Conservative management of esophageal perforation after pneumatic dilatation for achalasia

PURPOSE: To assess the results and indications of conservative management of esophageal perforation following pneumatic dilatation for achalasia.PATIENTS AND METHODS: Thirteen esophageal perforations complicating 524 dilatations in 412 patients (3%) were diagnosed by esophagogram. Medical treatment consisted of nasogastric succion, antibiotics and pleural drainage, if necessary. Conservative surgical treatment included left thoracophrenotomy, perforation closure, controlateral myotomy and anterior fundoplication. Surgical decision was based upon clinical and radiological parameters. Functional outcome was assessed by the means of the Eckardt's grading score.RESULTS: Six patients were successfully managed by medical treatment. Seven patients underwent conservative surgery, three of whom after failure of medical treatment. The presence of a pneumomediastinum at initial presentation led to immediate (n=2) or delayed (n=2) surgery in all instances. No patients died. In the surgical group, morbidity consisted of one wound infection, one pleural effusion and one venous thrombosis. One severe chest infection occurred in the medical group. Oral feeding was reintroduced after a median of 10 and 11 days in the surgical and medical groups, respectively. Functional results were satisfactory and similar in both groups.CONCLUSION: Conservative medical or surgical management of oesophageal perforation following pneumatic dilatation is safe, if the diagnosis is done early. Pneumomediastinum at initial presentation seems to predict failure of conservative medical treatment.