Key Points

• In the clinical setting of an esophageal perforation, performance of a negative water-soluble esophagogram should be immediately followed by that of a thin-barium esophagogram.
• Prompt diagnosis and early treatment is critical to a good outcome.
• Cervical esophageal perforations are managed by surgical drainage, débridement, and drainage. Repair of the perforation may not be possible.
• Thoracic and abdominal esophageal perforations require esophageal repair, lavage, and débridement of the surrounding tissue and drainage.
• Approaches, including use of stents, may be appropriate in a very carefully selected group of patients, with adequate drainage procedures.

The esophagus, strategically situated in the neck, mediastinum, and abdomen, is subject to irreparable injury; the consequences of perforation are grave and commonly result from technical misadventure. Despite advances in diagnostic methods and supportive therapy—including ventilatory support, antibiotics, and nutrition therapy—mortality rates for esophageal perforation are 13% in patients undergoing surgery less than 24 hours after injury and 55% for those in whom therapy is delayed.[1] Factors influencing mortality are (1) the age and general condition of the patient, (2) the location and cause of the perforation, and (3) the presence or absence of intrinsic esophageal disease. The common causes of esophageal perforation are discussed later. Anastomotic leaks and caustic esophageal injuries are discussed elsewhere in this volume.

In a review of 511 esophageal perforations,[2] 43% were caused by instruments, 19% were caused by trauma, 16% were spontaneous, 7% were caused by foreign bodies, 8% were caused by operative injury, and 7% were caused by tumor and miscellaneous causes. Endoscopy alone accounted for 35% of perforations by instruments, pneumatic dilation caused 25%, and bougienage caused 20%. Faulty endotracheal intubation, Sengstaken-Blakemore tubes, nasogastric tubes, sclerotherapy, and endoesophageal prostheses caused 20% of iatrogenic perforations. In a 1974 survey of endoscopic esophageal injury, the incidence of esophageal perforation was 0.03%.[3] Although endoscopic procedures are performed in increasing numbers, the more frequent use of flexible endoscopy, coupled with video imaging, has probably decreased the incidence of perforations. However, the increased use of intraoperative transesophageal echocardiography for cardiac surgery has contributed another source of perforation by instruments.

Sixty percent of cervical perforations are the result of endoscopy; the remainder are caused by penetrating trauma or foreign bodies. Injury most commonly occurs during passage of the endoscope through the cricopharyngeal sphincter, the narrowest zone of the esophagus. Older people, in whom neck extension may be limited and who often have osteoarthritic spurs juxtaposed to the posterior esophageal wall, are especially at risk. The second site of esophageal narrowing, the region of the aortic arch and the left main bronchus, is more likely to be perforated by ingested foreign bodies than by instruments. The gastroesophageal junction, the third zone of esophageal narrowing, is likely to be perforated during biopsy or dilation of both benign and malignant strictures or achalasia. Because the clinical manifestations, radiographic findings, treatment, and prognosis of cervical perforation differ from those of thoracic and abdominal perforations, cervical perforation is best discussed as a separate entity.