The four main causes of esophageal perforation are spontaneous perforation associated with protracted vomiting, also known as Boerhaave syndrome, iatrogenic injury from instrumentation, breakdown of esophageal reconstructions after esophagectomy, and penetrating trauma.^1–4 Regardless of the etiology, mediastinal contamination from salivary, gastric, and biliary secretions, with the associated bacteria, leads to both local and systemic inflammatory responses. If the perforation is not controlled promptly, it will give rise to sepsis, which if left untreated, nearly 100% of the time, will result in mortality within 1 week.^1,4,5 Despite advances in surgical technique and critical care over the past decades, esophageal perforation remains a challenging clinical problem. Early diagnosis and prompt surgical treatment are the hallmarks of successful outcome after spontaneous (i.e., Boerhaave syndrome) and iatrogenic esophageal perforation. Advocates for stenting, primary esophageal repair, drainage with a T-tube, esophageal exclusion, esophageal diversion, and esophagectomy with upfront reconstruction for perforations can be found. This chapter describes the techniques and indications for esophageal exclusion.

The extent of the inflammatory response depends on the location of the injury and the length of time from the injury, both of which correlate with extent of mediastinal contamination. Cervical perforations often are limited to the neck, resulting in minimal to absent mediastinal contamination. Such perforations are best managed by local drainage techniques.^1,6 However, intrathoracic and intra-abdominal perforations generally cannot be managed successfully by drainage alone and require either repair with diversion or exclusion in addition to drainage procedures. The choice whether to proceed with primary repair or with esophageal exclusion rests on multiple factors.

Numerous studies have shown that the length of time from injury to diagnosis is an important determinant of outcome. Cases diagnosed more than 24 hours after injury are associated with increased mortality.^1,2 The length of time from injury to diagnosis is proportional to the degree of mediastinal or abdominal contamination, the severity of inflammation and tissue edema, and ultimately, the need for esophageal diversion. Rather than focusing on absolute lengths of time, however, when formulating a plan for treatment, it is better to evaluate the patient as a whole, considering the extent of injury, the overall physiologic status of the patient, the quality of the tissues on exploration, and the underlying esophageal pathophysiologic process. Otherwise healthy patients who sustain iatrogenic perforation to the intrathoracic or intra-abdominal esophagus and are diagnosed immediately are ideal candidates for primary repair with drainage. Elderly, malnourished, septic patients on vasopressors who go undiagnosed for several days after perforation and on exploration are found to have “woody,” edematous, and inflamed tissues remain poor candidates for primary repair and are best served by diversion and drainage procedures.

Primary esophageal resection for perforation has been touted by some to produce superior mortality results to primary repair or diversion.^1,2,7 For the most part, however, these opinions emanate from older nonrandomized, retrospective studies that often do not adequately account for patient comorbidity. Clearly, resection remains an option for patients with extensive tissue destruction who require resection for control of sepsis. All too often, the primary objective of treating esophageal perforation—to have a patient who is alive at the end of the day—is forgotten.

For patients with an underlying primary esophageal malignancy, esophageal resection with or without reconstruction is a viable option depending on the physiologic status of the patient, the degree of obstruction, and the stage of the malignancy. Younger patients with early-stage disease, minimal mediastinal contamination, and good-quality tissues are best served by resection with immediate reconstruction. Older patients or those with poor physiologic reserve should be resected without immediate reconstruction. Patients with involvement of the esophagus and the airway are more appropriately managed with exclusion and diversion techniques or esophageal stenting (see Chapter 56).

Esophageal Exclusion

Midthoracic esophageal perforations generally are explored via right thoracotomy through the fifth intercostal space (Fig. 31-1). One should consider harvesting an intercostal muscle flap on entry because it may be beneficial to buttress the repair with intercostal muscle.

Distal thoracic or intra-abdominal esophageal perforations can be approached via left thoracotomy incision through the seventh intercostal space with takedown of the diaphragm as needed (Fig. 31-1). After entry, the chest is thoroughly explored with full visualization of the extent of esophageal injury, often requiring sharp dissection of the overlying esophageal muscle to reveal the full extent of mucosal injury (Fig. 31-2). The degree of contamination and the nature of the esophageal injury and surrounding tissues are noted.