DELAYED PRIMARY REPAIR OF INTRATHORACIC ESOPHAGEAL-PERFORATION - IS IT SAFE

The management of intrathoracic esophageal perforation with delayed di agnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with es ophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%) . Group A patients were older (p < 0.05) and group B had fewer iatroge nic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patie nts, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not signific ant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyze d. Group A had the lowest proportion of postoperative leaks (A, 0/4 pa tients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of lea k and morbidity did not lead to an increase in mortality. One death oc curred in each group, with an overall mortality of 17% (A, 1/5 patient s, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significan t). We conclude that in the era of advanced intensive care capabilitie s, primary repair of intrathoracic esophageal perforation can be safel y accomplished in most patients regardless of the time interval betwee n perforation and operation. Leakage at the suture site is common unle ss primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result i n an adverse outcome.