Thoracic perforations-surgical techniques

Esophageal perforation may occur spontaneously, iatrogenically or in connection with traumas. Sepsis may develop in connection with mediastinal and pleural exposure in a very short time as a consequence of disintegration of the esophagus. Esophageal perforation is an emergency accompanied with a high level of mortality and morbidity. Rate of mortality for the perforations in the thoracic region is higher than that in the cervical and abdominal regions. Delay in diagnosis and treatment is the most important factor to affect the mortality. A quick and true diagnosis of esophageal perforation is prerequisite for a successful treatment. There is no certain consensus in relation with the optimal treatment of that life-threatening condition. However, in the event that perforation is detected early in a healthy esophagus, then primary repair is recommended. When it is detected late, nonoperative conservative treatment would be appropriate. The rates of mortality for the operations following a period of 24 h after rupture formation are higher than 50%. Esophagectomy is a type of an operation that is to be considered in the event of an end stage benign esophageal disease or of a large esophageal damage that does not allow primary repair. Significant decrease has been observed in the morbidity and mortality of esophageal perforation due to the improvements in the endoscopical techniques today. Minimally invasive techniques, in which drug eluting stents come first, will become an important step for the treatment of esophageal perforations in the forthcoming years.

Minimally Invasive and Endoscopic Approach to Esophageal Perforation

Although esophageal perforation is rare, it is a life-threatening condition. The esophagus is very sensitive to rupture and perforation due to the absence of a serosal layer. More than half of the esophageal perforations are iatrogenic and most occur during endoscopy. Around 55% of esophageal injuries occur in the intrathoracic region, 25% in the cervical region, and 20% in the abdominal region. Clinical manifestations and mortality are related to various components such as the etiology, localization, type of injury, severity of contamination, injury to adjacent mediastinal structures, and time from perforation to treatment. When perforation occurs in the esophagus, saliva, stomach contents, bile fluid, and other secretions may pass into the mediastinum causing mediastinal emphysema, inflammation followed by mediastinal necrosis, and chemical mediastinitis. Early clinical suspicion and imaging are essential for successful treatment. Despite advances in technology and treatment, the morbidity and mortality rate due to esophageal perforation is still higher than 20% according to the reported studies. Until now, the main treatment of esophageal perforation was the surgical approach. Nowadays, endoluminal procedures such as endoscopic vacuum therapy, endoscopic stent placement, endoscopic clip closure, endoscopic suturing, and tissue adhesives have started to be applied more. In this review, the minimally invasive and endoscopic approach methods suitable for esophageal perforation according to the characteristics of the patients and the structure of the perforation were examined.