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2006 Abstracts: Repair of Esophageal Perforation: A Diversified Approach
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Repair of Esophageal Perforation: A Diversified Approach
Chance D. Felisky1, Elizabeth M. Kline2, Donald E. Low1; 1Dept of General, Thoracic, & Vascular Surgery, Virginia Mason Medical Center , Seattle , WA ; 2Dept of Thoracic Surgery, Charleston Thoracic, Charleston , SC

Objective: Esophageal perforation has a diverse presentation and high mortality rate. Outcomes have been linked to timing of diagnosis, location and extent of injury, and physiologic status. We believe the experience of the managing team, particularly with respect to the accurate assessment and appropriate application of the initial approach to repair, has become increasingly important due to the evolution of treatment alternatives. Methods: Records were reviewed for all patients treated at our institution with a diagnosis of esophageal perforation between June 1989 & June 2005. Results: 60 patients with esophageal perforation were treated in the study period. Mean age was 65.2 years (range 22-96), with 38 males and 22 females. Mean ASA was 3.0. Perforations were categorized as iatrogenic (n=37), barogenic (n=21), spontaneous (n=1) and abnormal esophagus (n=1). Locations included cervical (n=12), middle (n=5), and distal (n=44). Mean time to diagnosis was 33.2 hrs (range 1-360). 75% were diagnosed early (</=24 hours), and 25% late (>24 hours). Whenever feasible, UGI studies were done or repeated with the surgical team present. 50% of all patients presenting in the last 5 years were managed non-operatively, 18 over the entire study period. 42 patients were managed operatively. Mean time to operation was 29.9 hours (range 2-240). 31 underwent primary repair, 6 underwent resection (including revision of two defunctioning procedures that were performed prior to transfer to VMMC), and 7 underwent operative drainage alone. 7 Celestin tubes and 2 T-tubes were used. Intra-operative endoscopy was utilized in 17 patients. Mean LOS was 19.6 days (range 3-86). 33 complications occurred in 25 patients; 38% in the early group, 53% in the late. There were 2 deaths in the non-operative group and 1 death in the operative group, for an overall mortality rate of 5%. Conclusions: The use of an UGI contrast study viewed in real time by the managing surgeon for accurate assessment and planning, and the use of intra-operative endoscopy to precisely locate the perforation, assess mucosal integrity, and evaluate the quality of repair, have increased the opportunity for primary repair. This factor, along with selective utilization of intra-operative stents, T-tubes, and resection will avoid the necessity for defunctioning procedures. The incidence of non-operative management is increasing. In our operative experience, delay in diagnosis leads to an increase in complication rate but not mortality. Selection of the appropriate initial procedure is key to the best long term outcome and will decrease the overall mortality and morbidity in these complex patients.


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