Multimodality Treatment of Esophageal Disruptions: Discussion

In: Esophageal

2 Mar 2014

Multimodality Treatment of Esophageal Disruptions: DiscussionOnce the diagnosis of esophageal leak is made, the most critical decision is the choice of the most appropriate management. Large comparative or international studies of the current surgical techniques could not validate their real value in instances of esophageal disruption. On the contrary, in our treatment protocol, the first choice and alternative procedures were selected on the basis of underlying esophageal diseases, the nature, site, and magnitude of the disruption, and the time elapsed after onset of perforation.
The presence of surrounding mediastinal fibrosis in caustic strictures creates particular conditions in instrumental perforations. The injury and also the contamination often remain intramedias-tinal. Nonoperative treatment or gastrostomy (to minimize GI reflux) should be used in early small cervical or intramural perforations and early me-diastinitis. For intrathoracic instrumental perforations within 24 h, primary conventional resection with or without replacement (with jejunum or colon, dependent on the level of perforation) should be recommended. Endoprosthesis insertion proved to control the intramediastinal perforations (48 h). Transhiatal mediastinal drainage (Fig 2) with suction lavage and gastrostomy and tube thoracostomy for associated empyema is the most useful kind of mediastinal drainage for lower or middle third mediastinal abscess. Conventional collar mediastinotomy is preferred only in upper mediastinal abscess. cialis professional

Underlying stenosing lower esophageal diseases compromise healing of suture repair of the perforation. As a rule, in early cases, obstruction should be relieved together with the suturing and support of the closure. The antireflux procedures buttress both the suture line and formal operation. In late cases, resection, diversion, or intubation should be instituted. Transhiatal resection is indicated in perforated resectable carcinoma. Endoprosthesis insertion is the unique real possibility to exclude a perforation of unresectable esophageal malignances (primary or secondary), especially if a cuffed funnel tube will be used.

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