This protocol addresses esophageal perforation presenting without signs of systemic infection, where initial imaging confirmed either pneumomediastinum without contrast extravasation or a contained perforation — and where the standard non-operative approach has not achieved the expected outcome.
The patient has an esophageal perforation with no signs of systemic infection. Imaging confirms either pneumomediastinum without contrast extravasation, or a contained perforation. Approximately 25% of esophageal perforations meet criteria for a non-operative trial under these imaging and clinical conditions.
The prior management line — non-operative management, including intravenous fluid resuscitation, systemic broad-spectrum antibiotics, and nothing by mouth — did not achieve its primary goal: resolution of the leak on a repeat Gastrografin® swallow study within 3–7 days of the initial injury. The failure of the leak to seal, or a decline in clinical status during the watchful waiting period, triggers escalation to this protocol.
When clinical status declines or the leak does not seal, a repeat CT scan is obtained. Depending on findings, the approach may involve interventional or operative techniques.
DOI: 10.1007/s11605-022-05454-2
Approximately 25% of esophageal perforations can be treated non-operatively, particularly if the patient lacks signs of systemic infection and imaging confirms either pneumomediastinum without extravasation or a contained perforation.
If the patient's status declines during the watchful waiting period, a CT scan is repeated to rule out evolving mediastinitis or abscess that warrants surgical intervention or percutaneous drainage.
Esophageal stent placement also has been used as a successful salvage technique for esophageal perforations after a trial of non-operative management.
View source ↗