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Multidisciplinary Approaches to Common Surgical Problems pp 323–339Cite as

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

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Abstract

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.

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  1. Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA

    Mia DeBarros & Daniel G. Cuadrado

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  1. Department of Surgery, Tripler Army Medical Center, Honolulu, HI, USA

    Robert Lim

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DeBarros, M., Cuadrado, D.G. (2019). Esophageal Obstruction and Perforation: Incidence, Etiologies, Presentation, and Management. In: Lim, R. (eds) Multidisciplinary Approaches to Common Surgical Problems. Springer, Cham. https://doi.org/10.1007/978-3-030-12823-4_33

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