The treatment of esophageal perforation with delayed recognition and continuing sepsis

Five patients, recently treated for esophageal ruptures, provided a spectrum of "late" perforations. Treatment was individualized for each patient and ranged from suture closure of the perforation to esophagectomy. Four of the 5 patients survived and now have no dietary restrictions. The goals of treatment should be: (1) elimination of sources of chemical and bacterial soilage; (2) drainage of infected areas; (3) augmentation of host defenses by antibiotics; and (4) provision of adequate nutrition. Several treatment adjuncts, alone or in combination, may be used to accomplish these goals. The selection of treatment methods should be influenced by the site of perforation, the extent of local inflammation, the status of the residual esophagus, the overall status of the patient, and the chronicity of the perforation. As the risk of uncontrolled sepsis increases, the surgeon should take more aggressive and definitive steps, up to and including esophagectomy in certain cases, to prevent further soilage.