The Treatment of Oesophageal Perforations

Abstract

This report reviews 24 consecutive cases of oesophageal perforation which were treated during a 20-year-period at the Thoracic Surgical Clinic, Karolinska Sjukhuset, Stockholm, Sweden. Fourteen perforations followed oesophageal instrumentation, 5 were due to foreign bodies and 5 were spontaneous. Six patients were treated conservatively and survived. Two of 10 patients treated with drainage and antibiotics died of mediastinitis. Surgical closure of the perforation was performed in 8 patients, one of whom died of mediastinitis. The periods of hospitalization were 22, 61 and 32 days, respectively. A survey of the literature on oesophageal perforation (290 cases) revealed 3 factors which mainly affected the prognosis. Firstly, the mode of treatment related to the early mortality rate in that 18% died during conservative treatment, 30% after drainage and 16% following repair. Secondly, the type of perforation appeared to be another determinant of the outcome. Instrumental perforations were associated with a lower mortality rate (12%) than the other types (23%). Thirdly, the time lapse between the occurrence of the perforation and the onset of therapy had a profound influence upon both morbidity and mortality. Early treatment was associated with an early mortality rate of 9%, but increased to 26% following a delay of over 24 hours. Immediate diagnosis and treatment are of vital importance. Repair should be attempted in cases involving perforation of the thoracic oesophagus with a history of less than 24 hours duration, but may be successful even later. Conservative management seems to be justified in elderly patients in poor general condition and with restricted cardiopulmonary reserves.