Abstract
Purpose
Evidence is limited for outcomes of surgical versus conservative management for patients with cervical esophageal or hypopharyngeal perforations.
Methods
Patients with cervical esophageal or hypopharyngeal perforations treated between 1994 and 2014 were identified using an institutional database. Outcomes were compared between patients who underwent operative drainage and those who had conservative management with broad-spectrum antibiotics and withholding oral intake.
Results
Twenty-eight patients were identified with hypopharyngeal or cervical esophageal perforations, mostly due to iatrogenic (nasogastric tube placement, endoscopy, endotracheal intubation) injuries (68%). Fourteen were treated initially with conservative management and 14 with initial surgery. Six patients failed conservative treatment and two patients failed surgical treatment. Patients managed conservatively who had eaten between injury and diagnosis ( p = 0.003), those who had 24 hours or more between the time of injury and diagnosis ( p = 0.026), and those who showed signs of systemic toxicity ( p = 0.001) were significantly more likely to fail conservative treatment and require surgery. No variables were significant for treatment failure in the surgical group. Of the 20 patients who ultimately underwent a surgical procedure, two required a second procedure.
Conclusion
Patients who have eaten between the time of perforation and diagnosis, have 24 hours or more between injury and diagnosis, and those that show signs of systemic toxicity are at higher risk of failing conservative management and surgical drainage should be considered. For patients without these risk factors, a trial of conservative management can be attempted.
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Introduction
Perforation of the upper aerodigestive tract is a potentially life-threatening condition. While the etiology and management of thoracic esophageal perforations have been well described , those of the cervical esophagus and hypopharynx are far less common and the appropriate treatment more controversial. Early reports focused on immediate and definitive surgical management of cervical esophageal or hypopharyngeal perforations by transcervical exposure, primary closure of the defect, and the placement of transcutaneous drains . Subsequent authors have emphasized success with conservative management in select patients . By using broad-spectrum prophylactic antibiotics and withholding oral feeding, a conservative strategy may avoid the morbidity associated with surgery. However, there is very limited data to indicate when conservative treatment should be employed. The objective of this study was to evaluate management and outcomes of cervical esophageal and hypopharyngeal perforations from a single, tertiary care center.
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