OPERATIVE AND NONOPERATIVE MANAGEMENT OF ESOPHAGEAL PERFORATIONS

During a 21-yr period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had spontaneous perforation, 9 patients (11%) had foreign body related perforation and 7 patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus 8 thoracic perforations, contained in the mediastinum, were treated with antibiotics, i.v. hydration and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the 9 patients who died were operated on more than 24 h after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).