ESOPHAGEAL-PERFORATION - EMPHASIS ON MANAGEMENT

Background. Perforation of the esophagus is a deadly injury that requi res expert management for survival. Methods. We performed a retrospect ive clinical review of 66 patients treated at Emery University affilia ted hospitals for esophageal perforation between 1973 and 1993. Result s. Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower- third injuries occurred in 43 cases (65%), middle third in 14 (21%), a nd upper third in 9 (14%). Early contained perforations were managed s uccessfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural coni ami nation recognized early were managed by primary closure and drainage i n 28 patients. Reinforcement of the primary closure using stomach fund us, pleural, diaphragmatic, or pericardial flap was performed in 16 pa tients. Those perforations that escaped early recognition required tho ughtful management, using generous debridement and drainage and someti mes esophageal resection. The esophageal T tube provided control of le aks in 3 of these patients and was a useful adjunct. Using these manag ement principles, we achieved a 76% survival rate for all patients. Si x patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate . Conclusions. Esophageal perforation remains an important thoracic em ergency. Aggressive operative therapy remains the mainstay for treatme nt; however, conservative management may be preferred for contained pe rforations and the esophageal T tube may be used for late perforations .