Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?

A best evidence topic was written according to a structured protocol. The question addressed was, 'Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?' Seven papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 147 patients from the studies had oesophageal perforation, while 86 had oesophagectomies for delayed oesophageal perforation (DOP; defined as a perforation diagnosed after 24 h) and 57 had conservative procedures. The mortality rate ranged from 0 to 18% for patients with oesophagectomies, increasing to 50% with double exclusion and reaching as high as 68% in primary repair. In one report, it was found that conservative procedures inflicted higher morbidity than oesophagectomy, which eliminated the perforation, the source of sepsis and the underlying oesophageal disease; another study came to the same conclusion. One study concurred that oesophageal perforation was a surgical disease and only a few cases qualified for conservative procedures. In a review of 34 patients who had DOP, 19 were treated with conservative procedures and 15 oesophagectomy; the mortality rate for patients treated by conservative procedures was 68%, whereas it was 13.3% for patients treated by oesophagectomy. In another study, among the patients treated with conservative procedures, at least one required an additional operation and about 33.3% of patients who survived had continued difficulty with swallowing. In four of the studies, the authors observed that oesophagectomy for DOP was a better surgical option, which decreased mortality, and one study compared the treatment outcome between conservative procedures and oesophagectomy. The primary end-point in all the studies was elimination of the source of sepsis by extirpating the perforated oesophagus in comparison with conservative procedures. However, the consensus of opinion in all the presented evidence was in support of the theory that oesophagectomy was safer and better than conservative procedures. In conclusion, oesophagectomy for DOP was superior to conservative procedures. The limitation of the present review was the lack of many randomized controlled trials.