Multimodality Treatment of Esophageal Disruptions: Conclusion

In: Esophageal

4 Mar 2014

Conservative treatment may be sufficient in small intramediastinal (documented) spontaneous ruptures. Recovery even after primary closure of these ruptures within 24 h has been found uncertain by many authors. The patch procedures with well-vascularized diaphragmatic flap or gastric fundus ensure a more secure healing of the primaiy suture repair than other (pleural, intercostal muscle) applied flaps. If the transthoracic primary closure is contraindicated—as in our case with a right-side rupture after left pneumonectomy—transhiatal primary closure seems to be the procedure of choice. Large lacerations at the typical level should be dealt with by Woodward operation or resection. Failure after initial repair or severe sepsis calls especially for Urschel-type esophageal diver-sion-or mucosal stripping.

Injuries of the healthy esophagus demand a complex procedure for salvage of the organ. In early cases, primary closure with reinforcement (pleural diaphragmatic, extrathoracic muscle flaps [romboi-deus, pectoralis major, sternocleidomastoideus] is valuable. In late cases, intrathoracic tears, Woodward operation, and especially the organ-preserving Urschel-type diversion, performed simultaneously with the primary repair or after the failure of the initial attempt of the esophageal closure, are of particular value. To avoid reoperation and hazard of removal of the distal banding with heavy tissue ingrowth, Urschel (cit 18) had ulteriorly modified his original technique by exteriorizing polypropylene (Prolene) suture through Rumel plastic tourniquet alongside of the gastrostomy. Mucosal stripping, introduced recently by Akiyama et al, is a new interesting alternative of esophageal exclusion.
In esophageal disruptions due to operations (vagotomy, hiatal hernia repair, leiomyoma enucleation, Heller myotomy, pneumonectomy, etc), suture closure supported by fundoplication (Dor or Belsey type) or previously mentioned muscle flaps should be performed.
In early detected postpneumonectomy esophageal perforation, we recommend primary suture buttressed with serratus anterior or latissimus dorsi muscle flaps. Its value has been demonstrated in our patient having a similar a but delayed perforation.
Our 15-year experiences suggest that the key to improve the prognosis of this life-threatening emergency is the more appropriate selection of the primary applied procedure. Initial treatment should always be correlated with the previous state of the esophagus. Nonoperative assessment is rarely indicated. Only reinforced primary closure is justified today. Failure of the first procedure demands exlu-sion or resection.

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