Management of Esophageal Perforations

Background: Perforation of the esophagus remains a life threatening event, which requires rapid diagnosis and treatment. Possible therapeutic modalities are surgical repair, interventional endoscopic or conservative treatment.
Objectives: We were interested to examine our experience on the management of esophageal perforations with the aim to find parameters for the recommendation of the best therapeutic modality.
Methods: From 1998 to 2006 we treated sixtytwo patients with esophageal perforation and performed a retrospective analysis. Data were evaluated for cause of perforation, symptoms, therapeutic regimen, complications and mortality.
Results: Causes of perforation were iatrogenic or suicidal (n=33), or spontaneous (n=29). In the first group, the causes were dilatation 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 sponatenuos perforations were caused by tumors (n=19), Boerhaave syndrome (n=6), unknown origin (n=3), and Barrett’s ulcer (n=1). Most frequent symptoms were dysphagia (n=50), pain (n=35), fever (n=24), and vomiting (n=18). Twentyeight patients had a malignant tumor at the time of perforation, which was an esophageal cancer in eighteen cases. The treatment included surgery (n=32), which consisted of double layer oversuture and covering with adjacent tissue (n=26), or of esophageal resection (n=6). Thirty patients were treated interventionally with implantation of a stent (n=21), clipping (n=1), or conservatively without further measures (n=8). Patients of the surgery group presented a severe primary and postoperative general condition with renal failure (25%), respiratory insufficiency (65.5%), and need of Catecholamines (62.5%). This multiorgan involvement we found only occasionally in the interventional endoscopic and conservative group. During the posttherapeutic course, we observed a fistula in nineteen patients (30.6%), which occurred after stenting (n=14) or after surgery (n=5). The fistulas were treated conservatively (n=16), or surgically (n=3). Overall hospital mortality was 14.5% (n=9) and was similar in the surgery group (n=5) and the interventional or conservative group (n=4).
Conclusion: The choice of the best therapeutic modality has to be done still individually. It appears that surgical treatment is necessary in cases of severe general conditions. Interventional stenting or conservative treatment may be sufficient in case of localized mediastinitis with good general condition of the patient.

Session: Podium Presentation

Program Number: S033

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