Multimodality Treatment of Esophageal Disruptions

In: Esophageal

26 Feb 2014

Multimodality Treatment of Esophageal DisruptionsThe poor results following conventional treatment of esophageal disruptions—including even primary closure without reinforcement—incited us 15 years ago to introduce a multimodality assessment in this major surgical emergency.
The value of this more selective management of six spontaneous ruptures and 34 mostly intrathoracic (87.5%) esophageal perforations is evaluated in this retrospective study.

Materials and Methods
Forty patients, the majority (83.4%) with ruptures or perforations of the thoracic esophagus, were treated at the Thoracic Surgical Clinic in Budapest between 1981 and 1996. The nature of the disruptions, the types of procedure used, and the underlying esophageal diseases are shown in Tables 1-3.
Perforated Obstructing Diseases
Among the patients with preexistent obstructive esophageal disease (Table 4), suture with Heller myotomy and Dor (two patients) or Thai and Belsey fundoplication (three patients) were carried out in early perforated achalasia. Traction intubation with a personally designed cuffed funnel tube—providing a watertight and reflux-free exclusion—was used in six inoperable perforated esophageal malignancies (Fig 1) and in a 10-day-old instrumental perforation of a middle third caustic stricture. In an instance of a lower mediastinal abscess of a similar etiology and origin, transhiatal mediastinal drainage (discussed by Krisar et al) in 1969 for suction lavage combined with decompressive gastrostomy was performed (Fig 2). In a 7-day-old iatrogenic perforation of a peptic stenosis—in spite of the localized empyema—breakdown of the closure has been avoided by reinforcement of the suture line with a pedicled diaphragmatic flap. In a 7-month-old instrumental cervical perforation of a high intrathoracic lye stricture with related 10-cm-long mediastinal fistula, suture, fistulectomy accompanied by one-stage temporary intubation was successful.
Spontaneous Ruptures
In four late (24 h to 5 days) spontaneous ruptures (Table 5) through left thoracotomy, mediastinal decompression and two-layer closure were performed reinforced by transhiatal Thai fundoplication (two patients) or diaphragmatic flap (two patients). In a right-side rupture following left pneumonectomy (for recurrent bronchial cancer) and vomiting on the second postoperative day, a transhiatal primary closure was done and reinforced by the omentum and combined with transhiatal and right-side pleural (previously introduced) drainage gastrostomy and feeding jejunostomy. In instances of bilateral ruptures of the mediastinal pleura (two cases), the contralateral hydrothorax was drained through the left thoracic cavity. Only a nasogastric tube was used for GI decompression in all but one case.

Table 1—Esophageal Disruptions: Thoracic Surgical Clinic, Budapest, 1981 to 1996

No. of
Spontaneous rupture 6
Spontaneous malignant perforation 1
Instrumental 22
Traumatic 2
Foreign body 5

Table 2—Types of Procedures Used

Procedures Nonoperative, collar mediastinotomy
Reinforced primary closure
Transhiatal suture or mediastinal drainage
Surgical intubation
Suture with intubation or exclusion
Suture 4- myotomy+fundoplication
Woodward operation, exclusion-diversion with pleural drainage, coverage with serratus muscle flap

Table 3—Underlying Esophageal Diseases

No. of Patients
Achalasia 5
Malignant tumor 6
Caustic stricture 3
Peptic stricture 2

Table 4—Perforated Preexistent Obstructing Diseases (n=15)

Etiology No. of Patients TimeElapsed Treatment Outcome
Early perforated (instrumental)
Achalasia 2 <1 h S +Heller myotomy+Dor fundoplication Alive
Achalasia 3 <1 h S +Heller+Thai+Belsey operation Alive
Inoperable tumors 6 <1 h-12 h I Alive
Late instrumental perforations
Peptic stricture 1 7 d S +reinforcement with diaphragmatic flap
Caustic stricture 1 24 h Transhiatal mediastinal D Alive
Caustic stricture 1 10 d I _
High intrathoracic caustic stricture 1 7 mo S+I Alive

Table 5—Spontaneous Ruptures

Etiology No. of Patients (n=6) TimeElapsed Treatment Outcome
Late, typical 1 <24 h MD + S+distal exclusion prolonged pleural D Alive
2 <24 h-5 d MD + S+diaphragmatic flap buttress Alive 1
2 <24 h-30 d M D + S+fundoplication Alive
Atypical right side after 1 Transhiatal MD+S+mediastinal4-right pleural
left pneumonectomy D+gastrostomy+jejunostomy

Figure 1. Chest radiograph finding of a right-side hydropneumothorax caused by a perforated, inoperable esophageal tumor (left). Exclusion of perforation by surgically inserted cuffed funnel tube

Figure 1. Chest radiograph finding of a right-side hydropneumothorax caused by a perforated, inoperable esophageal tumor (left). Exclusion of perforation by surgically inserted cuffed funnel tube

Figure 2. Illustration of the transhiatal xuediastinal drainage.

Figure 2. Illustration of the transhiatal xuediastinal drainage.


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