In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action.
During a 21-year period, 72 patients were treated for esophageal perforations; the diagnosis was made only at postmortem examination in 13 other patients. Fifty-eight of 85 patients (68%) sustained iatrogenic perforations, 11 patients (13%) had "spontaneous" perforation, nine patients (11%) had foreign body related perforation, and seven patients (8%) had perforation caused by external trauma. Eleven cervical perforations, contained between the cervical paravertebral structures, plus eight thoracic perforations, contained in the mediastinum, were treated with antibiotics, intravenous hydration, and nasogastric drainage. The mortality rate after this nonoperative approach was 16% (3/19 patients). Indications for operative treatment in 53 patients were hydropneumothorax with mediastinal emphysema, sepsis, shock and respiratory failure. The operative mortality rate in these instances was 17% (9/53 patients). Six of the nine patients who died had been operated on more than 24 hours after the onset of symptoms. For cervical perforations the best results were obtained by drainage plus repair of the perforation (mortality rate: 0%; 0/10 patients) and for thoracic perforations by suturing supported by a pedicled pleural flap (mortality rate: 11%; 1/9 patients). Simple drainage of thoracic perforation was followed by a mortality rate of 43% (3/7 patients).
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