Multimodality Treatment of Esophageal Disruptions: Perforated Healthy Esophagus

In: Esophageal

28 Feb 2014

Perforated Healthy Esophagus
The following treatment was adopted in case of mostly instrumental perforations of the healthy esophagus (Table 6). Nonoperative assessment was used in two early small cervical perforations and collar mediastinotomy in two subsequent upper mediastinal abscesses. In case of lower third mediastinal lesions (24 to 48 h), the suture was covered either with a diaphragmatic (Fig 3) or with a modified, better vascularized, vertical fashioned, pleural flap. In late (48 h, 7 day, and 6 week) intrathoracic perforations, recovery was obtained by Woodward operation or in a long (15 cm) 9-day tear by suture and Urschel-type esophageal diversion. In a 6-week-old iatrogenic (by sclerotherapy) perforation with right-side empyema, a similar distal and also cervical banding (Fig 4) with Petzer tube esophagostomy, gastrostomy, and tube thoracostomy for suction lavage was successful. Resection was used only for an ischemic esophagus developed at the end of a left radical pneumonectomy and extended lymphade-nectomy. In a small middle third esophageal perforation developed 4 months after right pneumonectomy for recurrent bronchial tumor and subsequent empyema, coverage with serratus anterior muscle flap, combined with Schede-type thoracoplasty, proved to be useful. canadian health&care mall
The overall 30-day hospital mortality was 19.5%. The postoperative fatal complications related to pathologic conditions are summarized in Table 6. Although these operations were mostly used in late (24 h to 7 months) perforations and ruptures, in all but one instance the leakage was controlled. In our series, none of the patients with reinforced repair of early or late esophageal disruptions by autogenous pleural, diaphragmatic, muscular (serratus anterior, sternocleidomastoideus) flaps, or fundoplication had fatal outcome for breakdown of the closure. Only patients with renal, cardiac, or multiorgan failure in consequence of sepsis due to time elapsed before hospital admission died. The patient operated on for right-side postpneumonectomy spontaneous esophageal rupture died 3 weeks later for “kissing” duodenal ulcer.
Neither stricture nor need for a late dilation was necessary after removal of the bandings on the 10th and 21st postoperative days, respectively, after esophageal exclusion by Urschel et al technique, although in one case, only the anterior part of the distal banding was resected for deep tissue ingrowth. The site of the removed cervical banding and esophagostomy closed in 6 days following suture closure supported by a sternocleidomastoideus muscle flap in one patient and spontaneously in the other one.
Table 6—Perforation of the Healthy Esophagus

Etiology No. of Patients (n=15) TimeElapsed Treatment Outcome
Early cervical (instrumental)
Intramediastinal by foreign body 2 12-24 h Conservative Alive
2 24 h S+buttress with diaphragmatic or pleural flap Alive
Left pneumonectomy 1 Torek operation Alive
Late cervical (instrumental) 2 24-36 h Collar mediastinotomy Alive
Intrathoracic by foreign body extraction 1 24 h S+buttress with polyglactin suture (Vicryl) mash Alive
Traumatic 1 48 h Woodward operation Alive
Foreign body extraction 1 3d S+buttress with omentum+pleural and mediastinal D
Traumatic 1 7 d S+buttress with pleural flap+pleural D
Foreign body extraction 1 9 d S +Urschel diversion+pleural D Alive
Miscellaneous 1 7 d Johnson-type diversion, pleural D
Sclerotherapy 1 6 wk Diversion (Urschel)+thoracostomy suction lavage Alive
Postpenumonectomy 1 4 mo Coverage with serratus anterior muscle flap+Schede thoracoplasty Alive

Table 7—Relationship of Fatal Complications With the Underlying Diseases and Time Factor

Etiology Time Elapsed, d Treatment Cause of Death
Spontaneous rupture 5 S + DFLb Contralateral aspiration, sepsis, renal failure
Dilation of a lye stricture 10 Intubation Lung abscess, perforated duodenal ulcer, sepsis
Overlooked traumatic leak 7 S+PFLb Purulent pericarditis, mediastinitis, empyema, sepsis
Iatrogenic perforation of a peptic stricture 7 S + DFLb Renal failure
Miscellaneous 3 Exclusion (Johnson) Cardiac failure
Right-side spontaneous rupture following left Transhiatal S+pleural and “Kissing” duodenal ulcer
pneumonectomy mediastinal D + G+J
Foreign body extraction 3 S+coverage with omentum Purulent mediastinitis, sepsis+pleural+mediastinal D

Figure 3. Aspect of the pedicled diaphragmatic flap for esophageal suture line buttress.
Figure 3. Aspect of the pedicled diaphragmatic flap for esophageal suture line buttress.

Figure 4. Illustration of Urschel-Ergin type esophageal exclusion diversion.

Figure 4. Illustration of Urschel-Ergin type esophageal exclusion diversion.

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