Esophageal perforation
A. E. Flynn, E. D. Verrier, L. W. Way, A. N. Thomas and C. A. Pellegrini
Department of Surgery, University of California Medical Center, San Francisco.
Sixty-nine patients with perforation of the esophagus were treated at the
University of California, San Francisco, from 1977 to 1988. The perforation
was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a
result of external trauma in 23 (33%). Clinical findings included chest
pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59
patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms
demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays
of more than 24 hours occurred in about half of spontaneous and iatrogenic
perforations, but when the perforation was due to external trauma,
treatment was delayed infrequently. Operative therapy in 59 (86%) of the
patients included primary closure in 44 patients, drainage alone in 9
patients, and Celestin tube placement in 1 patient. Four patients with
benign strictures had esophagectomy, and 4 patients with achalasia had
Heller myotomy in addition to closure of the perforation. Eight (12%) of
the patients were treated nonoperatively. For thoracic perforations,
nonoperative treatment was reserved for patients who were diagnosed late
but who had minimal evidence of sepsis. Seven (10%) of the patients died.
Factors that influenced outcome included cause of perforation, anatomic
location, and patient age. Our study shows that a high index of suspicion,
aggressive use of esophagography, and individualized treatment are
necessary for the best results when treating esophageal perforation.
