title: Evolving management strategies in esophageal perforation: surgeons using nonoperative techniques to improve outcomes.
abstract: BACKGROUND
  Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes.
  
  
  METHODS
  Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality.
  
  
  RESULTS
  Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative.
  
  
  CONCLUSIONS
  Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.
authors.affiliation: Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA.
authors.forename: Madhan Kumar
authors.initials: MK
authors.lastname: Kuppusamy
authors.forename: Michal
authors.initials: M
authors.lastname: Hubka
authors.forename: Chance D
authors.initials: CD
authors.lastname: Felisky
authors.forename: Philip
authors.initials: P
authors.lastname: Carrott
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Kline
authors.forename: Richard P
authors.initials: RP
authors.lastname: Koehler
authors.forename: Donald E
authors.initials: DE
authors.lastname: Low
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004724:Endoscopy; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018529:Nutritional Support; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult