Oesophageal Perforations in Iceland: a Whole Population Study on Incidence, Aetiology and Surgical Outcome

Abstract

Background: Oesophageal perforation is a rare but life-threatening condition with a significant morbidity and mortality. In this retrospective, nationwide study, the results of oesophageal perforation are reported for a well defined cohort, with special emphasis on the incidence, aetiology and results of surgical treatment. Material and Methods: 29 consecutive patients (16 males) were diagnosed with perforation of the oesophagus at Landspitali University Hospital between 1980 and 2007. Patients had a mean age of 61 years (range: 7 months–90 years). Type of surgery, complications and survival were recorded. Average follow-up was 76 months. Results: Age-standardised incidence of oesophageal perforation was 3.1/1 000 000 per year during the study period. Out of 29 patients diagnosed with oesophageal perforation, the diagnosis was missed in 5 cases (17 %) and first made at autopsy. Iatrogenic injury was the most frequent cause (52 %), followed by spontaneous perforation (24 %) and foreign body ingestion (17 %). Thoracic perforations were seen in 73 % of patients, and 14 patients had an underlying oesophageal disease. Nineteen patients were treated surgically, in 16 cases with drainage of the mediastinum via thoracotomy and insertion of chest tubes. The median time from perforation to surgery was 6.5 h and median length of hospital stay was 15 days (range: 9–83). All surgically treated patients survived surgery, and the 5-year overall survival rate was 69 %. Conclusion: More than half of all oesophageal injuries in Iceland are caused by a iatrogenic injury. Mortality is significant and is related to a missed diagnosis. Patients treated surgically all survived surgery; however, complications were frequent and their hospital stay was long.

Key words

oesophageal perforation - incidence - symptoms - aetiology - treatment - survival

References

• 1 Brinster C J, Singhal S, Lee L, Marshall M B, Kaiser L R, Kucharczuk J C. Evolving options in the management of esophageal perforation.  Ann Thorac Surg. 2004;  77 1475-1483
• 2 Gondal G, Johanson E, Johannessen H O, Hofstad B. Behandling av oesophagusperforatjoner.  Tidsskr Nor Legeforen. 2008;  9 1050-1052
• 3 Wright C D, Mathiesen D J, Wain J C, Moncure A C, Hilgenberg A D, Grillo H C. Reinforced primary repair of thoracic esophageal perforation.  Ann Thorac Surg. 1995;  60 245-249
• 4 Linden P A, Bueno R, Mentzer S J et al. Modified T-tube repair of delayed esophageal perforation results in a low mortality rate similar to that seen with acute perforations.  Ann Thorac Surg. 2007;  83 1129-1133
• 5 Johnson E, Lundell L, Liedman B. Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations.  Dis Esophagus. 2005;  18 262-266
• 6 Jones 2nd W G, Ginsberg R J. Esophageal perforation: a continuing challenge.  Ann Thorac Surg. 1992;  52 534-543
• 7 Bufkin B L, Miller J I, Mansour K A. Esophageal perforation: emphasis on management.  Ann Thorac Surg. 1996;  61 1447-1452
• 8 Gupta N M, Karman L. Personal management of 57 consecutive patients with esophageal perforation.  Am J Surg. 2004;  187 58-63
• 9 Kollmar O, Lindemann W, Richter S, Steffen I, Pistorius G, Schilling M K. Boerhaave's syndrome: primary repair vs. esophageal resection – case reports and meta-analysis of the literature.  J Gastrointest Surg. 2003;  7 726-734
• 10 Wang N, Razzouk A J, Safavi A et al. Delayed primary repair of intrathoracic esophageal perforation: is it safe?.  J Thorac Cardiovasc Surg. 1996;  111 114-122
• 11 Brauer R B, Liebermann-Meffert D, Stein H J, Bartels H, Siewert J R. Boerhaave's syndrome: analysis of the literature and report of 18 new cases.  Dis Esophagus. 1997;  10 64-68
• 12 Altorjay A, Kiss J, Vörös A, Szirányi E. The role of esophagectomy in the management of esophageal perforations.  Ann Thorac Surg. 1998;  65 1433-1436
• 13 Port J L, Kent M S, Korst R J, Bacchetta M, Altorki N K. Thoracic esophageal perforations: a decade of experience.  Ann Thorac Surg. 2003;  75 1071-1074
• 14 Vogel S B, Rout W R, Martin T D, Abbitt P L. Esophageal perforation in adults – aggressive, conservative treatment lowers morbidity and mortality.  Ann Surg. 2005;  241 1016-1023
• 15 Cameron J L, Kieffer R F, Hendrix T R, Mehigan D G, Baker R R. Selective nonoperative management of contained intrathoracic oesophageal disruptions.  Ann Thorac Surg. 1978;  27 404-408
• 16 Freeman R K, Van Woerkom J M, Ascioti A J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.  Ann Thorac Surg. 2007;  83 2003-2008
• 17 Kiev J, Amendola M, Bouhidar D, Sandhu B S, Zhao X, Maher J. A management algorithm for esophageal perforation.  Am J Surg. 2007;  194 103-106
• 18 Kaplan E L, Meier P. Nonparametric estimation from incomplete observations.  J Am Stat Assoc. 1958;  53 457-481
• 19 Chung D A, Ritchie A J. Videothoracoscopic drainage of mediastinal abscess: an alternative to thoracotomy.  Ann Thorac Surg. 2000;  69 1573-1574
• 20 Cho S J, Kim Y D, Hoseok I, Lee S K, Jeong Y J. Treatment of mediastinitis using video-assisted thoracoscopic surgery.  Eur J Cardiothorac Surg. 2008;  34 520-524
• 21 Nguyen N T, Follette D M, Roberts P F, Goodnight J E. Thoracoscopic management of postoperative esophageal leak.  J Thoracic Cardiovasc Surg. 2001;  121 391-392