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Esophageal perforation

Key sources
The following summarized guidelines for the evaluation and management of esophageal perforation are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2019).


1.Diagnostic investigations

Computed tomography: obtain contrast-enhanced CT and CT esophagography as the imaging modality of choice in patients with suspected esophageal perforation.
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  • Laboratory tests

2.Diagnostic procedures

Upper gastrointestinal endoscopy: perform diagnostic endoscopy in patients with suspected esophageal perforation and doubtful CT findings.

3.Medical management

Nonoperative management: consider non-surgical management of esophageal perforation in stable patients with early presentation, contained esophageal disruption, and minimal contamination of surrounding spaces if highly specialized surveillance is available.

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  • Antibiotics

  • PPIs

4.Nonpharmacologic interventions

Nutritional support: keep patients eligible for non-surgical management NPO.
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5.Therapeutic procedures

Therapeutic endoscopy
Perform endoscopic treatment for closing esophageal perforation that occur and are recognized during an endoscopic procedure.
Consider endoscopy as first-line therapy in patients with late presentation and in patients with non-endoscopic esophageal perforation.

6.Surgical interventions

Indications for surgery: proceed with surgery in all patients who do not meet the criteria for non-surgical management:
delay in the management of < 24 hours
absence of symptoms and signs of sepsis
cervical or thoracic location of the esophageal perforation
contained perforation by surrounding tissues (intramural; minimal peri-esophageal extravasation of contrast material with intra-esophageal drainage; absence of massive pleural contamination)
no preexistent esophageal disease
possibility of close surveillance by expert esophageal team
availability of surgical and radiological skills all day and all night
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