Spectrum of oesophageal perforations and their influence on management

Abstract

Background: Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.Methods: All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed.Results: There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days. Conclusion:The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis

“…In general a specialist multidisciplinary approach, considering the patients' condition on one hand and the particular characteristics and dynamics of the oesophageal perforation on the other hand, is the key to an optimal treatment [215,[218][219][220][221][222][223].…”

Emergency Oesophagectomy for Oesophageal Perforation after Chemoradiotherapy for Oesophageal Cancer

“…The Northern Oesophago-Gastric Unit (Newcastle upon Tyne, UK), for example, observed a mortality rate of 24% in a series of 101 patients with oesophageal perforation. 9 Oesophageal perforation after chemoradiotherapy for oesophageal cancer is an even more desperate situation. If management by non-operative means is not feasible, emergency salvage oesophagectomy remains as a last resort to save the patient's life.…”

Against all odds. Conservative management of Boerhaave’s syndrome

“…Patients with minimal signs of sepsis and contained perforations can heal with non-operative conservative management consisting of broad-spectrum antibiotics, strict oral hygiene and total parenteral nutrition 2 17…”