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Ann Thorac Surg 2003;75:1071-1074
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Thoracic esophageal perforations: a decade of experience

^a Department of Cardiothoracic Surgery, Weill-Cornell Medical Center, New York, New York, USA

Accepted for publication October 14, 2002.

^* Address reprint requests to Dr Altorki, Department of Cardiothoracic Surgery, Weill-Cornell Medical Center, 525 East 68th St, New York, NY 10021, USA
e-mail: nkaltork{at}med.cornell.edu

	Abstract

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BACKGROUND: Perforation of the thoracic esophagus is a formidable challenge. Treatment and outcome are largely determined by the time to presentation. We reviewed our experience with esophageal perforations to determine the overall mortality and whether the time to presentation should influence management strategy.

METHODS: A retrospective chart review was performed on all patients treated for perforation of the thoracic esophagus from 1990 to 2001. There were 26 patients (14 men and 12 women; median age, 62 years; range, 36 to 89 years). Fourteen patients presented within 24 hours (early), and 12 patients presented after 24 hours (delayed). Nine of the 12 patients in the delayed group presented after 72 hours. The causes of the perforations were as follows: instrumentation (19 patients), Boerhaave’s syndrome (2 patients), intraoperative injury (1 patient), and other (4 patients). In the early group, 3 patients were treated conservatively, 10 patients underwent primary repair, and 1 patient required esophagectomy for carcinoma. In the delayed group, 3 patients were treated conservatively, 6 underwent successful repair of the perforation, 1 had a T-tube placement through the perforation and eventually required an esophagectomy, and 2 had an esophagectomy as primary surgical treatment.

RESULTS: Hospital mortality was 3.8% (1 of 26) and morbidity was 38% (10 of 26). Persistent leaks occurred in 3 patients, 2 after primary repair and 1 after T-tube drainage. All patients selected for conservative management successfully healed their perforation.

CONCLUSIONS: Primary repair can be carried out in most cases of thoracic esophageal perforation regardless of time to presentation, with a low mortality rate. A small but carefully selected group of patients may be treated successfully without operation. Esophagectomy should be reserved for patients with carcinoma or extensive necrosis of the esophagus.

	Introduction

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Perforation of the thoracic esophagus is a potentially lethal injury. Historically the factor most often associated with a high mortality is a delay in diagnosis. The condition is relatively uncommon, and unless it is temporally related to esophageal instrumentation, perforation of the thoracic esophagus may be easily confused with myocardial infarction, aortic dissection, pancreatitis, or other chest or abdominal emergencies. A delay in diagnosis results in extensive tissue destruction from mediastinal infection and local inflammatory response. These factors may impede a successful primary repair, and the mortality under these circumstances can exceed 50%, often as a result of uncontrolled sepsis or multiorgan failure [1–4]. Although primary repair remains the treatment of choice, some have advocated that a definitive solution lies in esophageal resection in order to prevent ongoing local sepsis [5–8]. The merits of the latter approach remain controversial. In this report, we examined our experience with thoracic esophageal perforations in the past decade with particular emphasis on the impact of time to diagnosis (early vs late), on the choice of treatment strategy, and on hospital outcome.

	Material and methods

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We conducted a retrospective chart review of all patients with thoracic esophageal perforations treated at our institution between January 1990 and December 2001. Patients with cervical esophageal perforations and those with anastomotic disruptions after esophagectomy were excluded. All hospital records and operative reports were examined. The data collected included demographic features, cause of perforation, underlying esophageal pathology, time to presentation, and type of treatment. The time from injury to diagnosis and treatment was defined as early if less than 24 hours, and late if greater than 24 hours. Outcome was determined by the incidence of postoperative morbidity and mortality. Mortality was defined as in-hospital death or death within 30 days of hospital discharge.

	Results

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Patients
A total of 26 patients were treated for thoracic esophageal perforation. Perforation was confirmed in each instance by a barium or water-soluble contrast esophagogram. Of the 26 patients, there were 14 men and 12 women with a median age of 62 years (range, 36 to 89 years). Fourteen patients presented within 24 hours (early group), and 12 patients presented after 24 hours (delayed group), including 9 patients who presented after 72 hours.

In the early group 12 patients had mild transient chest pain that promptly resolved before initiation of therapy, and therefore were considered essentially asymptomatic, whereas 2 patients presented with chest pain, tachycardia, and shortness of breath. In contrast, 11 of 12 patients in the delayed group had chest or epigastric pain, or both, as well as fever and leukocytosis. Five of the 12 patients were in florid sepsis that required mechanical ventilation and vasopressor support. The cause of the esophageal perforation and underlying esophageal pathology are shown in Tables 1 and 2. As in most studies, instrumentation was the most common cause of injury, particularly pneumatic dilation for achalasia.

Ten of the remaining 11 patients were treated by primary repair of the perforation. Six patients had achalasia and were treated with primary repair of the perforation, a long esophagomyotomy, and a Belsey fundoplication that only partially buttressed the repair. Two patients had their perforation after esophagoscopy for foreign body retrieval. One patient had a perforation after dilation of a stricture, and 1patient had postemetic spontaneous rupture (Boerhaave’s syndrome). These latter 4 patients underwent primary repair (2 buttressed and 2 unbuttressed). Finally, 1 patient with esophageal carcinoma underwent esophagectomy with immediate reconstruction.

Delayed group
Three patients were treated conservatively by withholding oral intake, intravenous antibiotics, and parenteral nutrition. One had a spontaneous perforation of the lower esophageal third that was contained within the mediastinum and drained spontaneously into the native esophagus. The other 2 patients had mediastinal abscesses drained by a tube (thoracostomy in 1 patient and cervical mediastinoscopy in the other). Of the remaining 9 patients, 5 had primary repairs (3 buttressed, 2 nonbuttressed). Esophagectomy was the primary treatment in 2 patients. One patient had neglected spontaneous rupture with extensive transmural necrosis of the lower third of the esophagus. Esophagectomy was carried out with delayed reconstruction. A second patient underwent esophagectomy for an unrecognized perforated carcinoma that presented as a parapneumonic empyema. Resection was followed by immediate reconstruction. One patient had T-tube drainage for an unrecognized, intraoperative esophageal injury during the repair of a thoracic aortic aneurysm. Ongoing sepsis, despite T-tube drainage, resulted in esophageal resection with delayed reconstruction. The last patient in this group presented after a failed previous primary repair of a perforation after bougienage for a stricture secondary to Crohn’s disease of the esophagus. Upon transfer the patient had significant cachexia, esophagopleural and bronchopleural fistulas, and a large apical empyema space with underlying entrapped lung. After a period of nutritional support, the patient underwent a second thoracotomy with repair of both fistulas and intercostal muscle flap reinforcement along with decortication and a limited four-rib thoracoplasty to obliterate the empyema cavity. The patient recovered uneventfully.

Outcome
There was no mortality in the early group. There was one death in the late group in a patient with liver cirrhosis and hematemesis treated by a Sengstaken-Blakemore tube with a resultant unrecognized 10-cm esophageal laceration. Primary repair was accomplished, but the patient died of progressive hepatic failure. At autopsy, the esophageal repair was intact. The overall mortality for the whole series was 4%. Ten patients had a complicated postoperative course for an overall morbidity of 38% (Table 3). The most common morbidity was the requirement of prolonged mechanical ventilation (beyond 72 hours) in 7 patients of whom 6 presented with a delayed perforation. A small persistent leak was noted on the postoperative esophagogram in 2 patients after primary repair (both buttressed) and both healed without further intervention. Repair was thus successfully accomplished in all 16 patients in whom it was attempted (10 early, 6 late). Finally, the perforation healed spontaneously in all 6 patients treated without thoracotomy.

	Comment

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The results reported herein, as well as those previously reported in the literature, emphasize that primary repair should be considered the treatment of choice regardless of time to presentation [7, 9–12]. However, some have suggested that patients with delayed or neglected perforations may be better served with an esophagectomy. For example, Salo and colleagues [6] reported on 34 patients with delayed perforations with a mortality of 68% after primary repair and 13% after esophagectomy. The authors concluded that resection is superior to repair in this group of patients. Similar results and conclusions were made by Altorjay and colleagues [5] and Orringer and Stirling [8]. As outlined above, our experience does not support that approach (Table 4). Esophagectomy was carried out in only 3 patients as a primary treatment option; 2 with esophageal cancer, and 1 with extensive esophageal necrosis from a neglected Boerhaave’s syndrome. The value of exclusion and diversion is not addressed by our experience. Although exclusion and diverson is a treatment option that can be exercised in some instances, we believe that stasis and bacterial overgrowth in the excluded esophageal segment may lead to continued mediastinal inflammation and sepsis. Indeed, the reported mortality with this approach is 35% to 40% [9, 13]. Similarly, management by T-tube placement through the perforation has a disappointing mortality in excess of 30% [9]. The single patient in this series managed by a T-tube ultimately required an esophagectomy.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey L. Port Robert J. Korst Nasser K. Altorki Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Port, J. L. Articles by Altorki, N. K. Search for Related Content PubMed PubMed Citation Articles by Port, J. L. Articles by Altorki, N. K. Related Collections Esophagus - other