Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy.

Treatment for esophageal perforation has traditionally been surgery, but development of more effective antibiotics and parenteral nutrition has led to a cautious trend toward nonoperative management. The goal of this investigation was to identify relevant presenting features that would guide a physician in making the therapeutic choice between medical and surgical therapy. Twenty-five consecutive patients with esophageal perforation--20 iatrogenic and five spontaneous--were reviewed. Treatment was medical in 12 cases and surgical in 13. The findings indicate that many patients with esophageal perforation can be treated medically. The following guidelines are suggested for selecting nonoperative treatment: (1) clinically stable patients; (2) instrumental perforations detected before major mediastinal contamination has occurred or perforations with such a long delay in diagnosis that the patient has already demonstrated tolerance for the perforation without the need for surgery; and (3) esophageal disruptions well contained within the mediastinum or a pleural loculus.