Contemporaneous management of esophageal perforation

doi:10.1016/j.surg.2009.06.058

Surgery

Volume 146, Issue 4, October 2009, Pages 749-756

https://doi.org/10.1016/j.surg.2009.06.058 Get rights and content

Background

Esophageal perforation is an important therapeutic challenge. We hypothesized that patients with minimal mediastinal contamination at the time of diagnosis could be managed successfully with nonoperative treatment modalities.

Methods

We performed a retrospective review of 119 consecutive patients with esophageal perforation from 1998 to 2008. Demographics, cause of perforation, clinical presentation, diagnostic methods, and management results were evaluated. The decision to operate was based on the extent of mediastinal contamination and systemic sepsis rather than cause of perforation.

Results

Median time to diagnosis among all patients was 12 hours (range, 1–120). Spontaneous (Boerhaave's) perforation occurred in 44 (37%) patients. Iatrogenic perforations constituted the remaining patients (n = 75). After instrumental perforation, 9 patients (13%) required esophagectomy, 48 patients were managed with repair and drainage, and the remaining 18 were managed nonoperatively. All 34 patients undergoing operative therapy for spontaneous perforations were treated with esophageal repair. Overall mortality was 14%, with intrathoracic perforations having 18% mortality, cervical 8%, and gastroesophageal junction 3%. Patients undergoing nonoperative therapy had a shorter hospitalizations (13 vs 24 days), fewer complications (36% vs 62%), and less mortality (4% vs 15%) compared with those undergoing operative intervention.

Conclusion

An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, nonoperative management may be successfully implemented in selected patients with a low morbidity and mortality if favorable radiographic and clinical characteristics are present.

Section snippets

Patients and methods

We conducted a retrospective review of 119 consecutive patients with esophageal perforation at the University of Pittsburgh Medical Center from 1998 to 2008. Approval for this retrospective analysis was obtained from the Institutional Review Board of the University of Pittsburgh. Patients with anastomotic leak were excluded from analysis.

Results

Patient demographics, as well as etiology and location of perforation, are depicted in Table I. The average age of the entire cohort was 62.1 years. Perforation was localized to the thoracic esophagus in 52% of patients. Overall mortality for the entire group was 14%. Thoracic esophageal perforations had the highest associated mortality rate of 18%, followed by the cervical esophagus (8%; P = .33) and gastroesophageal junction (3%; P = .05). Median time to diagnosis among all patients was 12

Discussion

The management of esophageal perforation remains a formidable challenge. Management options include primary repair, repair over a drain, esophageal exclusion, esophagectomy, and nonoperative management in selected patients. Recently, there has been increasing interest in the nonoperative management of esophageal perforation. The term “nonoperative management” is misleading because most of these patients will undergo ≥1 so-called “palliative interventions,” which include endoscopy, stent

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Central Surgical AssociationContemporaneous management of esophageal perforation

Background

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Surg

Am J Surg

Ann Thorac Surg

Management of esophageal perforation

Am J Surg

Central Surgical Association
Contemporaneous management of esophageal perforation