The approach depends on the perforation’s location, size, timing, and patient stability:

1. Before Surgery Evaluation:
   
   • Diagnosis:
     
     • Chest X-ray or CT scan with contrast (e.g., Gastrografin swallow) confirms perforation, showing extravasation, pneumomediastinum, or pleural effusion.
     • Endoscopy may identify the perforation site but is avoided if perforation is already confirmed (to prevent worsening).
     • Blood tests assess infection (e.g., elevated WBC, CRP) and organ function.
   • IV fluids, broad-spectrum antibiotics (e.g., piperacillin-tazobactam), and proton pump inhibitors (e.g., pantoprazole) stabilize the patient.
   • A nasogastric tube decompresses the stomach and prevents further leakage.
2. Treatment Approaches:
   
   • Surgical Repair (Primary Repair):
     
     • Performed under general anesthesia, lasting 2–4 hours.
     • Thoracotomy or Laparotomy:
       
       • A left thoracotomy (for distal esophagus) or laparotomy (for abdominal esophagus) provides access.
       • The perforation is identified, typically in the lower esophagus (60–70% of cases).
       • The tear is closed with two-layer suturing (inner mucosal, outer muscular) using absorbable sutures.
       • Surrounding tissues (e.g., pleural flap, omentum) may reinforce the repair.
       • The mediastinum and pleural space are irrigated to remove contamination, and chest tubes are placed to drain fluid or air.
     • Best for perforations diagnosed within 24 hours, with minimal contamination and viable tissue.
   • Endoscopic Management:
     
     • For small perforations (<1 cm) or delayed diagnosis in stable patients.
     • Endoscopic Stenting:
       
       • A covered self-expandable metal stent (SEMS) is placed over the perforation to seal it, allowing healing over 4–6 weeks.
       • Performed under sedation, lasting 30–60 minutes.
     • Endoscopic Clipping:
       
       • Small tears are closed with clips (e.g., over-the-scope clips).
     • Often combined with drainage (e.g., chest tube) for associated effusions.
   • Damage Control Approach:
     
     • For unstable patients or delayed diagnosis (>24 hours) with severe contamination.
     • Esophageal Diversion:
       
       • The esophagus is diverted with a cervical esophagostomy (spit fistula), and the distal esophagus is closed.
       • A feeding jejunostomy tube is placed for nutrition.
     • Drainage:
       
       • Chest tubes or surgical drainage of mediastinal/pleural abscesses.
     • Definitive repair or reconstruction (e.g., esophageal replacement with stomach or colon) is planned weeks to months later.
   • Conservative Management (Rare):
     
     • For small, contained perforations with minimal symptoms, diagnosed early.
     • Involves IV antibiotics, nil per mouth (NPO), parenteral nutrition, and close monitoring.
     • High failure rate (20–30%); often progresses to surgery.
3. After Surgery:
   
   • ICU monitoring for 2–5 days manages sepsis, ventilation (if needed), and nutrition.
   • Hospital stay: 7–21 days, depending on approach and complications.
   • A contrast swallow (7–14 days post-repair) confirms no leak before resuming oral intake.
   • Feeding tubes (jejunostomy or gastrostomy) provide nutrition during healing.