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Original Articles: General Thoracic

Esophageal Leaks Repaired by a Muscle Onlay Approach in the Presence of Mediastinal Sepsis

^a Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
^b Division of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
^c Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Accepted for publication May 6, 2009.

^_* Address correspondence to Dr Ris, Service de Chirurgie Thoracique et Vasculaire, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland (Email: hans-beat.ris{at}chuv.ch).

Background: Nineteen patients were evaluated after closure of intrathoracic esophageal leaks by a pediculated muscle flap onlay repair in the presence of mediastinal and systemic sepsis.

Methods: Intrathoracic esophageal leaks with mediastinitis and systemic sepsis occurred after delayed spontaneous perforations (n = 7) or surgical and endoscopic interventions (n = 12). Six patients presented with fulminant anastomotic leaks. Seven patients had previous attempts to close the leak by surgery (n = 4) or stenting (2) or both (n = 1). The debrided defects measured up to 2 x 12 cm or involved three quarters of the anastomotic circumference and were closed either by a full thickness diaphragmatic flap (n = 13) or a pediculated intrathoracically transposed extrathoracic muscle flap (n = 6). All patients had postoperative contrast esophagography between days 7 and 10 and an endoscopic evaluation 4 to 6 months after surgery.

Results: There was no 30-day mortality. During follow-up (4 to 42 months), 16 patients (84%) revealed functional and morphological restoration of the esophagointestinal integrity without further interventions. One patient required serial dilatations for a stricture, and 1 underwent temporary stenting for a persistent fistula; both patients had normal control endoscopy during follow-up. A third patient requiring permanent stenting for stenosis died from gastrointestinal bleeding due to stent erosion during follow-up.

Conclusions: Intrathoracic esophageal leaks may be closed efficiently by a muscle flap onlay approach in the presence of mediastinitis and where a primary repair seems risky. The same holds true for fulminant intrathoracic anastomotic leaks after esophagectomy or other surgical interventions at the gastroesophageal junction.

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