The Society of Thoracic Surgeons (2026) Expert Consensus Document on Management of Esophageal Perforation.

BACKGROUND: Esophageal perforation is an uncommon but life-threatening condition that occurs spontaneously or as an iatrogenic injury following endoscopic intervention. The aim of this document was to provide a multi-disciplinary consensus on the diagnosis, treatment and follow-up for patients with suspected esophageal perforation. METHODS: A multidisciplinary panel from the Society of Thoracic Surgeons (STS) convened to develop consensus recommendations for the diagnosis and management of esophageal perforation. Evidence was identified through systematic searches of PubMed and Embase (2010-2024) using the the Population-Intervention-Comparator-Outcome (PICO) framework, and statements were finalized through a modified Delphi process requiring greater than 75% agreement among experts. RESULTS: Ten distinct recommendation statements were developed based on available literature. The statements all achieved greater than 75% consensus from all authors. The recommendations endorse the use of CT esophagram over fluoroscopic esophagram for diagnosis and the option of omitting imaging altogether in the event of spontaneous pneumomediastinum. There is a paucity of randomized control trials comparing endoscopic approaches for therapeutic management. However, current literature supports an array of endoscopic approaches based on technical aspects of the perforation and individual experience and skill. CONCLUSIONS: Early diagnosis with CT esophagram and individualized management emphasizing endoscopic approaches such as stenting or vacuum therapy optimize outcomes in esophageal perforation. Multidisciplinary, patient tailored decision making guided by available evidence and expert consensus remains essential given the limited high quality data.