoesophageal fistula. Ther Adv Respir Dis. 2017;11(4):173–80.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Nirula R. Esophageal perforation. Surg Clin North Am. 2014;94(1):35–41.PubMedCrossRefGoogle Scholar
  32. 32.
    Obeso Carillo GA, Blanco Ramos M, Garcia Fontan EM, Perez Pedrosa A, Gil Gil P. Perforated pharyngoesophageal diverticulum as a cause of cervical infection with mediastinal extension. Cir Esp. 2012;90(8):533–5.PubMedCrossRefGoogle Scholar
  33. 33.
    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.PubMedCrossRefGoogle Scholar
  34. 34.
    Cheng Q, Liu B. Treatment of cervical esophageal perforation. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi (Journal of Clinical Otorhinolaryngology, Head, and Neck Surgery). 2013;27(18):989–90, 94.Google Scholar
  35. 35.
    Zenga J, Kreisel D, Kushnir VM, Rich JT. Management of cervical esophageal and hypopharyngeal perforations. Am J Otolaryngol. 2015;36(5):678–85.PubMedCrossRefGoogle Scholar
  36. 36.
    Mann W, Munker G. Drainage of deep mediastinal infections following perforation of the cervical esophagus (author’s transl). HNO. 1975;23(11):355–7.PubMedGoogle Scholar
  37. 37.
    Nakano T, Onodera K, Ichikawa H, Kamei T, Taniyama Y, Sakurai T, et al. Thoracoscopic primary repair with mediastinal drainage is a viable option for patients with Boerhaave’s syndrome. J Thorac Dis. 2018;10(2):784–9.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Pezzetta E, Kokudo T, Uldry E, Yamaguchi T, Kudo H, Ris HB, et al. The surgical management of spontaneous esophageal perforation (Boerhaave’s syndrome) 20 years of experience. Biosci Trends. 2016;10(2):120–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation: emphasis on management. Ann Thorac Surg. 1996;61(5):1447–51; discussion 51–2.PubMedCrossRefGoogle Scholar
  40. 40.
    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; discussion 64–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Nakabayashi T, Kudo M, Hirasawa T, Kuwano H. Successful late management of esophageal perforation with T-tube drainage. Case Rep Gastroenterol. 2008;2(1):67–70.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Naylor AR, Walker WS, Dark J, Cameron EW. T tube intubation in the management of seriously ill patients with oesophagopleural fistulae. Br J Surg. 1990;77(1):40–2.PubMedCrossRefGoogle Scholar
  43. 43.
    Abu-Daff S, Shamji F, Ivanovic J, Villeneuve PJ, Gilbert S, Maziak DE, et al. Esophagectomy in esophageal perforations: an analysis. Dis Esophagus. 2016;29(1):34–40.PubMedCrossRefGoogle Scholar
  44. 44.
    Seo YD, Lin J, Chang AC, Orringer MB, Lynch WR, Reddy RM. Emergent esophagectomy for esophageal perforations: a safe option. Ann Thorac Surg. 2015;100(3):905–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Bekkerman M, Sachdev AH, Andrade J, Twersky Y, Iqbal S. Endoscopic management of foreign bodies in the gastrointestinal tract: a review of the literature. Gastroenterol Res Pract. 2016;2016:8520767.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Ko HH, Enns R. Review of food bolus management. Can J Gastroenterol. 2008;22(10):805–8.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Khayyat YM. Pharmacological management of esophageal food bolus impaction. Emerg Med Int. 2013;2013:924015.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G, et al. Oral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e44S–88S.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Committee ASoP, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085–91.CrossRefGoogle Scholar
  50. 50.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87–108.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Kinsinger S. Elevated cancer risk perceptions among patients with Barrett’s esophagus: do psychological factors play a role? Dis Esophagus. 2018;31(4).Google Scholar
  52. 52.
    Spechler S. Barrett esophagus and risk of esophageal cancer: a clinical review. JAMA. 2013;310(6):627–36.PubMedCrossRefGoogle Scholar
  53. 53.
    Thrift AP. Barrett’s esophagus and esophageal adenocarcinoma: how common are they really? Dig Dis Sci. 2018;63(8):1988–96.PubMedCrossRefGoogle Scholar
  54. 54.
    Lim H, Kim DH, Jung HY, Gong EJ, Na HK, Ahn JY, et al. Clinical significance of early detection of esophageal cancer in patients with head and neck cancer. Gut Liver. 2015;9(2):159–65.PubMedCrossRefGoogle Scholar
  55. 55.
    Dewys WD, Begg C, Lavin PT, Band PR, Bennett JM, Bertino JR, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980;69(4):491–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Yang CW, Lin HH, Hsieh TY, Chang WK. Palliative enteral feeding for patients with malignant esophageal obstruction: a retrospective study. BMC Palliat Care. 2015;14:58.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med. 1993;329(18):1302–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Cwikiel M, Cwikiel W, Albertsson M. Palliation of dysphagia in patients with malignant esophageal strictures. Comparison of results of radiotherapy, chemotherapy and esophageal stent treatment. Acta oncologica (Stockholm, Sweden). 1996;35(1):75–9.CrossRefGoogle Scholar
  59. 59.
    Dai Y, Li C, Xie Y, Liu X, Zhang J, Zhou J, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014;10:Cd005048.Google Scholar
  60. 60.
    Dicle O, Goktay AY, Akbaylar H. Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents. Eur Radiol. 1999;9(7):1418–22.PubMedCrossRefGoogle Scholar
  61. 61.
    Bassi M, Luigiano C, Fabbri C, Ferrara F, Ghersi S, Alibrandi A, et al. Large diameter fully covered self-expanding metal stent placement for palliation of proximal malignant esophageal strictures. Dis Esophagus. 2015;28(6):579–84.PubMedCrossRefGoogle Scholar
  62. 62.
    Iwasaki H, Mizushima T, Suzuki Y, Fukusada S, Kachi K, Ozeki T, et al. Factors that affect stent-related complications in patients with malignant obstruction of the esophagus or gastric cardia. Gut Liver. 2017;11(1):47–54.PubMedCrossRefGoogle Scholar
  63. 63.
    Wang MQ, Sze DY, Wang ZP, Wang ZQ, Gao YA, Dake MD. Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas. J Vasc Interv Radiol (JVIR). 2001;12(4):465–74.CrossRefGoogle Scholar
  64. 64.
    Homann N, Noftz MR, Klingenberg-Noftz RD, Ludwig D. Delayed complications after placement of self-expanding stents in malignant esophageal obstruction: treatment strategies and survival rate. Dig Dis Sci. 2008;53(2):334–40.PubMedCrossRefGoogle Scholar
  65. 65.
    Sumiyoshi T, Gotoda T, Muro K, Rembacken B, Goto M, Sumiyoshi Y, et al. Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy. Gastrointest Endosc. 2003;57(7):882–5.PubMedCrossRefGoogle Scholar
  66. 66.
    Poincloux L, Sautel C, Rouquette O, Pereira B, Goutte M, Bommelaer G, et al. The clinical outcome in patients treated with a newly designed SEMS in cervical esophageal strictures and fistulas. J Clin Gastroenterol. 2016;50(5):379–87.PubMedGoogle Scholar
  67. 67.
    Lian JJ, Ma LL, Hu JW, Chen SY, Qin WZ, Xu MD, et al. Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms. J Dig Dis. 2014;15(5):224–9.PubMedCrossRefGoogle Scholar
  68. 68.
    Zehetner J, DeMeester SR, Ayazi S, Demeester TR. Home self-dilatation for esophageal strictures. Dis Esophagus. 2014;27(1):1–4.PubMedCrossRefGoogle Scholar
  69. 69.
    Suzuki T, Siddiqui A, Taylor LJ, Cox K, Hasan RA, Laique SN, et al. Clinical outcomes, efficacy, and adverse events in patients undergoing esophageal stent placement for benign indications: a large multicenter study. J Clin Gastroenterol. 2016;50(5):373–8.PubMedGoogle Scholar
  70. 70.
    Clayton SB, Castell DO. Multiple good options are available for achalasia management. J Clin Gastroenterol. 2015;49(3):194–8.PubMedCrossRefGoogle Scholar
  71. 71.
    Pandolfino JE, Gawron AJ. Achalasia: a systematic review. JAMA. 2015;313(18):1841–52.PubMedPubMedCentralCrossRefGoogle Scholar
  72. 72.
    Patti MG, Fisichella PM. Controversies in management of achalasia. J Gastrointest Surg. 2014;18(9):1705–9.PubMedCrossRefGoogle Scholar
  73. 73.
    Polguj M, Chrzanowski L, Kasprzak JD, Stefanczyk L, Topol M, Majos A. The aberrant right subclavian artery (arteria lusoria): the morphological and clinical aspects of one of the most important variations–a systematic study of 141 reports. ScientificWorldJournal. 2014;2014:292734.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    von Segesser L, Faidutti B. Symptomatic aberrant retro-esophageal subclavian artery: considerations about the surgical approach, management and results. Thorac Cardiovasc Surg. 1984;32(5):307–10.CrossRefGoogle Scholar
  75. 75.
    Tanaka A, Milner R, Ota T. Kommerell’s diverticulum in the current era: a comprehensive review. Gen Thorac Cardiovasc Surg. 2015;63(5):245–59.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of SurgeryMadigan Army Medical CenterTacomaUSA

Personalised recommendations