Esophageal perforation: the importance of early diagnosis and primary repair

Abstract

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.

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

“…If pain and subcutaneous emphysema develop following the surgical instrumentation, perforation should be suspected. Pain has been emphasized as the most common symptom in EP [1,7], and was observed at a level of 59% in our series.…”

“…These most commonly result from endoscopic manipulation or dilatations or as a complication of paraesophageal surgery, and account for up to 75% of published cases [3,[5][6][7]. In our series too, iatrogenic causes were the most important factor in EP, at a rate of 62%.…”

“…The symptoms of EP vary depending on the location, primary cause and time of rupture [1,7,8]. Common clinical manifestations of EP include chest pain, dysphagia, dyspnoea, subcutaneous emphysema, epigastric pain, fever, tachycardia and tachypnea.…”

Outcomes after oesophageal perforation: a retrospective cohort study of patients with different aetiologies

“…Surgery remains the mainstay of treatment; the conventional operative approach is considered to be primary repair of the perforation site and drainage. [7][8][9] Some surgeons advocate primary repair only for those patients presented within 24 hours of perforation, 10 while others would try primary repair as the initial treatment regardless of the timing of presentation. 9,11 Endoscopic treatment, including stenting, is becoming an increasingly popular means of treating oesophageal perforation in selected patients, and reportedly has a high technical success rate.…”

“…Contamination with food particles is common. Operative treatment with primary closure of the perforation and drainage is favoured by many [7][8][9] ; this is also our preferred approach. Many surgeons advocate primary repair irrespective of the timing of presentation.…”