Management of esophageal perforations.
BACKGROUND
Esophageal perforations remain a life-threatening event requiring rapid diagnosis and treatment. Surgical repair and interventional endoscopic or conservative treatment are the common treatment methods.


METHODS
From 1998 to 2006, the authors retrospectively analyzed 62 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, therapeutic regimen, complications, and mortality.


RESULTS
The causes of perforation were iatrogenic or suicidal (n = 33) or spontaneous (n = 29). In the first group, the causes were dilation of stenosis (n = 16), endoscopy (n = 7), transesophageal echography (n = 4), ingestion of acid or leach (n = 2), intubation (n = 2), ingestion of a foreign body (n = 1), and migration of a screw after osteosynthesis (n = 1). The spontaneous perforations were caused by tumors (n = 19), Boerhaave syndrome (n = 6), unknown origin (n = 3), and Barrett's ulcer (n = 1). The most frequent symptoms were dysphagia (n = 50), pain (n = 35), fever (n = 24), and vomiting (n = 18). At the time of perforation, 28 patients presented with cancer. Of these 28 patients, 18 had esophageal cancer. The treatment included surgery (n = 32), which consisted of double-layer suture (n = 26) or esophageal resection (n = 6). A total of 30 patients were treated interventionally with a stent (n = 21), clips (n = 1), or without further measures (n = 8). The patients in the surgery group presented with severe primary and postoperative general conditions including renal failure (25%), respiratory insufficiency (65.5%), and need for catecholamines (62.5%). This multiorgan involvement was found only occasionally in the conservative group. The overall hospital mortality rate was 14.5%, involving 9 patients (5 in the surgery group and 4 in the conservative group). Early treatment led to better survival than late treatment with a delay exceeding 24 h.


CONCLUSIONS
The treatment method still must be chosen on an individual basis. It appears that surgical treatment is necessary in cases of severe general conditions. The data from this study show that surgical repair and conservative treatment may be used successfully. The best outcome was obtained after immediate treatment.
Schmidt
Sven Christian
SC
Department of General, Visceral, and Transplantation Surgery, Charité Campus Virchow Klinikum, Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
Strauch
Stefan
S
Rösch
Thomas
T
Veltzke-Schlieker
Wilfried
W
Jonas
Sven
S
Pratschke
Johann
J
Weidemann
Henning
H
Neuhaus
Peter
P
Schumacher
Guido
G
D000328:Adult; D000368:Aged; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D004945:Esophagoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015607:Stents