The influence of the 'golden 24-h rule' on the prognosis of oesophageal perforation in the modern era

Abstract

Objectives: Rupture of the oesophagus is a surgical emergency with significant morbidity and mortality. We present our experience in managing such patients in a tertiary care cardiothoracic unit.

Methods: We conducted a retrospective clinical review of patients who were admitted following rupture of the oesophagus over a period of 6 years (2002-2008).

Results: In our unit, there were 27 admissions following isolated rupture of the oesophagus, of which 18 were males and nine were females. The median age was 65 years (range 22-87). Twenty-four (89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Primary surgical repair was done in 21 (77%) patients, a two-stage repair in 8% and conservative management in 16.6%. Mean hospital stay was 31 days (range 13-80 days). Overall, in-hospital mortality was five out of 27 patients (18.5%). Time from onset of symptoms to diagnosis of oesophageal perforation was early (<24 h) in 17 (63%) patients and late (>24 h) in the remaining 10 (37%) patients. In four out of the five non-survivors, there was a >24-h delay in diagnosis. The mortality rate among patients with a delayed diagnosis was 40% compared to 6.2% among those who were diagnosed in <24 h (p=0.047).

Conclusions: Our review confirms that an early diagnosis and management ('golden 24 h') are crucial for successful outcome in patients with rupture of the oesophagus. We reiterate the importance of critical care support, particularly in the early stages of management. For early detection, the primary and secondary care sectors need to be better educated.