The Success of Surgery in the First 24 Hours in Patients with Esophageal Perforation

Objective: Esophageal perforation (EP) is a critical and potentially life-threatening condition with considerable rates of morbidity and mortality. Despite many advances in thoracic surgery, the management of patients with EP is still controversial. Materials and Methods: We retrospectively reviewed 34 patients treated for EP, 62% male, mean age 53.9 years. Sixty-two percent of the EPs were iatrogenic. Spontaneous and traumatic EP rates were 26% and 6%, respectively. Three patients had EP in the cervical esophagus and 31 in the thoracic esophagus. Results: Mean time to initial treatment was 34.2 hours. Twenty patients comprised the early group <24 h) and 14 patients the late group (>24 h). Management of the EP included primary closure in 30 patients, non-surgical treatment in two, stent in one and resection in one. Mortality occurred in nine of the 34 patients (26%). Mortality was EP-related in four patients. Three of the nine patients that died were in the early group (p<0.05). Mean hospital stay was 13.4 days. Conclusion: EP remains a potentially fatal condition and requires early diagnosis and accurate treatment to prevent the morbidity and mortality.


Introduction
Since esophageal perforation (EP) was originally described more than 50 years ago, the diagnosis has been challenging, its management is controversial and mortality is high [1].The clinical course of EP essentially depends on the location and the extent of the injury as well as the time elapsing between the perforation and the start of the treatment [2].Primary surgical repair is the treatment of choice in early diagnosed EP.Surgical treatment of old or recurrent EP, however, is associated with local and systemic sepsis, which is often accompanied by significant morbidity and mortality [3].Despite the use of broad spectrum antibiotics and improved nutritional support, the mortality rate in EP is more than 20% [4].The aim of this report is to review the diagnostic examination, treatment and outcomes of 34 patients with EP.

Materials and Methods
Written informed consent was obtained from the patients.Thirty-four patients (n=34) with EP were evaluated in this study.These were retrospectively reviewed on the basis of age, gender, primary disease, etiology, perforation site, diagnostic methods, time to presentation, specific treatment methods, morbidity, mortality, survival and the cause of death.They were then divided into early (n=20) and late (n=14) groups (Tables 1 and 2).
Esophageal perforation was located in the cervical esophagus in 3 patients (9%) and in the thoracic esophagus in 31 (91%).The interval between the rupture and initial treatment ranged from 1 to 148 h (mean 32.9 h).Twenty patients comprised the early group (<24 h) (1 to 23 h, mean 8.1 h) and 14 the late group (>24 h) (26 to 148 h, mean 75.8 h).Table 4 shows the characteristics of the patients in the early and late groups.Pain was the most common symptom in 20 of the 34 patients (59%).Other symptoms included dyspnoea in 14 patients (41%), dysphagia in 12 (35%) and fever in 6 (18%).Subcutaneous emphysema was recorded in 7 patients (21%).
Esophageal perforation was diagnosed using contrast computerized tomography (CT) in 17 patients and esophagography in 10.Subcutaneous emphysema was detected in chest x-rays of 3 patients and during endoscopy in 4.
Primary closure was performed in 30 patients.Two patients received non-surgical treatment, while stenting was performed in one patient and resection in another.Eight patients were supported with flap following the primary closure, 4 with intercostal muscle, 2 with parietal pleura and 2 with diaphragm.All patients received antibiotic therapy and fluid resuscitation.The mainstay of a non-operative treatment was broad spectrum antibiotics, hyper alimentation and nasogastric suction.
We re-operated on 8 (3 in the early group) of the 30 patients: 4 had leakage (one patient in the early group.All were closed primarily.Three were supported with intercostal flap and one with diaphragm), 2 had abscess (one cervical and one thoracic perforation in the early group) and one had mediastinal abscess drainage (cervical perforation).Tube thoracostomy was performed on one patient in the early group to treat empyema.
Complications occurred in 11 patients (4 in the early group) (32%), in the form of leakage in 4 patients, sepsis in 3 (one patient had respiratory failure), abscess in 2, descending necrotizing mediastinitis in one patient and empyema in one.Overall mortality in the 34 patients was 26% (nine patients).Four of these died due to EP.One patient (aged 73) died on the 45 th day postoperatively due to electrolyte imbalance, 3 patients died from primary disease (2 from inoperable lung cancer, one from sarcoma) and one died from tracheainnominate artery fistula on the 60 th day postoperatively (this patient received a tracheostomy tube).A significant difference was determined between the mortality rates of the patients in the early (<24 h) and late (>24 h) groups (p<0.05).
Mean hospital stay was 13.4 days (range 6-40).When discharged, all patients were thought to have a normal diet without dysphasia.

Discussion
Esophageal perforation still represents a diagnostic and therapeutic challenge in spite of the increased clinical experience and innovations in surgical technique.Signs of EP have been described previously in the literature [1].Although EP was first described by Boerhaave in 1724, the first successful surgical repair was reported by Barrett in 1947 [1,3].
Iatrogenic perforations are the most common cause of EP.These most commonly result from endoscopic manipulation or dilatations or as a complication of paraesophageal surgery, and account for up to 75% of published cases [3,[5][6][7].In our series too, iatrogenic causes were the most important factor in EP, at a rate of 62%.Cervical perforation of the esophagus is generally less severe and more easily treated than intrathoracic or intraabdominal perforation.Intrathoracic perforations cause rapid contamination of the mediastinum [1].Cervical perforation was encountered in 3 patients (9%) in our series.
Diagnosis of EP can be difficult, as the presentation is often non-specific and mimics other disorders, such as spontaneous pneumothorax, myocardial infarction, aortic dissection, peptic ulcer, pancreatitis and pneumonia.The symptoms of EP vary depending on the location, primary cause and time of rupture [1,7,8].Common clinical manifestations of EP include chest pain, dysphagia, dyspnoea, subcutaneous emphysema, epigastric pain, fever, tachycardia and tachypnea.If pain and subcutaneous emphysema develop following the surgical instrumentation, perforation should be suspected.Pain has been emphasized as the most common symptom in EP [1,7], and was observed at a level of 59% in our series.
Diagnosis can be confirmed using contrast radiography, computed tomography (CT) scans or endoscopy [7].Contrast esophagography remains as the standard method of evaluation in the diagnosis of EP.CT is essential if the location of EP cannot be determined by contrast esophagography [1].In this study, contrast CT and esophagography facilitated the diagnosis of EP in 25 patients.
Intrathoracic EP represents a formidable challenge for thoracic surgeons.EP in intrathoracic esophagus leads to extravasation of oral secretions and intraluminal bacteria as well as gastric contents being refluxed into the mediastinum.Esophageal perforations [11] occurring within 24 h before or after the admission are regarded as early and late, respectively [4].The reported mortality for treated EP is 10% to 25% when treatment is initiated within 24 h of perforation [12].If treatment is delayed or started after 24 h, however, mortality increases (33-66%) [5,11].Nineteen of our 34 patients constituted the early group and 15 the late group.Three patients (16%) in the early group and 6 patients (54%) in the late group died, which is a significant difference.
Treatment of EP is aimed at preventing further spoilage of the EP, control and elimination of the infection, restoration and continuity of the gastrointestinal tract and maintenance of adequate nutrition [1,3].Surgery is still, however, the "gold standard." Various surgical procedures have been described, including the primary repair, reinforced repair, debridement, drainage and esophageal resection with simultaneous or staged (after exclusion and diversion) reconstruction [10].Nonviable tissues are the primary factor in the success of meticulous repair of the mucosal and muscular layers sepa-rately [12].The problem of persistent leakage and deterioration of the primary repair site led to the development of reinforced primary repair, in which tissue grafts are implanted to bolster the repair site [1].The tissues used for the reinforcement of the primary repair include free pericardial patch grafts, vascular pedicled flaps (pleura, diaphragm, intercostal muscle, gastric fundus and rhomboid and latissimus dorsi muscles).Sternothyroid and sternocleidomastoid muscles are also used for cervical perforation [1,13,14].
Conservative treatment of EP remains as a controversial topic.Non-operative management of EP is appropriate in the selected patients with well-contained perforations, intramural perforations, benign defects, absence of sepsis and minimal mediastinal and pleural contamination.This therapy involves a total prohibition of oral food intake for a minimum of 7 days, administration of broad spectrum antibiotics and parenteral hyperalimentation [14,[16][17][18][19]20].In our series, 2 patients received conservative treatment [14][15][16][17][18][19][20].Broad spectrum antibiotic therapy, prohibition of oral food intake for 5 days and parenteral hyperalimentation were applied in these cases [15].Patients were monitored using contrast CT on the 5 th day and discharged on the 6 th day.
In conclusion, EP is a rarely encountered and challenging condition requiring early diagnosis and accurate treatment  to prevent morbidity and mortality [20].Our experience suggests that early diagnosis and primary repair of EP should be urgently applied in order to achieve favourable postoperative results.

Figure 2 .
Figure 2. a-d.Photographs of a patient (Number 27).NG in right hemithorax at PA imaging (white arrow (a)), perforation at CT with oral contrast (b), site of perforation (white arrow shows perforation area (c), parietal flap (black arrow shows flap) (d).

Table 4 . Characteristics of early group and late group patients
*p<0.05