title: Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality.
abstract: OBJECTIVE
  To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation.
  
  
  BACKGROUND
  The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress.
  
  
  METHODS
  From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement.
  
  
  RESULTS
  Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2.
  
  
  CONCLUSIONS
  Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.
authors.affiliation: Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610, USA. steveb@aol.com
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Vogel
authors.forename: W Robert
authors.initials: WR
authors.lastname: Rout
authors.forename: Tomas D
authors.initials: TD
authors.lastname: Martin
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Abbitt
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015505:Chest Tubes; D003287:Contrast Media; D003974:Diatrizoate Meglumine; D004322:Drainage; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D012189:Retrospective Studies; D014945:Wound Healing
chemical_list: D003287:Contrast Media; D003974:Diatrizoate Meglumine