Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK

Abstract

Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23-86) years. The etiology of the perforations were Boerhaave's syndrome (n= 19), therapeutic endoscopy (n= 9), diagnostic endoscopy (n= 2), gastric lavage injury (n= 1), foreign body (n= 1), blunt chest trauma (n= 1), and spontaneous tumor perforation (n= 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair (n= 9), T-tube drainage (n= 7), emergency esophagectomy (n= 1), or intra-operative stent insertion (n= 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.

Esophageal Perforation: Clinical Patterns and Outcomes from a Patient Cohort of Western Norway

“…As with several previous studies [5,7,8,11,39,] our results were based on a retrospective evaluation of available data. Morbidity and mortality following esophageal perforation are generally high, although varying between series.…”

A Case of Rapid Diagnosis of Boerhaave Syndrome by Thoracic Drainage

“…Delayed diagnosis and treatment of Boerhaave syndrome, especially more than 24 h after symptom onset, is reportedly fatal (2)(3)(4)(5)(6)(7)(8). The patient in this case received immediate thoracic drainage that confirmed the diagnosis of Boerhaave syndrome, and she was treated rapidly and recovered.…”

“…The time between symptom onset and the correct diagnosis and its relationship to the mortality rate of Boerhaave syndrome are discussed in recent reviews listed in Table 2 (2-8). These articles demonstrate that the mortality rate for patients diagnosed within the first 24 h is significantly lower than for those patients diagnosed after the first 24 h (2)(3)(4)(5)(6)(7)(8).…”

“…Boerhaave syndrome is rare and occurs mainly in males and at the left posterolateral wall of the distal esophagus without any apparent precipitating factor. Previous case reports have focused on clinical features, work-up, and prognosis without any description of how to diagnose and rapidly treat it (2)(3)(4)(5)(6)(7)(8). Delayed diagnosis and treatment are closely associated with prolonged morbidity and increased mortality.…”

A Rare Case of Boerhaave Syndrome Presenting with Right Tension Pneumothorax and Review of the Literature

“…Mackler triad of chest pain, subcutaneous emphysema and vomiting is present in less than 30% of patients [9]. Literature review reveals the presenting complaints are more often vague and non-specific, thus making diagnosis difficult for experienced emergency department physicians, risking delays in definitive life-saving treatment.…”