Twelve hours after upper GI endoscopy with dilation, a patient has mild neck discomfort and a low-grade fever. CT with oral contrast shows a small contained leak from the cervical oesophagus that drains back into the oesophageal lumen, with no mediastinal collection and no systemic sepsis. What is the most appropriate management?

• A Immediate open primary repair with buttressed closure
• B Emergency oesophagectomy with gastric pull-up
• C Conservative management with nil by mouth, broad-spectrum antibiotics, and nutritional support ✓
• D Placement of a fully covered self-expanding metal stent across the leak

Explanation

Instrumentation injuries that are small, contained, drain freely back into the oesophagus, involve the cervical oesophagus, and occur in a sepsis-free patient have excellent outcomes with conservative management: nil orally, parenteral nutrition, and antibiotics. Aggressive surgery is reserved for free mediastinal contamination, uncontained leaks, or progressive sepsis. Oesophagectomy is a last resort for destroyed oesophagi, and stenting is considered when conservative measures fail rather than as first choice here.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.