Gastrointest Interv 2013; 2:1–6

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Gastrointestinal Intervention
journal homepage: www.gi-intervention.org

Review Article

Esophageal perforation: Continuing challenge to treatment

Ronald V. Romero,1, 2 Khean-Lee Goh 2, *

a b s t r a c t

Esophageal perforation carries with it a high morbidity and mortality if not treated appropriately and aggressively. Three approaches are available for the
treatment of esophageal perforation: conservative, endotherapy, and surgery. The location viz. cervical, thoracic, or abdominal portions of the esophagus
and size of the perforation influence treatment choice. Cervical perforations are usually small and can be treated conservatively as the perforation or leak
is also contained within the triangle of Killian in the neck. Most cervical perforations have a good outcome with conservative treatment with intravenous
antibiotics and nil by mouth. Treatment of thoracic perforations depends very much on the size of the perforation. Small perforations due to sclerotherapy
injection, for example, can be treated conservatively. Endotherapy can help avoid surgery in other cases: small tears from endoscopic insertion can be
clipped and esophageal fistulae can be injected with fibrin glue. Larger perforations can be treated with stent placement if the dehiscence of the lumen
circumference does not exceed 70%. Stent placement with self-expandable fully-covered plastic and metallic stents or partially-covered metallic stents
has been used with fairly good success. One of the problems with stent placement is the migration of these stents. Perforation of the intra-abdominal
portion of the esophagus often results in a very rapid development of peritonitis and sepsis and surgery is usually recommended. Surgery is manda-
tory in any part of the esophagus when the perforation is large or when patients do not improve with conservative or endoscopic treatment. In very ill
patients, esophageal exclusion surgery can be carried out until the patient’s general condition stabilizes. In cases of a diseased esophagus such as corrosive
injury related perforations or cancer of the esophagus, esophageal replacement surgery should be contemplated with total esophagectomy and gastric
pull-up surgery or creation of a neoesophagus with colonic interposition.
Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. Open access under CC BY-NC-ND license.

Keywords: Conservative, Endoscopic stenting, Esophageal perforation, Surgery

Introduction perforation risk increases to 2–10% with therapeutic intervention,

Esophageal perforation carries with it a high morbidity and
mortality rate if not treated appropriately and aggressively.1–3
Mortality rates for esophageal perforation range from 10% to 30%
in most studies.4,5 In a retrospective review, intrathoracic perfora-
tions had a mortality rate of 18%, followed by cervical perforations
with 8% mortality rate, and perforations at the gastroesophageal
junction with 3% mortality rate.2 Esophageal perforations can have
different etiologies. Spontaneous perforations occur as a result of a
sudden increase in intra-abdominal pressure during forceful
vomiting, such as in Boerhaave’s syndrome. Iatrogenic perforations
may result from diagnostic and therapeutic endoscopic procedures,
as complications of thoracic surgeries, and ingestion of caustic
substances. Perforations can also occur in diseased esophagus with
malignancy and infection. In a retrospective review of esophageal
perforations, 51% were iatrogenic and 33% were spontaneous per-
forations.1 Several prospective studies showed risks of perforation
for diagnostic upper endoscopy to be 0.05% or less.6,7 However, the
such as dilatation of strictures.7
Several factors determine the successful outcome of treatment
and these include the time interval between diagnosis of perfora-
tion and treatment, the location of the perforation,1,8,9 the cause of
the perforation, the underlying esophageal disease, and the pres-
ence of comorbid illness.1,2
Three approaches are available for the treatment of esophageal
perforation: conservative, endotherapy, and surgery. In this review,
we will discuss the importance of several clinical factors in the
diagnosis and treatment of esophageal perforation.
Diagnosis
Clinical manifestations
In a retrospective review of esophageal perforations by Abbas
et al, esophageal perforations had a median time of diagnosis of 12

1
Jonelta Foundation School of Medicine, University of Perpetual Help Rizal, Manila, Philippines
2
GI Endoscopy Unit, University of Malaya Medical Center, Kuala Lumpur, Malaysia
Received 2 December 2012; Revised 8 February 2013; Accepted 13 February 2013
* Corresponding author. GI Endoscopy Unit, Division of Gastroenterology and Hepatology, University of Malaya, 50603 Kuala Lumpur, Malaysia.
E-mail address: klgoh56@gmail.com (K.-L. Goh).

2213-1795 Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. Open access under CC BY-NC-ND license.
http://dx.doi.org/10.1016/j.gii.2013.02.002
2 Gastrointestinal Intervention 2013 2(1), 1–6

hours.2 The most common symptom of esophageal perforation is

chest pain, which is present in 70–80% of cases.8,10 However, the
clinical presentation of esophageal perforation depends on the
location of the perforation.
Cervical perforations can present with neck pain, dysphonia,
hoarseness, and cervical dysphagia.10 Subcutaneous cervical
emphysema has been observed, in 30% of cases.8 Thoracic perfo-
rations present with acute chest pain, and in 30% of cases, back pain
or radiation to the back.8 Perforations at the gastroesophageal
junction can manifest as acute abdominal pain, with signs of
peritonitis and rarely gastrointestinal bleeding.10 Pain can be
experienced at the back or epigastric area, which may be referred to
the shoulder, as a result of diaphragmatic irritation.11 Vomiting and
shortness of breath associated with pain can be seen in 25% of
cases.10 Signs of systemic inflammatory response also develop such
as tachycardia, tachypnea, and fever. Fever is an invariable finding
50% of the time, but is considered as a late sign.8,10

Diagnostic imaging

Imaging modalities that are useful in the diagnosis and work up

of esophageal perforation include a plain chest radiograph, Gas-
trografin upper gastrointestinal study, chest and upper abdomen
CT scan, and endoscopy. The most common finding in a chest
radiograph is pneumomediastinum, occurring in 42% of cases, fol-
lowed by pneumothorax and pneumoperitoneum (Fig. 1).8 Radio-
graphically evident subcutaneous emphysema is seen in 95% of
cervical perforations.11 However, the extent and location of the
perforation is difficult to assess in a plain chest radiograph. A water-
soluble contrast swallow or Gastrografin study can localize the site
and extent of perforation as seen by extravasation of contrast
(Fig. 2). A negative study, however, does not exclude the presence of
a perforation and a repeat study can be done after 4–6 hours.10
Chest and upper abdomen CT scan with oral contrast can better
visualize the site and degree of containment of the perforation Fig. 2. Gastrografin study showing contrast leak in the distal esophagus (arrow).
(Fig. 3).10 Endoscopic evaluation provides direct visualization of the
defect (Fig. 4). However, the use of endoscopy in the evaluation of

Fig. 1. Chest radiograph showing pneumoperitoneum (arrow). Fig. 3. Coronal chest computed tomography showing pneumomediastinum (arrow).
 Ronald V. Romero and Khean-Lee Goh / Treatment of esophageal perforation
Fig. 4. Endoscopic view of esophageal perforation after stricture dilatation, showing
the adventitia layer (arrow).
esophageal perforation remains controversial as air insufflation can
result in pneumomediastinum and cervical emphysema, which
may further aggravate the condition. Although several studies have
utilized carbon dioxide for insufflation during esophageal submu-
cosal dissection to minimize mediastinal emphysema, its utility in
esophageal perforation has yet to be determined.12,13
Treatment
Over the years, despite development of novel techniques and
recommendations to treat esophageal perforation, the goals of
treatment remain the same: to treat infection, minimize and pre-
vent further septic contamination; to provide nutritional support;
and to restore the continuity of the digestive tract.9,14
Location of the perforation
Cervical perforations are often iatrogenic, such as during intu-
bation with a gastroscope. Cervical tears can usually be treated
conservatively as the perforation or leak is contained within the
triangle of Killian in the neck. Endoscopic therapy with clipping is
possible but visualization of the area may be difficult and endo-
scopic stent placement may not be feasible. Most cervical perfo-
rations have a good outcome with conservative treatment with
intravenous antibiotics and nil by mouth.
Treatment of thoracic perforations depends on the size of the
perforation. Small perforations (e.g., due to sclerotherapy injection)
can be treated conservatively. Small tears from endoscopic inser-
tion can be clipped. However, successful closures of spontaneous
perforations by endoscopic clipping have been reported in recent
years.15,16 Esophageal fistulas can be injected with fibrin glue.17
Stent placement with self-expandable fully covered plastic and
metallic stents or partially covered metallic stents has been used
with fairly good success (Fig. 5).18 Migration is a particular problem
with fully covered stents where it has been reported in up to 25% of
cases.19 With conservative or endotherapy, simultaneous drainage
of any mediastinal or pleural collection of fluid or pus should be
carried out and patients put on intravenous antibiotics.
Perforation of the intra-abdominal portion of the esophagus
often results in a very rapid development of peritonitis and sepsis
and surgery is usually recommended. Small leaks or perforation,
such as a small tear from balloon dilatation or from sclerotherapy,
can be treated with stent placement across the cardio-esophageal
junction. Larger tears, such as in Boerhaave’s syndrome or sponta-
neous barotraumatic rupture of the esophagus, will require surgery.
3
Fig. 5. Successful stent placement showing the proximal end of the stent (arrows).
Conservative treatment
Early recognition of iatrogenic perforations, within 6 hours or
less than 24 hours, correlates with better prognosis and can be
managed conservatively.8,9 Conservative management includes nil
by mouth, intravenous fluids and antibiotics, total parenteral
nutrition, nasogastric tube, and chest drainage. In a 10-year retro-
spective study by Hasan et al, conservative management of esoph-
ageal perforation had a survival of 84.6%, mortality rate of 15%, with
chest infections as the most common complication in 46% of cases.8
Their study also revealed that perforations had favorable outcomes
when diagnosed within 6 hours. In another retrospective review,
successful nonoperative therapy resulted in shorter hospitalizations,
fewer complications, and lower mortality rates compared to oper-
ative treatment.2 However, conservative management should be
limited to patients who have a localized contrast extravasation on
imaging.5,8 Other indications for conservative treatment are the
absence of infective syndrome, cervical or thoracic perforations,
intramural perforation, and nontumoral perforation.9
Conservative management of perforations can be considered in
small perforations and with the following features: diagnosis made
early and perforation contained within the neck and mediastinum;
drainage into the esophageal lumen shown by contrast imaging;
injury does not occur in neoplastic tissue or corrosive injury; in the
abdomen or proximal to an obstruction; and absence of systemic
sepsis and availability of interventional radiological and surgical
expertise. In all cases managed conservatively, nutritional support
and the use of broad spectrum antibiotics as well as appropriate
radiologically guided drainage of localized collections of fluid and
pus should be carried out at the same time.8,20,21 Total parenteral
nutrition, broad-spectrum antibiotics, and proton pump inhibitors
should be given for a period of 14–21 days.9 Patients are maintained
nil by mouth for an average of 7 days until check contrast swallows
are performed to document healing and facilitate diet progression
to oral fluids.8,9 Successful esophageal healing with conservative
treatment has been reported to be as high as 96%, with an overall
mortality of 4.2%.22
Endoscopic therapy
Endoscopic therapy of esophageal perforations aims to restore
continuity of the esophagus for early feeding, prevent contamina-
tion of the mediastinum, and facilitate re-epithelialization of the
mucosal defect. This can be achieved by using hemoclips and stents
to seal the mucosal defect. Endoscopic hemoclipping has been
4 Gastrointestinal Intervention 2013 2(1), 1–6
Fig. 6. Stent removal after 6 weeks, showing re-epithelialization and closure of defect
(arrows).
shown to be successful for defects 3–25 mm in size and less than
25% of the esophageal circumference and a median healing time of
18 days.23,24 A novel over-the-scope clip has been recently devel-
oped to successfully close perforations up to 30 mm in diam-
eter.25,26 Larger perforations can be treated with stent placement if
the dehiscence of the lumen circumference does not exceed 70%.27
Various stents are commercially available for stenting esopha-
geal perforations; these include Ultraflex stent (Boston Scientific,
Natick, MA, USA), Niti-S stent (TaeWoong Medical, Gyeonggi-do,
Korea), Polyflex stent (Boston Scientific), and Flamingo Wallstent
(Boston Scientific). In a systematic review by van Boeckel et al,
stenting of esophageal perforations with fully covered self-
expandable metal stents (FSEMS), partially covered self-
expandable metal stents (PSEMS), and self-expanding plastic
stents (SEPS) had an overall clinical success rate of 85%.19 Surgical
interventions were only done in 13% of the cases. However, stent
migration was noted to be highest in SEPS followed by fully-
covered metallic stents and PSEMS with migration rates of 31%,
26%, and 12%, respectively.19 Stent migration is a common problem,
particularly for covered stents because there is nothing to hold the
stents in place and deployment of the largest diameter stents is
recommended.19 In a retrospective study by Swinnen et al, closure
of leak after PSEMS removal was 77.6%.28 In several instances tissue
overgrowth and hyperplasia render the stent adherent to the
Fig. 7. Treatment approach to esophageal perforations.
esophagus limiting its retrieval. A second stent is then inserted
through the initial stent to induce pressure necrosis of the hyper-
plastic tissue in-growth and stent retrieval can be attempted after 2
weeks.28 In an observational study, Fischer et al were able to
demonstrate that early stent placement, average time delay of 45
minutes, resulted in successful healing of esophageal perforation
and shorter duration of hospital stay.29 A novel biodegradable stent
has recently been developed to eliminate the problems of stent
retrieval. These stents are covered with biodegradable poly-
dioxanone monofilament with a polyurethane skeleton. In a series

by Cerná et al, covered biodegradable stents (SX Ella-BD; ELLA-CS,
Hradec Králové, Czech Republic) were used to treat anastomotic
esophageal leaks and perforation and technical success was 100%,
while clinical success was achieved in 80% of the cases.30 The stent
was fixed into position by balloon dilatation. The follow-up pro-
tocol described in the series include esophagography after 2 days,
radiograph of the stent every 4 weeks until complete degradation
was observed and endoscopy after 12 weeks of stent implantation.
Stent degradation was seen at around 11–12 weeks and was
dependent on pH, therefore stents placed at the distal esophagus
near the cardioesophageal junction were degraded earlier. A ran-
domized study comparing SEPS with biodegradable stents in the
treatment of refractory esophageal strictures showed that stent-
related complications resulting in dysphagia were higher after
biodegradable stent placement compared to SEPS, but stent
migration rates were similar.31 The main benefit of biodegradable
stents is that stent removal is not required after completion of
therapy, minimizing the number of reinterventions.
The optimal time of stent placement ranges from 4 weeks to 6
weeks to avoid secondary perforation, hemorrhage, or impaction of
the stent9 (Fig. 6). Stent retrieval complications, such as bleeding,
stent fractures, and impaction, were noted to be more common for
stents extracted beyond 6 weeks.32 However, larger defects may
require more than 6 weeks to heal and the initial stent should be
replaced within 6 weeks to prevent stent embedding.32
Surgery
The surgical approach for the treatment of esophageal per-
forations is influenced by the location and size of the perfora-
tion, viability of the esophageal mucosa, degree of local sepsis,
 Ronald V. Romero and Khean-Lee Goh / Treatment of esophageal perforation
and underlying pathology.9 Surgery is mandatory in any part of
the esophagus when the perforation is large or when patients do
not improve with conservative or endoscopic treatment. The
latter usually happens when diagnosis of the perforation is
delayed and if the perforation is noncontained resulting in
mediastinal or peritoneal contamination and systemic sepsis.2
Primary repair with suture of perforation with reinforcement
flaps is the main surgical treatment and has a favorable outcome
especially if done within 24 hours of diagnosis.33–35 However, in
the presence of empyema, debridement and pleural decortica-
tion are indicated to obtain full lung expansion and facilitate
sealing of the defect.9
In very ill patients, esophageal exclusion surgery can be carried
out until the patient’s general condition stabilizes. The aim of sur-
gery is to achieve primary repair of the perforation but identifica-
tion of the perforation may not be easy. Appropriate cleaning and
debridement of surrounding necrotic tissue with placement of
drains close to the site of perforation are important; T-tube
drainage has successfully provided a preferential flow of inflam-
matory debris to facilitate wound healing.36,37 Repair of perforation
can be reinforced with muscle or pleural flaps.9 A laparoscopic or
thoracoscopic approach is increasingly used for such repairs.38,39 In
cases of a diseased esophagus such as corrosive injury related
perforations or cancer of the esophagus, esophageal replacement
surgery should be contemplated with total esophagectomy and
gastric pull-up surgery or creation of a neoesophagus with colonic
interposition.40 Fig. 7 summarizes the treatment approach to
esophageal perforations.
Conclusion
Esophageal perforation is a life-threatening condition that must
be recognized and addressed aggressively. The treatment of
esophageal perforation is dependent on various clinical factors,
technology, and level of expertise available. Conservative man-
agement is possible for small and contained defects in the absence
of sepsis and aggravating underlying comorbid illnesses. Minimally
invasive treatment or endotherapy is a viable option for most
esophageal perforations especially with the development of newer
biodegradable stents. Surgical treatment is indicated for larger
defects and in overt sepsis requiring drainage and in perforations
involving diseased esophagus. The different treatment modalities
of esophageal perforation are not exclusive of each other but may
be used altogether in the management of the condition. Further
studies and technology may aim to improve the currently available
endoscopic treatment modalities, and to develop novel techniques
in the treatment of esophageal perforation.
Conflicts of interest
We declare that we have no conflict of interest with regards to
this paper.
References
1. Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the manage-
ment of esophageal perforations: a twenty-seven year Canadian experience.
Ann Thorac Surg. 2011;92:209–15.
2. Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Landreneau J,
et al. Contemporaneous management of esophageal perforation. Surgery. 2009;
146:749–55. discussion 755–6.
3. Ryom P, Ravn JB, Penninga L, Schmidt S, Iversen MG, Skov-Olsen P, et al.
Aetiology, treatment and mortality after oesophageal perforation in Denmark.
Dan Med Bull. 2011;58:A4267.
4. Jones 2nd WG, Ginsberg RJ. Esophageal perforation: a continuing challenge.
Ann Thorac Surg. 1992;53:534–43.
5. Lawrence DR, Moxon RE, Fountain SW, Ohri SK, Townsend ER. Iatrogenic
oesophageal perforations: a clinical review. Ann R Coll Surg Engl. 1998;80:115–8.
5
6. Sieg A, Hachmoeller-Eisenbach U, Eisenbach T. Prospective evaluation of
complications in outpatient GI endoscopy: a survey among German gastroen-
terologists. Gastrointest Endosc. 2001;53:620–7.
7. Quine MA, Bell GD, McCloy RF, Matthews HR. Prospective audit of perforation
rates following upper gastrointestinal endoscopy in two regions of England. Br J
Surg. 1995;82:530–3.
8. Hasan S, Jilaihawi AN, Prakash D. Conservative management of iatrogenic
oesophageal perforationsda viable option. Eur J Cardiothorac Surg. 2005;28:
7–10.
9. Chirica M, Champault A, Dray X, Sulpice L, Munoz-Bongrand N, Sarfati E, et al.
Esophageal perforations. J Visc Surg. 2010;147:e117–28.
10. Søreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical
decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011;
19:66.
11. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving
options in the management of esophageal perforation. Ann Thorac Surg. 2004;
77:1475–83.
12. Maeda Y, Hirasawa D, Fujita N, Obana T, Sugawara T, Ohira T, et al. A pilot study
to assess mediastinal emphysema after esophageal endoscopic submucosal
dissection with carbon dioxide insufflation. Endoscopy. 2012;44:565–71.
13. Uemura M, Ishii N, Itoh T, Suzuki K, Fujita Y. Effects of carbon dioxide insuf-
flation in esophageal endoscopic submucosal dissection. Hepatogastroenterol-
ogy. 2012;59:734–7.
14. Bufkin BL, Miller Jr JI, Mansour KA. Esophageal perforation: emphasis on
management. Ann Thorac Surg. 1996;61:1447–51. discussion 1451–2.
15. Sriram PV, Rao GV, Reddy ND. Successful closure of spontaneous esophageal
perforation (Boerhaave’s syndrome) by endoscopic clipping. Indian J Gastro-
enterol. 2006;25:39–41.
16. Rokszin R, Simonka Z, Paszt A, Szepes A, Kucsa K, Lazar G. Successful endo-
scopic clipping in the early treatment of spontaneous esophageal perforation.
Surg Laparosc Endosc Percutan Tech. 2011;21:e311–2.
17. Kimura T, Takemoto T, Fujiwara Y, Yane K, Shiono H. Esophageal perforation
caused by a fish bone treated with surgically indwelling drainage and fibrin
glue injection for fistula formation. Ann Thorac Cardiovasc Surg; 2012 Nov 15.
[Epub ahead of print]
18. van Boeckel PG, Dua KS, Weusten BL, Schmits RJ, Surapaneni N, Timmer R, et al.
Fully covered self-expandable metal stents (SEMS), partially covered SEMS and
self-expandable plastic stents for the treatment of benign esophageal ruptures
and anastomotic leaks. BMC Gastroenterol. 2012;12:19.
19. van Boeckel PG, Sijbring A, Vleggaar FP, Siersema PD. Systematic review:
temporary stent placement for benign rupture or anastomotic leak of the
oesophagus. Aliment Pharmacol Ther. 2011;33:1292–301.
20. Altorjay A, Kiss J, Vörös A, Bohák A. Nonoperative management of esophageal
perforations. Is it justified? Ann Surg. 1997;225:415–21.
21. Repici ARG. Stent for nonmalignant leaks, perforations, and ruptures. Tech
Gastrointestin Endosc. 2010;12:237–45.
22. Vogel SB, Rout WR, Martin TD, Abbitt PL. Esophageal perforation in adults:
aggressive, conservative treatment lowers morbidity and mortality. Ann Surg.
2005;241:1016–21. discussion 1021–3.
23. Raju GS. Endoscopic management of gastrointestinal leaks. Gastrointest Endosc
Clin N Am. 2007;17:487–503. vi.
24. Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW. Endoscopic clips for closing
esophageal perforations: case report and pooled analysis. Gastrointest Endosc.
2007;66:605–11.
25. Gubler C, Bauerfeind P. Endoscopic closure of iatrogenic gastrointestinal tract
perforations with the over-the-scope clip. Digestion. 2012;85:302–7.
26. Kirschniak A, Subotova N, Zieker D, Königsrainer A, Kratt T. The Over-The-
Scope Clip (OTSC) for the treatment of gastrointestinal bleeding, perforations,
and fistulas. Surg Endosc. 2011;25:2901–5.
27. Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, et al. Endoscopic
treatment of thoracic esophageal anastomotic leaks by using silicone-covered,
self–expanding polyester stents. Gastrointest Endosc. 2005;61:891–6.
28. Swinnen J, Eisendrath P, Rigaux J, Kahegeshe L, Lemmers A, Le Moine O, et al.
Self-expandable metal stents for the treatment of benign upper GI leaks and
perforations. Gastrointest Endosc. 2011;73:890–9.
29. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonop-
erative treatment of 15 benign esophageal perforations with self-expandable
covered metal stents. Ann Thorac Surg. 2006;81:467–72.

30. Cerná M, Köcher M, Válek V, Aujeský R, Neoral C,  Andrasina T, et al. Covered
biodegradable stent: new therapeutic option for the management of esophageal
perforation or anastomotic leak. Cardiovasc Intervent Radiol. 2011;34:1267–71.
31. van Boeckel PG, Vleggaar FP, Siersema PD. A comparison of temporary self-
expanding plastic and biodegradable stents for refractory benign esophageal
strictures. Clin Gastroenterol Hepatol. 2011;9:653–9.
32. van Heel NC, Haringsma J, Spaander MC, Bruno MJ, Kuipers EJ. Short-term
esophageal stenting in the management of benign perforations. Am J Gastro-
enterol. 2010;105:1515–20.
33. Tettey M, Edwin F, Aniteye E, Sereboe L, Tamatey M, Entsua-Mensah K, et al.
Management of intrathoracic oesophageal perforation: analysis of 16 cases.
Trop Doct. 2011;41:201–3.
34. Okten I, Cangir AK, Ozdemir N, Kavukçu S, Akay H, Yavuzer S. Management of
esophageal perforation. Surg Today. 2001;31:36–9.
35. Eroglu A, Can Kürkçüogu I, Karaoganogu N, Tekinbaş C, Yimaz O, Başog M.
Esophageal perforation: the importance of early diagnosis and primary repair.
Dis Esophagus. 2004;17:91–4.
6 Gastrointestinal Intervention 2013 2(1), 1–6

36. Nakabayashi T, Kudo M, Hirasawa T, Kuwano H. Successful late management of
esophageal perforation with T-tube drainage. Case Rep Gastroenterol. 2008;2:
67–70.
37. Griffiths EA, Yap N, Poulter J, Hendrickse MT, Khurshid M. Thirty-four cases of
esophageal perforation: the experience of a district general hospital in the UK.
Dis Esophagus. 2009;22:616–25.
38. Landen S, El Nakadi I. Minimally invasive approach to Boerhaave’s syndrome: a
pilot study of three cases. Surg Endosc. 2002;16:1354–7.
39. Toelen C, Hendrickx L, Van Hee R. Laparoscopic treatment of Boerhaave’s syn-
drome: a case report and review of the literature. Acta Chir Belg. 2007;107:402–4.
40. Pearson FG, Cooper JD, Deslauriers J, Ginsberg R, Hiebert C, Patterson GA, et al.
Esophageal surgery. Philadelphia: Churchill Livingstone; 2002.