Esophageal Perforation Repair
What the Examiner Expects
Repair of a full-thickness esophageal perforation, a surgical emergency with mortality rates exceeding 20% if diagnosis is delayed. The examiner expects you to classify the cause (iatrogenic from endoscopy — most common, Boerhaave's syndrome — spontaneous from forceful vomiting, or foreign body/caustic), determine the location (cervical, thoracic, or abdominal), and know that Boerhaave's classically perforates the left distal esophagus. Diagnosis is with water-soluble contrast swallow (Gastrografin) followed by thin barium if negative. CT chest with oral contrast can also detect the perforation and associated mediastinal contamination.
Key Examiner Focus Points
- Most common cause is iatrogenic (endoscopy); Boerhaave's is spontaneous (left distal esophagus)
- Time to diagnosis is critical — < 24 hrs favors primary repair
- Gastrografin swallow followed by thin barium if negative
- Primary repair in two layers reinforced with tissue flap (intercostal muscle, pleura, omentum)
- Delayed or septic presentation: drainage, exclusion/diversion, or T-tube drainage
Common Curveballs
Perforation is diagnosed 48 hours after an endoscopy with mediastinal contamination
Delayed presentation with contamination — primary repair is unreliable. Options include wide drainage and washout with T-tube esophageal drainage, esophageal exclusion with diversion (cervical esophagostomy + distal stapling), or endoscopic stent with percutaneous drainage. Primary repair after 24 hours has high leak rates.
Patient is hemodynamically stable with a contained cervical perforation
Many contained cervical perforations can be managed nonoperatively: NPO, IV antibiotics, serial imaging. If the patient worsens, proceed to transcervical drainage. Cervical perforations are more forgiving than thoracic due to easier drainage.
Boerhaave's patient with left pleural effusion and crepitus in the neck
Resuscitate aggressively, broad-spectrum antibiotics, emergent left thoracotomy. Repair in two layers, reinforce with intercostal muscle flap, place chest tubes, widely drain the mediastinum. Do not delay — this is a surgical emergency.
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