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BACKGROUND: Perforation of the esophagus is a challenging problem and can induce devastating complications. Although there are endoscopic and surgical treatment options available, the optimal management strategy remains unclear. The aim of this study was to evaluate the treatment and outcome of patients with esophageal perforations in an academic referral centre with a multidisciplinary specialist group for esophageal diseases.
METHODS: The records of all patients who were diagnosed with esophageal perforation between 2004 and 2011 were reviewed. Patients who underwent primary surgery were compared to patients who were treated endoscopically.
RESULTS: The study population consisted of 47 patients with a median age of 64 years. Cervical perforation was seen in 9 patients (19%), thoracic in 25 (53%) and abdominal in 13 (28%). The cause of perforation was iatrogenic in 29 patients (62%) and spontaneous in 17 (38%). The median time to diagnosis was 12 hours. The size of the perforation was >10mm in all cases. Surgical therapy (primary repair or esophagectomy) was performed in 26 patients (55%); 6 cervical, 11 thoracic and 9 abdominal perforations. Definitive endoscopic therapy (stent implantation or primary closure with clips) was performed in 21 patients (45%); 3 cervical, 14 thoracic and 4 abdominal perforations. Of these 47 patients, 16 (36%) died after a median time of one month. The mortality rate was significantly higher in patients with thoracic perforation who underwent endoscopic therapy (Table). There was no significant difference between the groups regarding time to diagnosis, perforation size and cause of perforation.
CONCLUSION: The results of the study suggest that thoracic perforation of the esophagus can not be managed endoscopically and thus should be treated with early surgery, independently from the cause of perforation or time to diagnosis. Cervical or abdominal perforation can be treated endoscopically in a high proportion of patients.

Mortality of patients who underwent surgical therapy compared to patients who underwent endoscopically therapy

	Surgical Therapy	Endoscopic Therapy	p-value*
Cervical Perforation	1/6 patients (16%)	0/3 patients (0%)	0.3
Thoracic Perforation	3/11 patients (27%)	10/14 patients (71%)	0.04
Abdominal Perforation	2/9 patients (22%)	0/4 patients (0%)	1.0