Esophageal perforation poses a significant interdisciplinary challenge to the entire therapeutic team. It can occur in three different anatomical compartments and therefore presents with diverse symptoms; most of them are highly non-specific which can significantly delay the time between perforation and final diagnosis. Despite the marked improvement in the availability of diagnostic techniques and therapeutic approaches, esophageal perforation remains a direct life-threatening condition with mortality rates reaching as high as 50%. The frequency of esophageal perforation is 3 in 100,000 in the United States, with intrathoracic perforations being most common (54%) followed by cervical esophagus perforations (27%), then intra-abdominal perforations (19%).
The esophagus is a 25-cm long fibromuscular tube that connects the pharynx to the stomach. It starts in the neck at the level of C6 vertebra, extending through the mediastinum until its insertion in the diaphragm at the level T10 vertebra via a separate opening in the right crus of the diaphragm. Along its vertical course, the esophagus has three constrictions:
The esophagus is divided into three portions:
Iatrogenic perforations are a group of perforations caused by instrumentation for diagnostic or therapeutic purposes. Diagnostic endoscopy, performed almost exclusively with flexible endoscopes, carries a low risk of perforation; however, therapeutic interventions such as pneumatic dilation, hemostasis, stent placement, foreign body extraction, cancer palliation, and endoscopic ablation techniques can dramatically increase the risk of perforation. Iatrogenic perforation is common in the hypopharynx or the distal esophagus while spontaneous rupture may occur in the posterolateral wall of the esophagus just above its diaphragmatic hiatus. Despite being rare overall, iatrogenic esophageal perforations can also be the result of invasive surgical maneuvers, with fundoplication and esophageal myotomy being the most common operations associated with the complication.
Esophageal perforation occurs in 3 in 100,000 people in the United States. Of those cases, 25% are cervical; 55%, intrathoracic; and 20%, abdominal.
Because the esophagus lacks a serosal layer, it is very vulnerable to rupture and perforation. Once a perforation occurs, retained gastric contents, saliva, biliary fluid, and other secretions may enter the mediastinum and cause chemical mediastinitis with mediastinal emphysema, inflammation, and subsequently, mediastinal necrosis. Within a few hours following a full-thickness tear in the esophageal wall, polymicrobial bacterial translocation and invasion occur, which can lead to sepsis and eventually death if there is a delayed diagnosis or lack of appropriate medical and surgical care. Pleural effusion often follows esophageal perforation, which can be either a sympathetic effusion (when the pleura is still intact) or an exudative effusion (when the mediastinal pleura ruptures and contaminated gastric fluid is drawn into the pleura by the negative intrathoracic pressure).
The clinical manifestations of esophageal perforations depend on several factors including the etiology of the perforation, the location of the perforation (cervical, intrathoracic or intra-abdominal), the severity of contamination, injury of nearby mediastinal structures (trachea in a case of penetrating trauma in cervical esophageal perforations or the pericardium in case of spontaneous thoracic perforations), and the time elapsed from the perforation until treatment.
Patients with esophageal perforations are of high mortality risk; even with prompt medical care, mortality can reach as high as 36% to 50%. Hence, optimized initial resuscitation is critical to ensure appropriate delivery of care to the affected patients. 
Standard Care of Management
Operative management is required for most patients to minimize morbidity and mortality.
Esophageal perforation poses a significant challenge to the entire therapeutic team. These patients may present with a variety of nonspecific symptoms, such as abdominal, retrosternal chest pain, or vomiting and may also exhibit signs of sepsis and shock. An interprofessional, cooperative team is crucial to delivering optimal and appropriate care. While the general surgeon is almost always involved in managing patients with esophageal ruptures and perforations, other specialists such as a radiologist, intensivist, thoracic surgeon, and expert endoscopist should be involved in providing adequate care for these patients. Surgical residents should also have a high threshold to suspect or diagnose esophageal perforations. A radiologist has a key role in the diagnosis of esophageal ruptures and tears, especially complex or small perforations with minimal leaks.
The mortality of esophageal perforations can be as high as 50%, thus to improve outcomes, prompt consultation with an interprofessional group of specialists is recommended.
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