| dc.description.abstract | During a 7-year period from January 1981 to December 1987 forty-two patients with perforation of the oesophagus (13 of the upper third, 15 of the middle third and 13 of the lower third) were studied at the Kenyatta National Hospital. There were 33 males and 9 females, aged between one year and seventy-five years, the mean age being 39 years. The incidence of oesophageal perforation showed a gradual increase during the study period.
The commonest presenting features were chest pain, occurring in 30 (71%) cases, cough in 21 (50%) cases, difficulty in breathing 14 (33%) cases, dysphagia in 10 (24%) cases and neck pain 9 (21%) cases. Tachycardia occurring in 33 (78.6%) cases, fever in 32 (76.2%), dyspnoea in 25 (59.5%), reduced air entry
23 (54.82%) and crepitations in 14 (33.3%) cases were the commonest clinical signs. These commonest features were non specific and non-diagnostic of oesophageal perforation.
Diagnosis was usually made from the history of the
oesophageal instrumentation or trauma, the findings of subcutaneous emphysema (13 cases) on physical examination, hydropneumothorax (17 cases) and mediastinal emphysema (4 cases) on chest X-rays, and extravasation during barium or dianosil swallow (12 out of 19 cases tested). Oesophagoscopy was performed on 18 patients and provided positive information in 14.
On the basis of clinical history and examination, cervical and chest X-rays, dianosil or barium swallow and oesophagoscopy the various aetiological groups were identified.
Instrumentation was the major cause of oesophageal perforation
accounting for 15 (36%) cases. The experience of the endoscopist did not seem to correlate with the frequency of perforation as 9 were caused by consultants and 6 by registrars. The second commonest cause of perforation was post-paraoesophageal surgery which accounted for 21% (9 cases) of the total. Oesophageal
disease was responsible 7 perforations, ingested foreign body for
6, penetrating trauma for 2 and two
rupture of the oesophagus. Majority
patients had spontaneous
of the perforations (36%)
occurred in the middle third of the oesophagus and most of them were on the right side (48%).
Twenty five patients were treated medically, and seventeen were treated surgically. The surgical procedures used were repair of perforation alone, closure of perforation and reinforcement using pleural flap, resection of perforation site and anastomosis, gastrostomy alone, neck exploration and drainage, oesophageal ligation and gastrostomy, oesophageal substitution by colonic by-pass, and insertion of Mousseau-Babin tube. The poorest results were obtained with resection and anastomosis as both patients died in the immediate post-operative period. Of all the definitive curative procedures, closure of perforation and reinforcement with a pleural flap appeared to offer the best results for intra-thoracic perforation.
The over-all mortality rate was 28.8% (12% for the medically treated and 16.8% for the surgically treated). In interpreting the results of treatment, the location of the-perforation, the nature of the oesophagus before the perforation (normal or diseased) and the delay in initiating treatment were found to be major factors
in determining the outcome. There were no deaths among the 13 patients with upper third perforations, and for middle and lower third perforations, mortality was increased four to sixfold when treatment was delayed beyond 24 hours.
This study suggests that perforation of the oesophagus is not a rare condition and it seems to be on the increase. Physical and X-ray findings are often non-diagnostic, and hence, a high index of suspicion is required for the diagnosis. Drainage alone may suffice for cervical oesophageal perforations. For intra thoracic perforations, wide drainage of the chest and primary repair of the perforation and plication of the suture line with pleura or any other form of flap provide superior results.
However, an individualized plan of management is necessary in each case and a rigid adherence to solely surgical or medical regimens will not yield the best results. Of paramount importance is prompt diagnosis and treatment. | en |
| dc.description.department | a
Department of Psychiatry, University of Nairobi, ; bDepartment of Mental Health, School of Medicine,
Moi University, Eldoret, Kenya | |
