Treatment of oesophageal perforation: a multivariate analysis

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.     

Perforation and rupture of the esophagus. Apropos of 35 cases

A series of 35 oesophageal perforations from the period 1980-1987 is reported. Sixteen perforations followed oesophageal endoscopy, 10 were spontaneous, 8 were due to foreign bodies and one was post-operative. The delay in reaching the right diagnosis was less than 24 hours in 18 cases and more than 24 hours in 17 cases. Oesophageal leak was demonstrated in 86% of our cases by contrast study; in the others by rigid oesophagoscopy. Perforation occurred in the cervical oesophagus in 6 patients, thoracic oesophagus in 28 and abdominal oesophagus in 2 (one had a double perforation). Three patients were managed non operatively and survived. Cervical oesophagostomy and oesophageal diversion were used in 4 patients as primary treatment because of perforation occurring in caustic burn cases (2 cases, both survived) or late severe sepsis (2 cases, both died). Two patients with neoplastic stricture were treated by oesophago-jejunal bypass without resection and partial oesophago-gastrectomy respectively: both survived. Direct suture and closure of the perforation were performed in 26 patients. Two died, one because of oesophageal leak. Post-operative localized leaks developed in 5 other patients without any mortality and 4 healed with conservative management. The overall mortality rate was 11% (4 patients). All had a delayed diagnosis (more than 48 hours). We suggest that even in patients with delayed diagnosis of a non-malignant oesophageal perforation, direct suture and closure should be attempted under protection of functional oesophageal diversion and "contact drainage" to canalize a possible post-operative localized leak. Good oesophageal diversion can be achieved by naso-oesophageal suction and gastric suction through gastrostomy or with oesogastric antireflux procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Esophageal perforation: a therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.     

An Eastern perspective on oesophageal perforation: a high incidence of ingested bones

Background: Oesophageal perforation is uncommon, with controversy surrounding its optimal management. Our local experience shows a high incidence of oesophageal perforation secondary to ingested bones. Methods: Fourteen patients with oesophageal perforation treated at Changi General Hospital in Singapore between January 1996 and December 2006 were retrospectively reviewed. Results: The median age was 52 years (16–79 years), with eight men and six women. There were 11 thoracic perforations and 3 cervical perforations. Ten perforations were the result of foreign body ingestion, three were spontaneous and only one was iatrogenic. The offending foreign body was a fish bone in five patients, a chicken bone in four and a tooth in one. Three of our 14 patients were treated surgically. The remaining 11 patients were treated non‐operatively. All nine patients with fish or chicken bone perforation were treated conservatively, except two in whom conservative therapy failed and they subsequently required surgery. The median length of hospital stay was 7 days (2–109 days). There was one death. Conclusion: Oesophageal perforation requires prompt diagnosis and treatment. Most of our oesophageal perforations are secondary to ingested bones. Such cases can often be treated conservatively in our experience.     

Treatment of perforation in the healthy esophagus: analysis of 12 cases

Background Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. Materials and methods We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. Results Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis—more than 24 h after the perforation event—seems to be the only factor correlated with fatal outcome (p = 0.045). Conclusions The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.     

Instrumental perforations of the oesophagus and their management.

The records of 39 patients who had developed a perforation of the oesophagus after instrumentation were reviewed. Ten (group A) had cervical and 29 (group B) thoracic oesophageal perforation. Twenty three perforations occurred during dilatation of an oesophageal stricture, 10 during oesophagoscopic removal of a foreign body, and six during diagnostic oesophagoscopy. Of the 21 patients treated within 36 hours (early treatment group), four (19%) died; of the 18 treated more than 36 hours after the perforation (late treatment group), nine (50%) died. None of the 10 patients in group A had strictures and only two presented late. After drainage of the neck and mediastinum the outcome was successful in all patients. Thirteen of the 29 in group B were treated early and four of these died; nine of the 16 treated late died, the total mortality for thoracic perforation being 48%. An oesophageal stricture was present in 23 patients. Twelve of these underwent various forms of conservative surgery and there were 10 deaths. This contrasts with the 11 who received radical treatment with resection and reconstruction, only two of whom died. The six patients with no pre-existing stricture were treated with conservative forms of surgery, with one death.     

A report of three cases with an oesophageal perforation treated with a coated self-expanding stent

A perforation of distal oesophagus in benign cases occurs usually as a complication of endoscopic procedures or due to perforating external trauma. Perforations caused by blunt trauma are rare and usually involve high-energy accidents. The time of diagnosis, severity of the perforation, degree of mediastinal and pleural contamination and treatment are the most important factors predicting the outcome. Treatment may be conservative, comprise primary suturation or include oesophageal resection. We present three cases with a benign oesophageal perforation, which we have treated with a coated stent. One of the cases suffered from a thoracic oesophageal perforation due to a lesser trauma, while the other two cases are perforations caused by complications of endoscopy.     

Mechanical injuries of the esophagus

The authors have observed 15 patients with perforation of the oesophagus in the cervical (6) and thoracic (9) portions. Four patients died (26,8%). The authors consider that the operation of choice for the perforation of the oesophagus must be the operation of closure of the oesophagus wound or resection of the altered and perforated oesophagus, especially for injuries in the thoracic portion.     

Surgical treatment of cancer in the middle 3d of the esophagus]

19 cases with carcinoma of the middle third of the oesophagus were treated by resection in one session by laparotomy and right thoracotomy: in two cases with instrumental perforation substitution of the oesophagus by stomach via the retrosternal route--in 15 cases resection and high intrathoracal oesophagogastrostomy--in 2 cases resection and colon interposition because of previous gastric resection. 2 patients died postoperatively. 2 patients survived more than 5 years. There is an indication for resection in all functionally and technically operable cases.     

Management of esophageal perforations: the value of aggressive surgical treatment

BACKGROUND: The treatment of esophageal perforation remains controversial, particularly in terms of the type of operative therapy. This report analyzed results of an aggressive treatment protocol. METHODS: Patients with esophageal perforations in a normal esophagus or those with a motor disorder were treated by operative closure. All defects were buttressed or closed by either muscle or pleura. Sternocleidomastoid muscle was used to buttress or primarily close the defects in the neck, and a flap of diaphragm was often used for thoracic perforation. Patients with perforated cancer or severe underlying disease had an esophagectomy. RESULTS: Sixty-four patients had operation: 50 underwent preservation of the esophagus after closure of the perforation and 14 underwent resection. The leak rate was 17%, but all healed. One patient treated with primary closure died (1.5% mortality); only 1 patient required subsequent esophagectomy. Thirteen of 14 patients treated with esophagectomy had an excellent result. CONCLUSION: The aggressive approach to esophageal perforations with attempt at uniform closure or resection of severe disease produced excellent results with reduced morbidity and low mortality.     

Conservative management of iatrogenic oesophageal perforations--a viable option.

OBJECTIVE: Iatrogenic Oesophageal perforations are a dreaded complication and there is no consensus as to their best management. The aim of our study was to assess the results of conservative management in these cases. METHODS: Twenty-six patients with iatrogenic perforations of the oesophagus treated over a 10-year period were reviewed retrospectively. They were managed conservatively by keeping them nil by mouth on intravenous fluids and intravenous antibiotics. Out of these 26, nine were patients of carcinoma of the oesophagus while the remaining 17 had benign pathologies. Twenty-two were diagnosed within 6h, while the remaining four were diagnosed over 24h after perforation. Twenty-three of the 26 were caused by oesophageal dilatations. RESULTS: Twenty-two (84.6%) of the 26 survived on this regimen. Out of the four that died, two had advanced carcinomas and died of chest complications, one died of a myocardial infarction and the fourth was an old debilitated man who died of renal failure. All four who died had extension of the leak into the pleural cavity. Early diagnosis and treatment is of critical importance and is only possible by maintaining a high index of suspicion. CONCLUSIONS: Conservative management when applied to cases of iatrogenic oesophageal perforations gives results comparable to or better that those reported in series where early surgical intervention was practised. Extension of the leak into the pleura carries a worse prognosis.     

Management of Esophageal Perforation

Despite recent advances in thoracic surgery, the management of esophageal perforation remains problematical and controversial. Thirty-one patients were treated for an esophageal perforation between 1986 and 1998. The esophageal perforation was iatrogenic in 25 cases, spontaneous in 2, traumatic in 2, and caused by a tumor and tuberculous lymphadenitis in 2 patients. There were 10 cervical, 19 thoracic, and 2 abdominal perforations. The interval from perforation to operation was less than 24 h in 12 patients and more than 24 h in 19 patients. The surgical procedures included a primary repair in 12 patients, a resection in 8, and conservative treatment with minor surgical approaches in 11. The mortality rate was 20% (4/20 patients) in the surgical treatment group and 45.5% (5/11 patients) in the conservative treatment with minor surgery group. The overall mortality was 29% (9/31 patients). The prognosis is thus concluded to depend on the cause and location of the perforation, the presence of underlying esophageal diseases, and the surgical procedure chosen. Received: October 12, 1999 / Accepted: May 30, 2000     

Diagnosis and management of esophageal perforations.

Esophageal perforation remains a difficult diagnostic and management problem. Recommendations regarding treatment remain controversial. A 15-year experience with perforation of the esophagus from all causes was reviewed at Louisiana State University and Veterans Administration, Medical Centers (Shreveport, LA). The majority of the injuries involved the thoracic esophagus (28 or 54%), followed by the cervical (21 or 40%), and the intraabdominal esophagus (3 or 6%). Iatrogenic causes constituted most of the injuries (52%), followed by external trauma (23%), barogenic rupture (15%), and ingested foreign bodies (10%). Diatrizoate methylglucamine 66 per cent, sodium diatrizoate 10 per cent (Gastrografin; Squibb, Princeton, NJ) contrast studies and flexible esophagoscopy were performed in 44 and 22 patients, respectively. In the cervical esophagus, contrast studies were more sensitive and specific than endoscopy (P less than .01), but both studies were equally effective as diagnostic methods in thoracic perforations. Cervical perforations were treated with either drainage alone (7 patients) or primary repair with drainage (14 patients) with an operative mortality of 4.8 per cent. Several procedures were used in thoracic perforations, which carried a mortality of 36 per cent and were more lethal than cervical tears (P less than 0.2). Any thoracic esophageal perforation treated more than 24 hours after the onset of symptoms, irrespective of what procedure was used, was associated with a significantly higher mortality than if operated on earlier (P less than .001). Five patients with perforated carcinomas were treated by esophageal resection with no mortality. Significantly higher mortality was seen with a delay in diagnosis, thoracic perforations, and Boerhaave's Syndrome. A subset of patients with perforated carcinomas may benefit from esophageal resection with delayed reconstruction.     

Esophageal Perforation

Esophageal perforation can be caused by any instrument, device, or foreign body reaching the hypopharynx. Diagnosis remains difficult. If esophageal perforation is suspected, Gastrografin (meglucamine diatrizoate) swallow study, eventually followed by barium swallow study, is the most useful diagnostic test. Absolute rules cannot be made about the selection of nonoperative or surgical treatment. If diagnosed early, cervical or thoracic esophageal perforations can sometimes be treated conservatively if there are no signs of systemic sepsis. Recurrent leakage after surgical closure is not unusual. Local tissue flaps can reinforce the closure, particularly after delayed operation, thereby often avoiding the necessity for a reoperation or an esophageal exclusion.     

Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality

OBJECTIVE: To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation. SUMMARY BACKGROUND DATA: The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress. METHODS: From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement. RESULTS: Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2. CONCLUSIONS: Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.     

Foreign body perforation of the normal oesophagus.

Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (> 48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesophagoscopy. A third of the perforations were cervical, the remainder intrathoracic. All patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment.     

Treatment of Early and Delayed Esophageal Perforation

Esophageal perforations are life threatening emergencies associated with high morbidity and mortality. We report on 22 consecutive patients (age 20–86; 13 female and 9 male) with an oesophageal perforation treated at the university hospital Duesseldorf. The patients' charts were reviewed and follow-up was completed for all patients until demission, healed reconstruction or death. Patients' history, clinical presentation, time interval to surgical presentation, and treatment modality were recorded and correlated with patients' outcome. Six esophageal perforations were due to a Boerhaave-syndrome, eleven caused by endoscopic perforation, two after osteosynthesis of the cervical spine and three foreign body induced. In 7 patients a primary local suture was performed, in 4 cases a supplemental muscle flap was interposed, and 7 patients underwent an oesophageal resection. Four patients were treated without surgery (three esophageal stent implantations, one conservative treatment). Eleven patients (50 %) were presented within 24 h of perforation, and 11 patients (50 %) afterwards. Time delay correlates with survival. In 17 (80.9 %) cases a surgical sufficient reconstruction could be achieved. One (4.7 %) patient is waiting for reconstruction after esophagectomy. Four (18.2 %) patients died. A small subset of patients can be treated conservatively by stenting of the Esophagus, if the patient presents early. In the majority of patients a primary repair (muscle flap etc.) can be performed with good prognosis. If the patient presents delayed with extensive necrosis or mediastinitis, oesophagectomy and secondary repair is the only treatment option with high mortality.     

Personal management of 57 consecutive patients with esophageal perforation

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.     

Perforation and rupture of the oesophagus: treatment and prognosis

AIM OF THE STUDY: To analyze treatment and prognosis of perforations and ruptures of the oesophagus. MATERIAL AND METHODS: This retrospective study included 40 patients (26 men and 14 women; mean age = 59 +/- 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic (n = 6) or following ingestion of a foreign body (n = 1). Thirty-three perforations were thoracic: iatrogenic (n = 15), spontaneous rupture (n = 14), following ingestion of foreign body (n = 3) or traumatic (n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture (n = 13), oesophagectomy (n = 11) or double exclusion (n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body). RESULTS: The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion. CONCLUSION: Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.     

Endoclipping of iatrogenic colonic perforation to avoid surgery

BACKGROUND: Colonoscopy is an established tool for the diagnosis and management of colonic and rectal pathology. Even though colonic perforation is rare after colonoscopy, it is a serious and typical complication. The definitive management remains controversial. Both operative and nonoperative techniques have been described in the literature, though the standard treatment for these patients is still an operative repair of the perforation site. Recently, endoscopic clip application was recommended, particularly for iatrogenic perforations, but less is known about the effectiveness of endoluminal repair of colonic perforations with clips. METHODS: In this series, 7589 colonoscopies were performed over a 34-month period in a tertiary-level referral center. Three perforations occurred during 5413 diagnostic colonoscopies. Therapeutic colonoscopy was under taken in 2176 patients, resulting in a total of 27 perforations. Out of 30 patients with colonic perforation, five patients underwent operative management and 25 patients were subsequently treated nonoperatively. RESULTS: In 27 patients, endoscopic application of inert metallic clips was used for closure of iatrogenic perforation. Twenty-five of these patients were treated non-operatively, while two patients underwent surgery. The mean postoperative length of hospitalization for patients was 12.2 days, compared to 3.5 days for patients treated conservatively. CONCLUSIONS: Endoluminal repair of colonic perforations with clips and further conservative treatment seems to provide a tool that avoids the major additional trauma associated with laparotomy or laparoscopy and minimizes the length of hospitalization.