Advisability of concomitant immediate surgery for perforation and underlying disease of the esophagus

Since 1979 our policy for management of esophageal perforation has included correction of underlying esophageal disorder as part of the initial treatment in selected cases. A series of 23 patients is presented, of whom 3 were managed conservatively and 20 surgically. The overall mortality rate was 8.7%. Concomitant operation of underlying esophageal disease and perforation was done in eight cases within 12 hours of the perforation. These operations included emergency resection and esophagogastrostomy in five patients (4 with stenosis and 1 with cancer). A Heller myotomy was done in addition to suture repair in two patients with achalasia, and a Belsey Mark IV hernia repair was added to the esophageal suture closure in a patient with gastroesophageal reflux and hiatal hernia. A postoperative fistula healed spontaneously in one of the eight patients, and the early postoperative course was uncomplicated in the other seven. Simultaneous correction of underlying esophageal disease in patients with iatrogenic perforation of the esophagus seems to be safe when perforation is diagnosed at an early stage. Such a radical approach is clearly beneficial.