title: Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience.
abstract: BACKGROUND
  Perforation of the esophagus remains a challenging clinical problem.
  
  
  METHODS
  A retrospective review was performed of patients diagnosed with an esophageal perforation admitted to the London Health Sciences Centre from 1981 to 2007. Univariate and multivariate logistic regression was used to determine which factors had a statistically significant effect on mortality.
  
  
  RESULTS
  There were 119 patients; 15 with cervical, 95 with thoracic, and 9 with abdominal perforations. Fifty-one percent of all the perforations were iatrogenic and 33% were spontaneous. Multivariate logistic regression analysis revealed that patients with preoperative respiratory failure requiring mechanical ventilation had a mortality odds ratio of 32.4 (95% confidence interval [CI] 3.1 to 272.0), followed by malignant perforations with 20.2 (95% CI 5.4 to 115.6), a Charlson comorbidity index of 7.1 or greater with 19.6 (95% CI 4.8 to 84.9), the presence of a pulmonary comorbidity with 13.9 (95% CI 2.9 to 97.4), and sepsis with 3.1 (95% CI 1.0 to 10.1). A wait time of greater than 24 hours was not associated with an increased risk of mortality (p=0.52).
  
  
  CONCLUSIONS
  Malignant perforations, sepsis, mechanical ventilation at presentation, a higher overall burden of comorbidity, and a pulmonary comorbidity have a significant impact on the overall survival. Time to treatment is not as important. Restoration of intestinal continuity, either by primary repair or by excision and reanastomosis can be attempted even in patients with a greater time from perforation to treatment with respectable morbidity and mortality rates.
authors: Division of Thoracic Surgery, The University of Western Ontario, London, Ontario, Canada.
authors: Pankaj
authors: P
authors: Bhatia
authors: Dalilah
authors: D
authors: Fortin
authors: Richard I
authors: RI
authors: Inculet
authors: Richard A
authors: RA
authors: Malthaner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D015331:Cohort Studies; D016001:Confidence Intervals; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery; D004939:Esophageal Perforation / Q000209:etiology / Q000401:mortality* / Q000601:surgery*; D004940:Esophageal Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods; D004945:Esophagoscopy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006785:Hospitals, University; D006801:Humans; D007049:Iatrogenic Disease; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D009864:Ontario; D010166:Palliative Care / Q000379:methods; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012422:Rupture, Spontaneous / Q000601:surgery; D018709:Statistics, Nonparametric; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult