Introduction

Esophageal injuries (EI) are sudden, rare, and serious clinical events. If a perforation occurs, prompt diagnosis and treatment are crucial. Otherwise, contaminated digestive contents can spill over the perforation, causing serious inflammation of the mediastinum and other organs. The systemic toxic symptoms caused by the infection caused by EI can even lead to death [1, 2]. Esophageal perforation can occur in the cervical, thoracic, or abdominal anatomic regions. The mortality rate of EI can range from 4% to 40%, although the overall incidence of esophageal injuries is relatively low [1]. Causes of injury include interventional procedures, ingestion of foreign objects, penetrating and traumatic thoracic injuries, and barotraumatic causes [1–5]. Despite advances in thoracic surgery, the treatment of esophageal perforations remains controversial [5, 6]. Diagnosis is based on a high index of suspicion and advanced testing based on clinical findings. Diagnosis of EI can be established using esophageal radiography, chest computed tomography (CT), and endoscopic procedures. Today, treatment outcomes are better because of advances in nutritional support and broad-spectrum antibiotics. The choice of treatment depends on the cause, location, and extent of the perforation, the degree of contamination, and the time between the perforation and diagnosis [7]. Medical treatment is administered if there is no mediastinal leak on the contrast-enhanced esophagogram, the patient has not been orally fed between the injury and diagnosis, there is no esophageal pathology accompanying the perforation, and the deviations in physiological values are minimal. Other causes require surgical intervention. Surgical interventions for esophageal perforations include primary repair, resection (esophagectomy and esophagogastrostomy), T-tube drainage, and exclusion/diversion. Intraluminal stents can also be used. However, the recent development of less invasive treatment methods has diversified the treatment options. Esophageal surgery is most commonly performed in the cervical and thoracic regions [6–8]. Effective treatment of esophageal perforations requires a multidisciplinary approach. The clinical presentation should determine the choice of treatment method for EI. Full-thickness injuries, in particular, can pose serious life-threatening risks due to contamination of the mediastinum by digestive contents. Therefore, early diagnosis and timely intervention are integral to the treatment of EI [1–4, 7, 9]. Prolonged time between diagnosis and treatment has been associated with high mortality and morbidity rates. Mortality in EI can reach as high as 40%. Achieving desired outcomes from treatment for this condition depends on factors such as preexisting comorbidities, the cause of rupture, the location of the esophageal injury, and the delay in initiating treatment. Because there is no single gold standard treatment strategy, each patient must be evaluated individually [5].

Aim

In the present study, we aimed to examine in detail the factors affecting the morbidity and mortality of cervical and thoracic EI.

Material and methods

Our study was based on a retrospective analysis of 75 cases of EI at the Harran University Faculty of Medicine Hospital between 2003 and 2023. This cohort included a heterogeneous patient population in terms of age, sex, and injury mechanism. Data on demographic characteristics, cause of injury, level and extent of injury, diagnostic methods, treatment approaches, length of hospital stay, and morbidity/mortality factors were collected from patient records. In particular, the separation of the injury site into cervical and thoracic regions was due to the consideration of access to surgical intervention. Various diagnostic methods, including radiography, CT, esophagography, and flexible endoscopy, were used in the management of EI. These imaging methods facilitated both the diagnosis and localization of the injury. Water-soluble contrast material was also used for diagnosis. In addition, extravasations were observed on esophageal scans performed with water-soluble contrast material, and a diagnosis was made. The duration to the definitive diagnosis was classified into time intervals: 12 hours before, 12–24 hours after, and 24 hours after. Patients who died due to non-esophageal complications or intra-abdominal approaches were excluded from the study. Esophagoscopy for diagnostic or therapeutic purposes was performed using rigid and flexible esophagoscopes. Oral feeding was immediately ceased in the suspicion of EI and discontinued if an esophageal rupture was suspected. Intravenous (IV) fluid and antibiotics against Gram-positive, Gram-negative, and anaerobic microorganisms were initiated. Urgent contrast-enhanced esophagograms were obtained. Patients with an early diagnosis underwent surgery; in cases of delayed diagnosis or inoperable disease, medical intervention was performed first. Conservative treatment was administered to patients with small, suspicious perforations, perforations caused by malignancy, delayed diagnoses, or contraindications to surgery. The patients were monitored for fever, cervical and/or mediastinal emphysema, and chest pain supported by a pleural flap. Surgical intervention was reserved for cases under medical treatment, if necessary. Medical treatment consisted of intravenous fluids, broad-spectrum antibiotics, nutrition, and drainage, as necessary. With surgical intervention, the perforated esophageal wall was primarily repaired using non-absorbable suture.

Results

Between 2003 and 2023, 75 patients with EI who were treated in our hospital were enrolled in the study. During the first and second decades, 30 (40%) patients and 45 (60%) patients, respectively, were evaluated, whereas in the second decade, 45 (60%) patients were evaluated. Forty-eight (64%) of the patients were male, and 27 (36%) were female, with a mean age of 35.24 years (range: 1–80). The percentage of patients aged < 17 years was 22.3% (n = 17). The mean age of patients within this age range was 6.8 years. Most non-iatrogenic injuries were due to penetrating and foreign bodies (38% and 28%, respectively). In terms of location, 40 (53.3%) cases of EI were found in the cervical region, and 46.7% in the thoracic region. Patients diagnosed early underwent immediate surgical intervention. In the treatment algorithm, patients with significant EI were managed surgically as soon as possible following diagnosis. Clinical and demographic characteristics are summarized in Table I. The most common symptoms of cervical EI were dysphagia, difficulty swallowing, and odynophagia painful swallowing in 30 (75%), bloody vomiting in 8 (20%), severe cough in 8 (20%), hoarseness in 4 (10%), and shortness of breath in 6 (15%) patients. For thoracic EI, severe chest pain to the back was evaluated in 12 (34%), difficulty in swallowing in 6 (9.4%), shortness of breath in 6 (9.4%), hemoptysis in 3 (4.7%), and bloody vomiting in 3 (4.7%). No symptoms were observed in 4 (5.3%) cases. The diagnosis was established using esophagography, tomography, and endoscopy in 46%, 46%, and 6% of cases, respectively. It was determined within 0–12 hours in 51 (68%) patients, within 13–24 hours in 8 (10.7%) patients, and within 24 hours or more in 16 (21%) patients. The mean duration of diagnosis was longer, and the delay in diagnoses was more frequent between 2003 and 2013, compared to the period between 2013 and 2023. Over the past decade, early diagnosis and intervention have significantly reduced morbidity and mortality rates. Upon investigating the etiological factors of the EI esophagus, it was observed that 80% of the cases were attributed to trauma-related causes, while 20% were due to iatrogenic esophageal perforation. Moreover, concomitant injuries were detected in 20% of cases. The rates of accompanying injuries and the resulting complications of traumatic injuries were found to be significantly higher.

Regarding treatment modalities, primary repair was the most frequently performed intervention, accounting for 66.7% of EI cases, whereas conservative management was employed in 33.3% of cases. The data suggest that primary esophageal repair may be more effective and associated with fewer complications than conservative management, and that primary repair should be selected. This finding could be considered significant evidence supporting the preference for primary repair in the treatment of esophageal injuries (p < 0.05). On the other hand, conservative treatment is the preferred treatment for esophageal cervical injuries.

The choice of nutritional support was total parenteral nutrition in 58 (77.3%), jejunostomy in 9 (12%), and gastrostomy in 8 (11%). The feeding conditions were as follows: in addition to total parenteral nutrition, 58 (77.3%) and 9 (12%) underwent jejunostomy, and 8 (11%) underwent gastrostomy. Nutrition was provided through total parenteral nutrition and nasogastric feeding in cases diagnosed early, within the first 12 hours. In cases of delayed diagnosis, percutaneous endoscopic gastrostomy or jejunostomy was performed. This difference was statistically significant (p < 0.05).

The mean hospital stay (LOS) was 25.69 ±25.508 (5–132) days. Factors affecting LOS were the duration between injury and diagnosis period, etiological factors, and the presence of additional pathology (p < 0.05). The mortality rate was 12%, and 66 patients were discharged. Delayed diagnosis and the consequent increase in complications contribute to an increase in both mortality and morbidity rates. The mortality rate was higher for cervical injuries and in patients who were non-surgically managed. Additional surgical procedures and pathologies were observed more frequently in cervical injuries. A diagnostic time of 24 hours or more and treatment options were associated with higher morbidity and mortality (Table II).

Discussion

Esophageal perforation is a rare but serious medical condition associated with significant morbidity and mortality. Rapid diagnosis and appropriate treatment are crucial for patient outcomes [10]. Most esophageal perforations occur as a result of endoscopic procedures or injuries caused by sharp objects or firearm injuries. Endoscopically related esophageal perforations usually arise during esophageal dilation or other therapeutic interventions rather than diagnostic procedures. Iatrogenic injury frequently occurs in the cricopharyngeal region of the neck, at or just proximal to a pathological esophageal stricture [11–13]. The incidence of instrumental esophageal perforation in the literature has been reported to be as high as 25% [9]. During the removal of foreign bodies from the esophagus, sharp and embedded objects can lead to perforation. In one study, iatrogenic injury was detected in 17.8% of 13,092 patients undergoing endoscopic foreign body removal. Flexible procedures were associated with a 1.4% rate of injury [14]. Another study reported a 22.2% incidence of iatrogenic injury in other instrumental interventions [15]. In our series, the rate was around 20%, consistent with previous studies.

In cases of iatrogenic injury, diagnosis was made after further investigations prompted by clinical suspicion and symptoms. Common symptoms include severe chest pain and dysphagia. In the literature, the most common symptoms are retropharyngeal pain (78%), dysphagia (45%), and odynophagia (38%) [14]. In our study, cervical and thoracic injuries were evaluated separately. Cervical perforations presented with dysphagia (75%), hematemesis, and cough (20%). Thoracic injuries commonly present with back pain and chest pain (34%). Subcutaneous emphysema, pneumomediastinum, or hydropneumothorax may be observed on chest radiographs. A definitive diagnosis was made using contrast esophagography. CT also has high diagnostic value. CT findings such as pneumomediastinum, mediastinal abscess, air-fluid levels, or air in the paraesophageal area raise suspicion of perforation [13, 14]. In one study, contrast imaging for diagnosing esophageal injury was reviewed in a series of 18 patients: 5 showed no contrast leakage, 10 had abscesses without contrast leakage, and 3 had both contrast leakage and abscess [14]. In our study, contrast leakage was observed by esophagography in 46% of patients, while 46% were diagnosed via CT based on findings of leakage and abscess with air-fluid levels. In 6% of patients, diagnosis was made via endoscopy.

Clinical condition, duration between injury and diagnosis, and comorbidities of the patient are the most important determinants of treatment options. The treatment approach for esophageal perforation depends on the patient’s clinical condition, the time interval between perforation and diagnosis, and any underlying disease [16]. The presence of secondary perforation due to esophageal disease remains a major issue [17]. When a diagnosis is made within the first 24 hours, there is general agreement on the need for urgent intervention with primary repair and mediastinal drainage. After 24 hours, survival rates drop significantly, and no single treatment method is considered superior [13, 18]. However, another study reported that the time between injury and diagnosis may not be as critical; even with delayed diagnosis beyond 24 hours, surgical intervention is still recommended [10].

Esophageal perforation carries a high risk of mortality, and the treatment approach is shaped by the location, extent, and etiology of the perforation. Surgical intervention is prioritized in cases of widespread contamination, but in limited and stable perforations, non-surgical approaches can also be employed. Conservative treatment may be preferred in patients with minimal systemic infection signs, spontaneous drainage of contents, and absence of malignancy. However, even in such cases, surgical intervention may become necessary over time, and conservative treatment should be supported by close clinical monitoring [19].

In our study, early diagnosis of esophageal injury was found to be significant. Early diagnosis and primary repair were more successful than conservative methods. In 2 patients, despite diagnosis occurring after more than 30 hours, primary repair was performed. These perforations were managed with stent placement. Successful repair involves debridement of surrounding tissues, separate closure of mucosal and muscular layers, and reinforcement of the injured area with a flap. Pleura, omentum, pedicled intercostal muscle, or pericardial fat tissue may be used as flaps. Excellent results have been achieved in recent years with muscle flaps. These techniques have reduced mortality to 7% and decreased the incidence of fistulas [20, 21]. In cases of massive esophageal necrosis or malignancy [22, 23], reconstruction via transhiatal or thoracic approaches is performed either in the same stage or in a delayed fashion, depending on the patient’s condition and the degree of contamination. For thoracic perforations that were diagnosed late, various treatment strategies have been proposed [5, 24], aiming to drain the infected mediastinum and pleura as well as any gastric secretions in these spaces. Open or closed thoracic drainage, T-tube placement, and rarely extrusion-diversion procedures are commonly used. In cervical perforations, when the safety of repair is uncertain due to widespread inflammation, T-tube placement or simple drainage is preferred. Some authors have advocated extrusion and diversion techniques for complicated perforations [13, 25], although these require a second major surgery. None of our patients underwent such interventions. Outcomes of extrusion and diversion procedures have been inconsistent, and associated mortality rates vary widely [13, 20]. When perforation occurs in the presence of ulceration or benign/malignant disease, resection and esophagogastric replacement may be considered. Radical surgery is required when there is an underlying malignancy. In cases of perforation due to esophageal malignancy, transhiatal esophagectomy with cervical esophagogastrostomy has yielded favorable results. Some authors prefer near-total esophagectomy with cervical anastomosis, which reduces the use of inflamed tissue and allows better lymphatic drainage. In selected patients with limited iatrogenic perforations resulting from procedures such as esophagoscopy, foreign body aspiration, esophageal intubation, pneumatic dilation, or bougienage, medical therapy may be a good alternative to surgery. However, the decision to proceed with conservative therapy must be made urgently and after careful assessment. Some researchers have supported the use of conservative management.

Leakage following esophageal anastomosis or perforation repair prolongs hospital stay, hinders oral hydration and nutrition, and may lead to localized infection or sepsis. Despite appropriate surgical treatment, small fistulas may develop postoperatively and may not completely heal. Effective management of complications is as crucial as early diagnosis. Rapid identification and treatment of post-surgical fistulas, strictures, or stent-related complications are among the key determinants of mortality.

Recently, various forms of esophageal stent placement have been used to treat esophageal fistulas and anastomotic leaks. Endoscopic stent placement is also sometimes preferred in cases of spontaneous esophageal perforation (Boerhaave’s syndrome). In our study, in patients with delayed diagnosis of EI esophageal injury whose vital signs and laboratory findings did not normalize despite medical and surgical treatment, endoscopic stent placement became inevitable. Endoscopic stents were placed in 13.3% of our patients. Except for one, all stents were later removed. One stent could not be retrieved because it became embedded in the esophageal mucosa due to inappropriate stent selection. The patient was in septic shock. The endoscopic stent allowed the patient to stabilize and recover from sepsis. Due to the embedded stent, a second stent was placed following a literature review. These two stents were removed without complications 4 years later, and the patient was discharged without requiring esophagectomy or any other invasive surgical procedure.

Our findings confirm critical decision-making points regarding the diagnosis and treatment of esophageal injury. These data highlight the potential for better survival outcomes with early diagnosis and proper treatment. Even with optimal management, esophageal perforations are associated with a high mortality rate of up to 13.5% [8, 9]. Due to their high morbidity and mortality rates, esophageal perforations have a poor prognosis. Delayed diagnosis and the resulting increase in complications are associated with higher mortality and morbidity rates. EI is of vital importance due to its location and anatomical configuration. Despite advances in surgical techniques, intensive care, and antimicrobial therapy, mortality rates in modern series still range between 12% and 50%. One study reported a mortality rate of 33%, while another reported 5.3% [10]. In our study, the mortality rate was 12%. Mortality and morbidity may vary by anatomical location. One study found mortality rates of 50% for cervical, 33% for thoracic, and 16.7% for abdominal injuries [15]. In our series, cervical perforations had the highest mortality, at 52%.

The management of esophageal injuries requires a multidisciplinary approach. The patient’s clinical condition, location, cause, and timing of the perforation are key factors in determining the treatment strategy. While surgical repair remains the gold standard in many cases, minimally invasive techniques and endoscopic stent placement are gaining importance as effective and safe alternatives in selected patients. Conservative treatment may also be considered in carefully selected cases. By integrating the principles of stenting with continuous negative pressure therapy, the use of this innovative approach enables effective drainage, defect closure, and tissue granulation. Future studies focusing on combined therapies and innovative minimally invasive techniques are expected to improve further the management of this complex clinical condition [13]. The results suggest that primary esophageal repair may offer advantages, including fewer complications, compared with conservative management. While these findings are promising, further evidence is needed before drawing definitive conclusions about its preference in the treatment of esophageal injuries. Limitations include the retrospective design and single-center data, which may affect generalizability. Future prospective multicenter studies are needed to further refine treatment algorithms.

Conclusions

Esophageal perforation is a critical clinical condition requiring urgent intervention, with delayed diagnosis and treatment associated with significant morbidity and mortality. In our study, iatrogenic causes were predominant, and early diagnosis was shown to be a key determinant of survival. Contrast esophagography and computed tomography provided high diagnostic sensitivity, while treatment strategies varied depending on the localization, etiology, and timing of diagnosis. Early surgical repair and, in selected cases, endoscopic stent placement in delayed presentations yielded favorable outcomes. Higher mortality rates observed in cervical perforations likely reflect the anatomical complexity of this region. Our findings underscore the importance of timely diagnosis, appropriate imaging, and individualized treatment strategies in the effective management of esophageal perforations.