Tu1770 Esophageal Perforation: Review of Outcomes From a Single-Institution Series

Background: Esophageal perforation is an important therapeutic challenge. The aim of this study was to review the outcomes of esophageal perforations treated by a specialized unit in esophageal surgery. Methods: We performed a retrospective review of 52 consecutive patients with non-neoplasic esophageal perforation, between January 1991 and December 2008. Demographics, cause and location of perforation, time of diagnosis, management results and outcomes were evaluated. The management and outcomes trends over time were evaluated. For that, the cases were catalogued in three groups of 6 consecutive years. Results: Spontaneous perforation occurred in 9 (17,3%) patients. Iatrogenic perforations were present in 15 (28,8%) patients and 28 (53,8%) patients had traumatic perforations. In half of the patients diagnosis was done in the first 24 hours. The perforation's location was cervical in 14 (26,9%) cases, thoracic in 31 (59,6%) and abdominal in 7 (13,5%). The traumatic perforations were diagnosed significantly later than the other causes (p=0,02). In 9 patients (17,3%) the treatment was non-operatively. For the patients submitted to surgery (82,7%), a primary repair was done in 23 cases (53,5%), a bipolar exclusion was performed in 18 (41,9%) and a conservative operative approach (drainage only) performed in 2 (3,8%). There were significant differences in the type of operative treatment according to the location (p=0,035) [thoracic perforations were more times treated with bipolar exclusion]. In the analysis of the trends over time, there were significant differences in the location (p=0,027) and the type of management (p=0,012) [more patients treated surgically with primary repair in the last periods]. The morbidity and mortality rates were 46,2% and 13,5%, respectively. There were significant differences in morbidity according to the cause of perforation (p= 0,047) [the iatrogenic perforations had less morbidity] and the type of management (p= 0,041) [the patients treated conservative either operatively or non-operatively had lower morbidity rate], but only the type of management was an independent risk factor in the logistic regression analysis (OR 0,071, CI95% 0,007-0,696, p=0,003). There were significant differences in mortality according to the age (p=0,022) [older patients with higher mortality rate] and age was an independent risk factor in multivariate analysis (OR 1,095, CI95% 1,003-1,196, p=0,005). There weren't significant differences in morbidity and mortality rate over time. Conclusion: An approach to esophageal perforation based on injury severity and the degree of mediastinal and pleural contamination is of paramount importance. Although operative management remains the standard in the majority of patients with esophageal perforation, non-operative management may be successfully implemented in selected patients with a low morbidity rate.