Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality

Abstract

Objective: To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation.

Summary background data: The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress.

Methods: From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement.

Results: Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2.

Conclusions: Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.

FIGURE 1. A, An extensive esophageal leak partially drained into a left chest tube. B, CT examination demonstrates a residual posterior collection.

FIGURE 2. A posterior placed radiologic chest tube adequately drains the esophageal leak.

FIGURE 3. A, A radiologically placed “pigtail” catheter drains an extensive esophageal perforation. B, An esophogram demonstrates complete healing.

FIGURE 4. A standard chest tube (A) and a radiologically placed tube (B) drains posterior esophageal perforations.

FIGURE 5. A contained mediastinal perforation heals with a small residual collection following limited thoracotomy and drainage.