Hybrid Minimally Invasive Management of Thoracic Esophageal Perforations: Technical Feasibility in Selected Patients

BACKGROUND: Thoracic esophageal perforation (EP) is a life-threatening emergency. While minimally invasive techniques have been successfully utilized, the heterogeneity of clinical presentations (perforation location, delays in treatment, tissue quality, etc.) has prevented the establishment of a standardized management approach. We present our experience with a minimally invasive management protocol combining thoracoscopy and endoscopy. METHODS: Between December 2023 and January 2025, 5 patients with thoracic EP underwent a thoracoscopic approach. Primary closure via direct suturing, lavage, and drainage was performed when feasible. Persistent leaks were addressed with endoscopic interventions, including vacuum-assisted therapy and stent placement. A retrospective review of patient medical records was conducted. RESULTS: Of the five perforations, four were right-sided, and one was left-sided. Three cases were spontaneous, while two were iatrogenic (one following bariatric surgery and the other after endoscopic dilation). One patient had a perforation associated with malignancy, and another was on long-term high-dose steroid therapy. Management was initiated within 24 hours after the onset of symptoms in 3 patients and after 48 hours in 2 patients. Persistent leaks occurred in 3 patients (two late presentations and one corticosteroid impregnation). There were no fatalities. Esophageal preservation was achieved in all cases, and all patients resumed oral intake by the end of follow-up. CONCLUSIONS: Thoracic EP can be effectively managed using minimally invasive techniques. Avoiding thoracotomy and complex surgical procedures may offer significant benefits for critically ill patients.