Surgical management of esophageal perforation

The recognition and management of esophageal perforation remain a problem. Diagnostic and treatment delays are common, and controversy continues regarding approaches to surgical intervention. Overall survival has increased with improved adjunctive modalities; however, morbidity and mortality remain high. A total of 115 consecutive cases of nonmalignant esophageal perforation were reviewed. There were 69 thoracic, 27 cervical, and 19 abdominal perforations. Etiology of the perforations was iatrogenic in 65 patients, traumatic in 28, and spontaneous perforation in 22. Symptoms included pain (71%), fever (51%), dyspnea (24%), and crepitus (22%). Contrast roentgenography was used in 78 patients and demonstrated the perforation in all but two patients. All but 20 patients had operations. In the last decade, the survival rate was 11.4 per cent for patients treated within 24 hours of perforation. Survival significantly improved in the last 10 years because of hyperalimentation, cardiopulmonary monitoring, and better antibiotic coverage. Treatment of choice is primary closure with drainage, regardless of the duration of the perforation. In selected patients who have cervical esophageal perforation, nonoperative management has a role.