Malignant thymoma invading pulmonary artery. Changing treatment options

BACKGROUND

Curative treatment of malignant thymoma is resection; however, this may be precluded by invasion of vital organs.

PATIENTS AND METHODS

Two patients with extensive intrathoracic spread of thymoma (Stages III and IV A) are presented. Treatment involved a combination of resection, radiotherapy and chemotherapy.

RESULTS

One patient survived 9 years, 4 months, but eventually died of metastatic spread; the other one is well and without evidence of disease 30 months after treatment.

CONCLUSIONS

Thymoma is a slow-growing tumor. Successful surgical treatment in advanced cases is possible, if aided by radiotherapy and chemotherapy. The adjuvant therapy converts a non-resectable tumor to a resectable one.

Late complications of collapse therapy for pulmonary tuberculosis

STUDY OBJECTIVES

Collapse therapy for pulmonary tuberculosis involved placement of various materials to occupy space and keep the lung collapsed. Complications are encountered decades later.

PATIENTS AND METHODS

Between 1980 and 1997, we treated 31 patients with a history of pulmonary tuberculosis in whom collapse therapy had been used and who later developed complications related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable pneumothorax was present in 1 patient, and migration of a foreign body with formation of subcutaneous mass occurred in 3 patients. All patients with empyema were treated with antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted.

RESULTS

Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and 1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap remained closed. Following extraction of paraffin blocks, infection developed in one patient. During the follow-up period, three patients died, all of unrelated causes.

CONCLUSIONS

Delayed complications of collapse therapy for tuberculosis should be treated without delay. Pressure on adjacent structures or their erosion presents danger and mandates immediate extraction; however, there is no need for routine removal of every residual plombe. Further increase in the number of multiple-drug resistant strains may force the return of collapse therapy.

The place of surgery in the treatment of re-emerging pulmonary tuberculosis

BACKGROUND

A marked worldwide increase in prevalence of pulmonary tuberculosis occurred during the past 15 years. The reasons for this change include the worldwide epidemic of AIDS, poverty and unprecedented migration of people.

METHODS

During the past 12 years, we operated on 57 patients with pulmonary tuberculosis or its sequelae. In 42 patients the disease was active at the time of operation.

RESULTS

Two patients died of operative complications; one, of unrelated causes. There were three major non-fatal complications. In 49 patients tuberculosis was eradicated; five patients still have active disease and remain under drug therapy.

CONCLUSIONS

High level of clinical awareness is the most important factor in disclosure and early treatment of pulmonary tuberculosis. Indications for operation are strengthened by alcoholism, drug abuse, poverty and other social factors. BCG vaccination of tuberculin-negative children should be considered as a preventive measure.

Video-assisted thoracic surgery--state of the art

Video-assisted thoracic surgery (VATS) is one of the main medical revolutions of the past decade. For its satisfactory performance, the following prerequisites are essential: (1) knowledge and experience in thoracic surgery; (2) team of experienced anesthesiologists; (3) preoperative assessment of respiratory function; (4) adequate postoperative care; and (5) instruments specially designed for thoracoscopic surgery. VATS is routinely performed under general anesthesia with double lumen endotracheal intubation for separate control of each lung. Insufflation of carbon dioxide must not exceed 1-3 mm Hg. Too high pressure may cause harmful reduction of venous return and mediastinal shift with impairment of ventilation. Presence of adhesions should be determined by finger exploration of the pleural cavity. Operative ports should be placed carefully, avoiding damage to the intercostal nerves and vessels. The video technique can be used with efficiency for the following indications: pneumothorax, resection of pulmonary nodules, biopsies of lung, pleura and mediastinal structures, resection of mediastinal tumors, management of empyema, and hemostasis and closure of lacerations after trauma. Indications for esophageal procedures include esophagomyotomy for achalasia and resections of benign lesions. Repair of perforated esophagus is a matter of controversy, but in early stages it can be done thoracoscopically. Although video-pericardioscopy has been performed by some surgeons, this procedure can be done easier and faster using the direct approach without the video equipment. There are differences of opinion with regard to major pulmonary and esophageal resections for cancer. The apparent advantage of diminished pain is offset by inadequate resection, spread of malignant cells and potential damage to the resected specimen with loss of important information concerning pathology. Complications of VATS are few, and include prolonged air leak, dysrhythmia, respiratory failure, bleeding and infection. Due to progress over the past several years, VATS has become an inseparable part of thoracic surgery and should be included in the basic training of every thoracic surgeon.

Pneumothorax: experience with 1,199 patients

OBJECTIVE

To study the outcome of pneumothorax managed in a university-affiliated metropolitan medical center.

DESIGN

A retrospective review.

SETTING

Busy metropolitan medical center.

PATIENTS AND METHODS

Records of 1,199 patients with pneumothorax were reviewed and analyzed.

RESULTS

Primary spontaneous pneumothorax occurred in 218 patients, secondary spontaneous pneumothorax occurred in 505, traumatic in 403, and iatrogenic in 73. Ninety-six patients with small pneumothorax (8%) were managed by observation, and 1,103 patients (92%) were managed by tube thoracostomy. Drainage of the pleural cavity was continued for 1 to 7 days in 893 patients (81%), 8 to 10 days in 176 patients (16%), and > 10 days in 34 patients (3%). Drainage for > 10 days was classified as persistent pneumothorax. In these 34 patients and in 132 others with a second ipsilateral recurrence (a total of 166 patients), direct pleuroscopy was performed. The pleuroscopy findings and further management are outlined in the algorithm.

CONCLUSIONS

Pneumothorax is a common condition affecting all age groups. If the volume of the pneumothorax is > 20% of the pleural space, pleural drainage is indicated. For management of persistent or recurrent pneumothorax, the use of pleuroscopy (direct or video-assisted) is of great value and should be part of routine management.

Surgical management of tracheal tumors

BACKGROUND

Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor.

METHODS

In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved.

RESULTS

One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor.

CONCLUSIONS

Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Gangrene of the lung: treatment in two stages

BACKGROUND

Pulmonary gangrene is a rare complication of severe lung infection with devitalization of lung parenchyma and secondary infection. If untreated, gangrene of the lung leads to sepsis, multiple-organ failure, and death. Resection of all gangrenous tissue is mandatory and is lifesaving. Pleural empyema commonly accompanies gangrene of the lung; in its presence, dissection of hilar structures for resection can lead to mediastinitis or bronchopleural fistula and should be avoided.

METHODS

Three patients with pulmonary gangrene were treated in two stages: immediate fenestration first and then delayed resection of gangrenous lung in a clean field and immediate closure of the pleural window.

RESULTS

Two patients underwent pneumonectomy and 1 patient, lobectomy. All patients recovered without complications.

CONCLUSIONS

Creation of a pleural window (fenestration) for 1 week enables safe and curative resection of a gangrenous lung or lobe in a clean field and in a patient in stable condition.

Gastric rupture complicating inadvertent intubation of the esophagus

Rupture of the stomach complicating resuscitative measures is usually fatal. A 74-year-old man who suffered a myocardial infarction and cardiac arrest had perforation of the stomach when the esophagus was inadvertently intubated, ventilating the stomach. Laparotomy was performed and the gastric perforation sutured. In spite of the extensive trauma, the patient, incredibly, recovered. Although very few cases have been reported in which the esophagus has inadvertently been intubated resulting in gastric perforation, this is a potential possibility and should be borne in mind when intubation is followed by abdominal distension, rigidity and tenderness.

Pleural empyema: 24-year experience

BACKGROUND

Despite the widespread use of antibiotics, empyema remains a common and serious problem, and its treatment is controversial.

METHODS

Our experience in 380 patients with empyema was retrospectively reviewed.

RESULTS

The causes of empyema were as follows: pneumonia (n = 308), late complication of tuberculosis (n = 24), trauma (n = 15), pulmonary gangrene (n = 3), retained foreign body (n = 1), and undetermined (n = 29). An exudative state was diagnosed in 273 patients, a fibrinopurulent state in 55, and an organizing state in 52. Pleuroscopy was performed in 107 patients resistant to treatment, and this revealed an expansible lung in 49 patients, a nonexpansible lung in 51, and exceptional findings (foreign body, necrotizing pneumonitis, and perforated esophageal cancer) in 7. Treatment was modified accordingly. Five patients died (mortality, 1.3%).

CONCLUSIONS

Pleuroscopy is very helpful in disclosing factors responsible for resistance to treatment and in carrying out thorough pleural toilet. The use of talc in selected patients causes pleurodesis and prevents the reaccumulation of pus. Decortication is the ideal treatment in the organizing stage, enabling complete lung expansion. Fenestration is lifesaving in moribund patients who cannot tolerate decortication.

Traumatic rupture of hydatid cysts

OBJECTIVE

To stress the relation between rupture of hydatid cysts and trauma.

DESIGN

A case series.

SETTING

A university-affiliated hospital for emergency medicine.

PATIENTS

Four college students who suffered traumatic rupture of hydatid cysts. All injuries were sustained during sporting activities.

INTERVENTIONS

Resection or unroofing of the cysts with careful removal of all hydatid elements, and suture-plication of the residual liver cavities.

RESULTS

The ruptured cysts were located in the liver, spleen and splenic flexure of the colon. At exploration, additional hydatid cysts were found, usually in the liver. Treatment resulted in complete recovery in all patients.

CONCLUSIONS

Traumatic rupture of hydatid cysts related to sporting activities may be commoner than indicated by the rarity of reports. Increased awareness of this possibility in areas where hydatid disease is endemic is encouraged.

Extralobar sequestration presenting as massive hemothorax

Pulmonary extralobar sequestration is a rare anomaly, usually diagnosed during the first months of life. A case of extralobar pulmonary sequestration in an adult, manifesting itself as massive hemothorax, is presented.

Pleuroscopy: therapeutic applications

Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.

Retrosternal goiter

BACKGROUND

Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer.

METHODS

During a 22-year period, we treated 44 patients with intrathoracic multinodular goiter.

RESULTS

The goiter was resected in 40 patients; 4 patients were rejected because of prohibitive risk. There were three minor complications and no deaths.

CONCLUSIONS

The specific indications for resection include compression of adjacent structures, prevention of future complications, and obtaining a diagnosis. Fine-needle aspiration for diagnosis is not always possible and rarely reliable, and there is no effective medical therapy. Cervical incision is nearly always adequate, with few exceptions, such as very large posterior goiter, mediastinal blood supply, or carcinoma necessitating mediastinal dissection.

Mediastinal staging of lung cancer: the changing role of mediastinoscopy

In order to evaluate the role of mediastinoscopy in determination of resectability in lung cancer, we reviewed retrospectively our experience with this procedure. Of 936 mediastinoscopies performed during the past 22 years, 830 were performed for preoperative evaluation of patients with presumably resectable bronchogenic carcinoma. Metastases in superior mediastinal lymph nodes were found in 295 of 798 patients with histologically proven lung cancer (37%). These patients were spared an unnecessary thoracotomy. There was one death and no other major complications. Computerized tomography of the chest should be performed in all patients with bronchial cancer. If enlarged mediastinal nodes are demonstrated, mediastinoscopy is indicated for histologic evaluation of those nodes and for staging. Mediastinoscopy is a safe and highly reliable procedure with 100% specificity and over 90% accuracy, and is extremely important in staging and predicting resectability in lung cancer. It helps to avoid a futile thoracotomy in patients with incurable disease.

Symptomatic diaphragmatic hernia: surgical treatment

Seventy-eight cases of symptomatic diaphragmatic hernia are reported--55 hiatal (42 sliding, 9 rolling, 4 intrathoracic stomach), 19 diaphragmatic hernias proper (12 Bochdalek, 7 Morgagni) and four diaphragmatic eventrations. Pulmonary function was compromised by massive herniation in ten cases. Four hernias were incarcerated. Surgery was performed in 76 cases, as emergency in ten. Two patients were rejected because of poor pulmonary function. One patient died and three hernias recurred. The results were satisfactory in 72 cases. In sliding hiatus hernia, gastro-oesphageal reflux is the main problem and investigations should include oesophagoscopy, fluoroscopy and manometry, with treatment directed at prevention of reflux. Surgical treatment, if indicated, is usually fundoplication and dilatation of strictures. In rolling hiatus hernia and all types of diaphragmatic hernia proper, the hernia per se is the main problem, with risk of incarceration. Surgery is always indicated and should comprise reduction of hernia contents, excision of the sac and closure of diaphragmatic rift.

Thoracic splenosis

BACKGROUND

Thoracic splenosis is an uncommon side effect of thoracoabdominal trauma involving injury to the diaphragm and spleen. Only 20 patients with a similar problem have been reported previously.

METHODS

Two patients with thoracic splenosis were studied.

RESULTS

One of the patients had undergone thoracotomy for resection of a "pulmonary nodule". The other remains under observation.

CONCLUSION

Presence of a pulmonary nodule in a patient with history of injury to the diaphragm and spleen should arouse suspicion of splenosis. Appropriate investigation may prevent an unnecessary and potentially harmful operation.

Neglected lung cancer

Pulmonary nodules of unknown nature may be cancerous and are best treated by early resection. During the past 20 years we have seen 65 patients in whom asymptomatic pulmonary nodules from 5 to 20 mm in diameter were discovered on routine roentgenograms between 1 and 4 years prior to their referral to surgery. These patients have not been investigated for cancer. Instead, they had been 'observed' or treated with antibiotics while their nodules increased in size. At the time of referral, 29 patients had widespread metastases, 28 had locally invasive State III lung cancer, eight had Stage I or Stage II lesions. Only 16 patients had their tumors resected. Sixteen patients (24.6%) survived 1 year or longer; six patients (9.3%) survived more than 2 years. Early resection of all undiagnosed pulmonary nodules is essential. 'Expectant' or antibiotic treatment of these lesions should be condemned. Educational programs for family physicians are urged.

Talc pleurodesis. Experience with 360 patients

Talc was used intrapleurally for the creation of pleural adhesions in 360 patients. The indications for use were malignant pleural effusion in 169 patients, benign effusions in 41, recurrent pneumothorax in 122, empyema in 19, and chylothorax in 9. Of 336 patients available for follow-up, excellent results (complete pleurodesis) were achieved in 284 patients (84.5%), fair results in 28 (8.3%), and poor results (no adhesions) in 24 (7.2%). The results were best in empyema (100%) and better in pneumothorax than in pleural effusions. With repeat talc insufflation, the results were improved to excellent in more than 90% of the patients. Talc is the most effective and least expensive agent for creation of pleural adhesions. Its use is simple and easily tolerated by the patients. Because of the carcinogenic effect of asbestos, purified talc that is free of asbestos fibers must be used.

The penetration of ciprofloxacin into bronchial mucosa, lung parenchyma, and pleural tissue after intravenous administration

We have studied the concentrations of ciprofloxacin in serum, bronchial mucosa, lung parenchyma, and pleural tissue after a single intravenous dose of 200 mg in 20 patients subjected to lung surgery. The concentrations of ciprofloxacin in the tissues exceeded that in the serum by 3-fold to 7-fold: serum 0.6 micrograms.ml-1, bronchial mucosa 1.9 micrograms.g-1, lung parenchyma 3.4 micrograms.g-, and pleural tissue 1.7 micrograms.g-1. The achievable concentrations of ciprofloxacin in the tissues of the lower respiratory tract are above the MICs for most lung pathogens.

Less than lobar resections for bronchogenic carcinoma

We performed less than lobar resections for peripheral clinical Stage I primary lung cancers on 170 patients treated between 1973 and 1987 at two university centers, one in Hawaii and one in Israel. Most patients were poor risks and several had FEV1 < 1 liter. There were 6 (3.5%) hospital deaths. There were 58 segmental resections, 97 wedge resections and 15 less than lobar resections not otherwise specified. Seventy-three patients (43%) are living free of cancer from 5 to 11 years postoperatively and 20 additional patients died of causes unrelated to lung cancer after 5 years; thus disease free five year survival was 54.7%. Patients with adenocarcinoma had poorer prognosis than other cell types. Twenty-three patients (13.5%) had synchronous or metachronous second primary lung cancers. Nine of these patients are long term survivors. Twenty-four patients (14.1%) developed local recurrences with or without distant metastases. This promising long term cancer-free survival and the frequency of second primary lung cancers justifies less than lobar resection for peripheral, Stage I bronchogenic carcinoma, especially in the poor risk patient.

Pneumothorax following induction chemotherapy in patients with lung metastases: a case report and literature review

A 29-year-old patient presented with bilateral pulmonary lesions following surgery for recurrent placental site trophoblastic tumor (PSTT). On day seven after institution of the 'EMA' regimen (etoposide, medium dose methotrexate with folinic acid rescue and actinomycin-D), complete pneumothorax occurred. Closed-system air drainage brought only transient lung expansion and subsequent talc pleurodesis was needed. During follow-up, complete regression of lung metastases was observed. A literature survey of post-chemotherapy pneumothorax in patients with lung metastases disclosed fourteen hitherto reported cases. Including the present PSTT case, non-epithelial gynecologic malignancy (3 patients) ranks second to osteogenic sarcoma (6 cases) with regard to the primary tumor involved.

Suture closure versus stapling of bronchial stump in 304 lung cancer operations

Suture closure of the bronchial stump was compared with staple closure after 304 operations for bronchogenic carcinoma over an 8-year period. In 154 cases (112 lobectomies and 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester, and in 150 cases (120 lobectomies and 30 pneumonectomies) an autosuture stapler was used. The time for suture closure ranged from 5-15 minutes, whereas stapling was accomplished uniformly in c. 90 seconds. Bronchopleural fistula developed after suture closure in seven cases (4.5%), but in none after stapling closure. Stapling of the bronchial stump after lobectomy or pneumonectomy for lung cancer is safer and quicker than suture closure, and is recommended as the method of choice.

Foreign bodies in the gastro-intestinal tract

Between 1971 and 1990, 70 patients with foreign bodies in the gastro-intestinal tract were admitted to our service. There were 35 children and 35 adults. Foreign bodies were found in the pharynx and the oesophagus in 22 patients, with 1 perforation; and in the stomach and intestines in 27, with 14 perforations. Fifteen foreign bodies were swallowed and defecated, 6 were inserted into the rectum. Coins were found in 8 patients, toys in 3, pins and needles in 6, chicken bones and fish bones in 15, and toothpicks, shaving blades, cutlery, dentures, plastic bag containing cocaine, parts of a foam rubber mattress and other items in the remainder. Foreign bodies retained in the oesophagus must be removed promptly lest obstruction and perforation occur. Many foreign bodies that have passed the oesophagus progress uneventfully to defaecation. Others become retained and should be removed. If retained in the stomach, endoscopic removal may be attempted before resorting to a laparotomy. Perforation is an urgent indication for operation. Those patients inclined to swallow foreign bodies intentionally and those who insert items into the rectum should undergo psychiatric evaluation.

Acute pseudo-obstruction of the colon

Fourteen patients with acute pseudo-obstruction of the colon (Ogilvie's syndrome) were treated over a 16-year period. Ten patients (71.4%) had a recent history of mental illness and were treated with hypnotic and sedative drugs uninterruptedly for many months. The clinical picture and abdominal radiographs on admission to hospital were typical of acute mechanical obstruction of the colon; 1 patient had a perforation of the transverse colon. Obstruction was ruled out by barium enema in 9 patients, by colonoscopy in 3 and by immediate laparotomy in 2. Twelve patients were treated conservatively by nasogastric tube, correction of fluid and electrolyte imbalance, enemas, cessation of all hypnotic and sedative drugs, and decompression of the colon using a rigid rectoscope and rectal tube. There were no complications and no deaths. Ogilvie's syndrome should be suspected in patients with symptoms of large-bowel obstruction whose history discloses intake of hypnotic and sedative drugs. After mechanical obstruction is ruled out, conservative management is indicated. It should include cessation of all psychopharmacological agents and decompression of the colon by rectal intubation or colonoscopy. If conservative measures fail and the caecum increases in size, operative decompression by transverse colostomy rather than cecostomy is indicated.

Cholecystostomy as a definitive operation

Cholecystostomy for decompression and drainage of the biliary tree is indicated when the elderly, poor risk patient with destructive inflammatory process in the gallbladder is unable to tolerate a more extensive operation. Cholecystostomy is often criticized as an inferior operation, because it provides some palliation but leaves the patient with most problems unattended. To re-evaluate the role of cholecystostomy in the management of acute disease of the gallbladder, we reviewed our experience with it. During the years 1974 to 1987, 37 patients underwent a cholecystostomy. Patients ranged in age from 58 to 90 years, with an average age of 69 years. Twenty-eight patients had acute destructive cholecystitis, usually complicated by perforation, peritonitis or ascending cholangitis. Five had severe pancreatitis; three, cholelithiasis, and one patient, carcinoma of the bladder. Twenty-seven of the 37 patients had severe systemic disease and were critically ill. At the operation, calculi were extracted and the gallbladder and abscess were drained. Two patients died, yielding a mortality rate of 5.4 per cent. Tube cholangiography was done in 33 patients. Although residual stones were demonstrated in seven patients, the stones were removed electively at a later date under much more favorable conditions. None of the 35 survivors had symptoms of disease of the gallbladder during the follow-up period, which ranged from one to 12 years. Cholecystostomy is a curative operation indicated in critically ill and elderly patients for whom extensive operation is a prohibitive risk.

Technical aids in surgery. Two muscle-sparing thoracotomies--techniques and indications

Two types of muscle-sparing thoracotomies are described. They have been used over the past 11 years in 396 patients. These incisions are ideal for wedge resections, biopsies, exploratory thoracotomies, excisions of emphysematous blebs, decortications, and a variety of other operations, including pulmonary resections in selected patients. They provide entirely adequate exposure, while minimising the trauma of thoracotomy.

Traumatic perforations of the esophagus

Over the past 15 years nine patients with traumatic mechanical perforations of the esophagus have been treated. Seven perforations were iatrogenic, two were accidental. One patient treated conservatively did well. Two patients were operated on without delay. Their hospitalization was short and they had no complications. Six patients were referred to surgery after a delay ranging from 5 days to 17 days from the time of perforation. Their hospitalization ranged from 9 to 113 days, averaging 62.7 days. Complications were common and two patients died. In order to assure survival of patients with esophageal perforation, early aggressive treatment is essential in nearly all instances. In an occasional patient with a small and clean perforation at the esophageal inlet, conservative treatment may be justified.