The management and prognosis of oesophageal perforation

Abstract

Our experience with the management of 28 patients with oesophageal perforation is reviewed. The majority of perforations followed oesophageal instrumentation. The occurrence of pain, fever or cervical crepitus following endoscopy should raise the suspicion of oesophageal perforation. Plain radiographs of the neck, chest and abdomen provided confirmatory evidence of the presence of a perforation in 89 per cent of our cases. Contrast studies of the oesophagus demonstrated the site and extent of the leak in 21 of the 26 cases in which they were performed. The overall mortality for the series was 32 per cent. The mortality for thoracoabdominal perforations was nearly three times that for the cervical segment. Instrumental perforations were associated with a lower mortality than spontaneous perforations or those following paraoesophageal surgical procedures. The coexistence of an oesophageal obstruction with a perforation did not have an adverse effect on the outcome. The time lapse between the occurrence of the perforation and surgical intervention had a profound influence on the morbidity and mortality. Early closure of the perforation with drainage was associated with a 25 per cent mortality for thoracoabdominal perforations and no complications in the survivors. A delay of over 24 h, on the other hand, was associated with a high incidence of septic complications in both cervical and thoracoabdominal perforations, a longer period of drainage and a 50 per cent mortality in the latter group. A plea is therefore made for early surgical intervention in both cervical and thoracoabdominal perforations.