When conservative treatment failed it was promptly abandoned a n d operation performed.
Nasogastric suction is the vital element in conservative treatment, keeping the stomach empty, allowing sealing of the. perforation t o take place. Careful positioning of the tube and regular aspiration are important. O n e patient might not have required laparotomy had an erect chest X-ray been performed showing the tube curled in the oesophagus. The proportion requiring later definitive surgery was similar t o that following simple closure'. Sixteen patients required n o surgery after a median follow-up of 5.3 years. Opposition t o conservative treatment relates t o the possible consequences of a n error in diagnosis. However, as Taylor has shown, with regular reassessment, problems of misdiagnosis should become rapidly apparent and conservative treatment can then be abandoned.
He reported no serious consequences resulting from the short delay in correcting the diagnosis'. The chief contra-indications are lack of patient compliance, unsuccessful nasogastric intubation and late presentation. Air swallowing prevents sealing and is suspected if intraperitoneal gas increases despite adequate nasogastric decompression. Using conservative