Esophageal perforations. The need for an individualized approach.

Since 1971 we have treated 33 patients with esophageal perforation caused by instrumentation in 21 patients, trauma in six, and spontaneous perforation in six. Chest pain, fever, mediastinal air, and an abnormal esophagogram were frequent but not invariable findings. Surgical therapy, consisting of primary repair and drainage in 12 patients, drainage alone in five, esophageal diversion in two, and esophagogastrectomy in one, was initiated within 24 hours in 14 patients, all of whom survived. A delay of more than 24 hours in six patients resulted in 33% mortality. Nine patients with small instrumental perforations were treated successfully with antibiotics alone, while three other patients with late traumatic (n = 2) and spontaneous (n = 1) perforations were treated nonoperatively; all three died. Overall mortality for the series was 15.5%. Except for small contained instrumental injuries, esophageal perforations demand prompt exploration, with primary repair and drainage as the procedure of choice.