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Ann Thorac Surg 1995;60:248-249
© 1995 The Society of Thoracic Surgeons
DR DAVID J. SUGARBAKER (Boston, MA): I would like to ask Dr Wright a question, and comment first on a very nicely presented paper and nice discussion of this very devastating problem to the patient and many times to the entire staff caring for the patient.
In that late group of patients there was a 70% leak rate, four deaths, 2 patients who required subsequent esophagectomy, and an average length of stay in excess of 40 days; given all of those factors, is there another alternative approach to this one that you would consider or that you would suggest at this time should be looked into, or are you content with those figures?
DR RICHARD I. WHYTE (Ann Arbor, MI): Doctor Wright, I enjoyed your presentation a lot. It was very well done.
As you know, we also espouse primary repair whenever possible, but we do not buttress the repair. I was wondering what the evidence is that buttressing is necessary or even helpful. Second, you make the assumption that the functional result after primary repair is clearly worse than esophagectomy. I do not know if there is a lot of data to support that contention. Most of the published reports on esophageal repair or perforation deal with the acute episode in the early recovery, and there are really very few data dealing with the long-term results of this condition.
DR JAMES W. PATE (Memphis, TN): I also congratulate Dr Wright and associates on their excellent clinical results and for emphasizing two important principles: the benefit of viable, healthy muscle buttresses over esophageal suture lines and the fact that it is never too late to repair and salvage a perforated esophagus. We have had repairs as late as 49 days after perforation with salvage of a functioning esophagus [1]. Whatever delay alone contributes, if anything, to prognosis and mortality, I think the cause of the perforation is more important.
I have taken the liberty of rearranging some of Dr Wright's data. Half of his cases (14) were postemetic perforations (Boerhaave's syndrome); iatrogenic perforations during dilation was next. These are quite different, etiologically. In the late cases, there were no instrumental perforations; they were all Boerhaave's disease. Of the Boerhaave's cases, 62% had a delay in diagnosis; 63% had preoperative sepsis with shock, among whom 3 (60%) had leaks and 2 (66%) died. All iatrogenic perforations were promptly diagnosed and operated on with minimal sepsis and postoperative leaks and no deaths. The different results can be attributed to the different preoperative status, related to cause, rather than to just time. Thus, the cause appears to be the basic determining factor in outcome.
DR SAFUH ATTAR (Baltimore, MD): My question relates to the 30% mortality in your late cases. This is an acceptable mortality considering the high rate of mortality in these patients. However, in retrospect, would you think that a different operation, as Dr Sugarbaker asked, such as esophagectomy would have been better than the complex procedures you went through? In our previous series we had 8 cases treated by esophagectomy due to either perforated cancer or to ulcerations from caustic material and the survival rate was much better; we had much less than 30% mortality.
DR STEVEN J. MENTZER (Boston, MA): Doctor Wright, I enjoyed your excellent paper. I noted that you have treated at least one esophageal perforation with a T tube. Given the amount of morbidity related to prolonged sepsis, I wondered if you might comment on the use of a T tube or alternative drainage techniques should a leak occur after primary repair.
DR S. K. MOHANTY (Huntington Beach, CA): What I want to ask is what kind of suture you use for your primary repair, not the buttressing as much. Also, how often in late cases were you able to do a two-stage repair? Finally, would you comment on the data published by Dr Skinner, if I am not mistaken, about esophagectomy in late cases?
DR JOSEPH E. BAVARIA (Philadelphia, PA): I thought this was a wonderful presentation. My question is, would you change or alter your approach to esophageal perforation in a trauma case, which we have actually seen quite a bit these days in the gunshot wound population. Would you use muscle flaps all the time?
DR WRIGHT: First of all, obviously the reason why we are still talking about various treatment options is that there is no randomized study. I doubt that one will ever be done. We do have strong opinions representing the merits of primary repair and I think there are results that substantiate these opinions.
To address Dr Sugarbaker, I pointed out that we thought, after careful review of these patients, that the deaths and complications were unrelated to leaks. The length of stay and the postoperative problems that these patients had were related to their debility and sepsis that were present preoperatively.
To address Dr Whyte, we buttress the repair because it is a belts-and-suspenders approach. We believe that when you are operating in a contaminated field the repair often will leak. If the repair is buttressed we have changed a devastating postoperative complication into a minor nuisance. Seven of our nine postoperative leaks were contained and healed with no further treatment. So we think a very important component of primary repair is to buttress these repairs.
With regard to the functional results of primary repair, we did not perform esophageal function studies on these patients postoperatively. We followed them up for a minimum of 1 year. One patient 4 years postoperatively had development of a recurrent benign stricture, which was nondilatable, and eventually needed an esophagectomy for that. No other late patients had esophagectomies. All other patients have been able to eat a normal diet.
To address Dr Pate, I also looked at the causes of the perforations and compared the death rates. For postemetic perforation, the overall death rate was 14% with no deaths in 6 early patients and 2 deaths (25% mortality) in the late group. Accordingly, we think that late presentation is a risk factor, but nonetheless a repair still can be performed.
To address Dr Attar's question, I would just reemphasize what I mentioned to Dr Sugarbaker, that the postoperative complications that these patients get are because of prolonged preoperative mediastinitis and sepsis and do not relate to what kind of operation you do on them. We do perform esophagectomy for perforated carcinoma and perforated nondilatable stricture, and we think it is a very good operation for those two indications. If you have failed primary repair in a late septic patient if would be quite reasonable to perform a resection.
To address Dr Mentzer, we did treat one of our 41 patients with a T tube. This was a massively obese lady with bilateral empyemas, adult respiratory distress syndrome, renal failure, and respiratory failure. She had a 30-day-old well-contained perforation and we were able to put a T tube in her to control her leak and connect it to a fistula. However, most perforations even when diagnosed late can be closed successfully with a buttressed primary repair.
Reference
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