Treatment of perforation in the healthy esophagus: analysis of 12 cases.

BACKGROUND: Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. MATERIALS AND METHODS: We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. RESULTS: Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045). CONCLUSIONS: The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

Role of manometry and pH-metry in patients with symptoms and signs of gastroesophageal reflux disease.

To assess the correlation between esophageal manometry and 24-h pH-metry and the clinical, endoscopic and radiological picture, we carried out a retrospective analysis of the data of 175 patients in 2001-2002 with symptoms of gastroesophageal reflux disease and/or the established presence of esophagitis. The data were analyzed on the basis of the mean, standard deviation (SD) and percentage (%). Student's "t"-test was used to calculate statistical significance (P < 0.05). pH-metry was positive in 112 cases (64% R+) and negative in 63 (36% R-). Manometry revealed a significant sphincter hypotonia and a greater involvement of peristalsis in R+ patients. There was no significant relationship between symptoms and response to medical treatment compared to a positive pH-metry. Ninety-three (53%) patients presented esophagitis, while 58 (33%) had a hiatal hernia. Esophagitis was more frequent in R+ patients, while hiatal hernia was equivalent in both groups. In the diagnosis and treatment of gastroesophageal reflux disease, the first step is empirical medical therapy. If symptoms persist, esophagogastroduodenoscopy and barium radiology are performed to evaluate the presence of esophagitis and/or gastroesophageal reflux and any related diseases. Manometry and pH-metry (the gold standard for the diagnosis of gastroesophageal reflux disease) are therefore always performed in patients with atypical symptoms of patients to be subjected to surgical treatment.