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Introduction
The management of esophageal perforation and mediastinal sepsis is challenging. Treatment strategies differ between surgical units and as a consequence outcomes can vary widely in this patient group. We present our 10-year experience of esophageal perforation and evolving treatment strategy for this condition.
Methods
This was a retrospective review of all esophageal perforations including both patients with a spontaneous or iatrogenic perforation and cases of mediastinal sepsis due to anastomotic leak following cardio-esophagectomy. Patients were grouped according to their treatment strategy. The primary outcome measures were in-hospital death and length of stay (total hospital stay and Intensive Care Unit (ICU) stay).
Results
In total, thirty-seven patients were included. Twenty-five were male with a median age of 59 (range 21-80). Seven patients suffered iatrogenic perforations (3 esophageal dilatations, 2 food bolus removal, 2 gastroscopy). Eleven patients presented following spontaneous esophageal perforations and a further Eighteen suffered anastomotic leaks following cardio-esophagectomy and one leak following cardio-myotomy.
Twenty-six patients underwent surgery for their perforations compared to eleven who were conservatively managed. Surgical management involved either thoracotomy with primary repair or creation of a controlled fistula using a T-tube (20), cardio-esophagectomy (3) or thoracoscopic washout (3). All patients had enteral feeding routes inserted in conjunction with surgery. Conservative management constituted either simple insertion of chest drains (8) or stent placement (3).
Death following non-operative management occurred in 4 patients compared to two (36% vs 7% p<0.05)in those who underwent surgery.
Conclusion
Urgent operative management is a safe treatment option for patients who have oesophageal perforation and are fit to undergo a surgical exploration. Thoracotomy with repair of the perforation over a T-tube with defunctioning gastrostomy, feeding jejunostomy and drainage of the thorax and mediastinum, appears a safe policy and is our preferred approach. Patients with existing esophageal pathology may be considered for emergency cardio-esophagectomy.