Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?

Abstract

A best evidence topic was written according to a structured protocol. The question addressed was, ‘Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?’ Seven papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 147 patients from the studies had oesophageal perforation, while 86 had oesophagectomies for delayed oesophageal perforation (DOP; defined as a perforation diagnosed after 24 h) and 57 had conservative procedures. The mortality rate ranged from 0 to 18% for patients with oesophagectomies, increasing to 50% with double exclusion and reaching as high as 68% in primary repair. In one report, it was found that conservative procedures inflicted higher morbidity than oesophagectomy, which eliminated the perforation, the source of sepsis and the underlying oesophageal disease; another study came to the same conclusion. One study concurred that oesophageal perforation was a surgical disease and only a few cases qualified for conservative procedures. In a review of 34 patients who had DOP, 19 were treated with conservative procedures and 15 oesophagectomy; the mortality rate for patients treated by conservative procedures was 68%, whereas it was 13.3% for patients treated by oesophagectomy. In another study, among the patients treated with conservative procedures, at least one required an additional operation and about 33.3% of patients who survived had continued difficulty with swallowing. In four of the studies, the authors observed that oesophagectomy for DOP was a better surgical option, which decreased mortality, and one study compared the treatment outcome between conservative procedures and oesophagectomy. The primary end-point in all the studies was elimination of the source of sepsis by extirpating the perforated oesophagus in comparison with conservative procedures. However, the consensus of opinion in all the presented evidence was in support of the theory that oesophagectomy was safer and better than conservative procedures. In conclusion, oesophagectomy for DOP was superior to conservative procedures. The limitation of the present review was the lack of many randomized controlled trials.

INTRODUCTION

A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].

THREE-PART QUESTION

In [a patient presenting with a benign oesophageal perforation] is [oesophagectomy] superior to [conservative therapy] in terms of [mortality and morbidity]?

CLINICAL SCENARIO

You had carried out an oesophagectomy as a way of extirpating the local sepsis in a young man who presented with delayed oesophageal perforation and evidence of severe sepsis. The condition of the patient deteriorated, and he died 24 h after surgery. The arguments were in favour of not adopting such an aggressive surgical option, because it was believed to have exacerbated the response to trauma and worsened the patient's clinical state. Instead, the option would have been simply to drain with insertion of a chest tube and possibly a laparatomy and ligation of the gastroesophageal junction until the patient was stable. Thinking of what will guide your decision should another patient present with same condition, you resort to a literature search.

SEARCH STRATEGY

The literature search was done by MEDLINE from 1966 to November 2011 using the PubMed interface (oesophagectomy [All fields] OR esophagectomy AND delayed AND oesophageal perforation [All fields] OR esophageal perforation [mesh terms] OR oesophageal [All fields] AND perforation [All fields] OR esophageal perforation [All fields] AND mortality [subheading] OR mortality [All fields] OR mortality [mesh terms]). The reference citations of the articles found through these searches were also reviewed for relevant articles.

SEARCH OUTCOME

One hundred and fifty papers were found using the reported search. Of these, seven papers were identified that provided the best evidence to answer the question. The results are tabulated in Table 1.

Table 1:

Best evidence papers

Author (date), journal, country Study type (level of evidence)	Patient group	Key results	Outcome	Comments
Sutcliffe et al. (2009), Ann R Coll Surg Engl, UK [2] Retrospective study (level 3)	11 patients had thoracic DOP	6 with DOP had surgery performed and 4 had conservative procedure	For patients with DOP, mortality was higher in patients managed conservatively (75 vs 17%; not significant)	Surgery was superior to conservative procedures The kind of surgical intervention was not explicit
Bresadola et al. (2008), Langenbecks Arch Surg, Italy [3] Retrospective study (level 3)	14 patients met the inclusion criteria	6 patients had oesophagectomy	Thoracic lesions with associated sepsis demand an aggressive approach such as oesophagectomy	Fair sample size Compared group of patients No follow-up
Orringer and Stirling (1980), Ann Thorac Surg, USA [4] Retrospective study (level 4)	11 patients had DOP	Oesophagectomy eliminated the perforation and source of sepsis, while conservative procedures often inflicted more morbidity than oesophagectomy	The mortality rate was 3 (13%) for both early and delayed groups	The mortality rate was not separated between the early and delayed groups No follow-up
Altorjay et al. (1998), Ann Thorac Surg, Hungary [5] Retrospective study (level 3)	16 (59.3%) of the 27 patients who had DOP had oesophagectomy	Oesophageal resection was a valid approach even in cases of DOP	The hospital mortality rate was 3.7% (1 of 27). Postoperative complication rate was 14.8 for oesophagectomy vs 25.9% for conservative procedure	Good sample size Severity of sepsis graded Good follow-up Summed up mortality
Salo et al. (1993), J Thorac Cardiovasc Surg, Finland [6] Retrospective study (level 3)	34 had DOP with mediastinal sepsis	19 patients had conservative procedures; 15 had oesophagectomy	The mortality rate was 68% of patients who had conservative procedure vs 2 (13%) who had oesophagectomy (p = 0.001)	Compared patients who had conservative procedure with those who had oesophagectomy Good sample size No follow-up
Iannettoni et al. (1997), Ann Thorac Surg, USA [7] Retrospective study (level 3)	42 patients had DOP associated with benign oesophageal disease	26 had conservative procedures (primary repair) and 16 had oesophagectomy	For the patients with conservative procedure, 13 required at least one additional operation, whereas the 15 who had oesophagectomy required no further operation. One of 3 patients with conservative procedures had continued difficulty with swallowing and required further interventions	Patients were followed up and outcome was described
Tettey et al. (2011), Tropical Doctor, Ghana [8] Retrospective study (level 4)	10 patients with DOP	3 patients had conservative procedures; 7 patients had oesophagectomy	Mortality rate was 1 of 7 (14.3%) for the oesophagectomy group Fewer cases are qualified for conservative procedure	Small sample size; non-randomized

DOP: delayed thoracic oesophageal perforation.

RESULTS

Sutcliffe et al. [2] described 11 patients presenting with delayed oesophageal perforation (DOP), one of whom was unfit for surgery. Of the remaining 10, immediate surgery was performed in six, while four were treated conservatively. For patients referred late, mortality was higher in patients managed conservatively (75 vs 17%; not significant). Surgery appeared to be superior to conservative treatment for patients referred with delayed oesophageal perforation.

Bresadola et al. [3] reviewed the records of seven patients who were treated for thoracic oesophageal perforation and compared the treatment strategy with that for six patients with cervical oesophageal perforation. Six patients with thoracic oesophageal perforation underwent oesophagectomy. It was concluded that thoracic oesophageal lesions with associated sepsis or major loss of substance demanded an aggressive approach, with oesophagectomy being the best and safest option.

In the report by Orringer and Stirling [4], 24 patients with intrathoracic oesophageal perforations were treated by oesophagectomy. Thirteen patients had early oesophageal perforation and 11 patients had DOP. There were three hospital deaths (13%). Conservative procedures for a perforation with pre-existing esophageal disease often inflicted more morbidity than oesophagectomy, which eliminated the perforation, the source of sepsis and the underlying oesophageal disease.

Altorjay et al. [5] reviewed 27 patients who underwent oesophagectomy for perforation of the thoracic oesophagus. Among the 27 patients who were treated by oesophagectomy, 16 had DOP. The hospital mortality rate was 3.7% (1 of 27). They stated that oesophagectomy definitively eliminated the source of intrathoracic sepsis, the perforation and the affected oesophagus.

Salo et al. [6] carried out a review of 34 patients who had DOP with mediastinal sepsis. Nineteen patients had conservative procedures and the remaining 15 were treated by oesophagectomy. The mortality rate in the patients with conservative management was 13 of 19 (68%), whereas the mortality rate for oesophagectomy was two of 15 (13.3%). They concluded that in the management of DOP with mediastinal sepsis, oesophagectomy was superior to conservative procedures, which often led to mediastinal leakage, continued sepsis and even death.

Iannettoni et al. [7] reviewed 42 patients with intrathoracic oesophageal perforation associated with benign oesophageal disease, 26 of whom had conservative procedures and 16 of whom underwent oesophagectomy. Among the patients treated with conservative procedures, at least one additional operation was required in 13 patients. Of the 15 patients treated by oesophagectomy, none required further operative treatment. In conclusion, approximately one-third of patients surviving conservative management of oesophageal perforations had continued difficulty with swallowing and required oesophageal dilatation or esophageal reconstructive procedures, or a combination of both. Oesophagectomy was a better option in those patients with strictures or diffuse oesophageal disease.

Tettey et al. [8] described 16 patients with oesophageal perforation. Ten of these patients had DOP, of whom three received conservative management, whereas seven had oesophagectomy. They concurred with the fact that oesophageal perforation was a surgical disease and only a few cases may qualify for conservative management.

CLINICAL BOTTOM LINE

The evidence supports the notion that oesophagectomy is not only a way of extirpating the local sepsis in the thoracic cavity, but also of eliminating the dual soilage from the oral cavity and the stomach, and that oesophagectomy in such critically ill patients with delayed and irreparable oesophageal perforations is safer and more effective than conservative procedures. The limitations of the present study include the lack of randomized controlled trials and lack of follow-up.

Conflict of interest: none declared.