Current management of esophageal perforation: 20 years experience

Abstract

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

The Success of Surgery in the First 24 Hours in Patients with Esophageal Perforation

“…Patients were monitored using contrast CT on the 5 th day and discharged on the 6 th day. In conclusion, EP is a rarely encountered and challenging condition requiring early diagnosis and accurate treatment to prevent morbidity and mortality [20]. Our experience suggests that early diagnosis and primary repair of EP should be urgently applied in order to achieve favourable postoperative results.…”

“…Non-operative management of EP is appropriate in the selected patients with well-contained perforations, intramural perforations, benign defects, absence of sepsis and minimal mediastinal and pleural contamination. This therapy involves a total prohibition of oral food intake for a minimum of 7 days, administration of broad spectrum antibiotics and parenteral hyperalimentation [14,[16][17][18][19]20]. In our series, 2 patients received conservative treatment [14][15][16][17][18][19][20].…”

“…This therapy involves a total prohibition of oral food intake for a minimum of 7 days, administration of broad spectrum antibiotics and parenteral hyperalimentation [14,[16][17][18][19]20]. In our series, 2 patients received conservative treatment [14][15][16][17][18][19][20]. Broad spectrum antibiotic therapy, prohibition of oral food intake for 5 days and parenteral hyperalimentation were applied in these cases [15].…”

Traitement endoscopique des perforations iatrogènes

“…Le traitement endoscopique est plus difficile pour l'oesophage cervical : les endoprothèses y sont souvent mal tolérées et le manque de recul peut compromettre la réalisation d'une fermeture directe de la perforation [21]. En cas de perforation oesophagienne sur une achalasie, une néoplasie résécable, une sténose caustique, ou si la perforation est très étendue (> 2 cm), un traitement chirurgical d'emblée est souhaitable [22]. Le traitement endoscopique est surtout indiqué dans le cas d'une perforation visualisée immédiatement au cours du geste initial.…”

Endoscopic closure of iatrogenic perforation

“…For instance, cervical esophageal perforation had the lowest mortality rate at 0% to 5.9%, followed by 10.9% to 16.7% in thoracic esophageal perforation, whereas abdominal esophageal perforation had the highest mortality at 13.2% to 16.7%. 5,15 The other factor that influenced the mortality rate was timing of detection, the mortality rate was reported to be at 3.0% to 7.4% when perforation diagnosed within 24 hours whereas the mortality rate would be as high as 20.3% to 36.4% when the diagnosis was made after 24 hours.…”