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Ann Thorac Surg 1996;61:1451-1452
© 1996 The Society of Thoracic Surgeons
DR HAROLD C. URSCHEL, JR, (Dallas, TX): Thank you, Dr Bufkin, for a very clear presentation. Our approach back in the early 1960s was very similar to that presented here, with the exception of the T tube. When we saw a fairly early large perforation and repaired it primarily, reinforcing it with pleura or intercostal bundle or even occasionally omentum, we would still see leaks in a certain percentage of patients secondary to that repair. Because of that, in the mid-1960s we began to use exclusion and diversion on all the larger esophageal perforations regardless of the time we saw them, early or late, and the ones that we basically could not treat conservatively.
This procedure involves preventing a continued chemical burn from the stomach. We exclude the esophagus below the perforation after we close the perforation. We close it either with pleura, the intercostal bundle, or with omentum. We started with Teflon, and now we use Silastic. We tie it with either chromic or, if we want to bring out a Rumel tourniquet, with Prolene or something like that and bring it out below the diaphragm with a gastrostomy.
We do this in every case regardless of how secure it looks because we can never trust the situation completely. At the same time, we do a side-to-side cervical esophagostomy to the skin. Although this is side to side, it provides 100% diversion because of the angulation of the esophagus.
The advantage of this technique is that the patients can usually go home in a week, and they do not need a second general anesthetic. If you use a chromic tie, this comes undone by itself in about 3 weeks. If you use the Rumel, you can release it in about 3 weeks. You can close the esophagostomy under local anesthesia, converting the side to side to a Heineke-Mikulicz. Some patients need one dilatation. We have not had to resect any cases.
We presented the early cases in 1972 at the Southern Surgical Association. Since then we have accumulated about 106 patients, but nobody has required resection and almost no one has needed a second operation. Although this initially appeared to be radical treatment, it is actually the simplest and safest approach to the large or late perforation.
DR BUFKIN: We recognize Dr Urschel's important contribution to the treatment of esophageal perforation. We did not experience large problems with leak after our primary repairs. We used exclusion and diversion in 1 patient with irreparable middle-third perforation and found it useful in that setting. Based on our experience with primary repair, we believe that routine exclusion and diversion is not necessary.
DR URSCHEL: What do you put the T tube in for?
DR BUFKIN: We prefer to manage the patients with irreparable injuries as a controlled esophagocutaneous fistula because it is a simple technique in a very sick group of patients. We use the T tube to provide precise control of the esophageal secretions. It can be done easily, and we have enjoyed good results with it.
DR URSCHEL: But you have to operate on them to put the T tube in them, and I think this increases the morbidity of the procedure. These are the cases for which you ought to be using primary diversion and exclusion. This was the technique that Osler Abbott presented at the American Association of Thoracic Surgery, at which he discussed all the other papers. Dr Sweet got up and said he thought that Dr Abbott did not have a good concept. To put a T tube in holds the perforation open. You still have to operate on them a second time anyway.
DR MANSOUR: This is in answer to Dr Urschel's question. The question is that you still have to open the chest to close the hole in the exclusion procedures. When we open the chest to close the hole, we find that the tissues are very inflamed and edematous and cannot be repaired primarily. One of our patients had gangrene of the lower lobe of the lung, which we had to take care of as well. While we are there, we place the T tube. We are not talking about another operation. As a matter of fact, our operation is one; yours is two.
The T tube has been used very successfully, not only in this country, but also abroad. Naylor and colleagues [1] used it in 10 patients with excellent results. In rapidly deteriorating patients with gross pleural sepsis, drainage of mediastinal and pleural collections undoubtedly contributes to stabilization, but there remains the fundamental problem of the underlying esophageal defect. In our experience, T-tube intubation led to rapid clinical stabilization with marked reduction in hospitalization. Esophageal exclusion, however, has the theoretic disadvantage of creating a distal obstruction, which might promote drainage of mucus through the perforation and will require two surgical procedures.
DR JOSEPH S. McLAUGHLIN (Baltimore, MD): Doctor Bufkin, I thoroughly enjoyed your report. It was well presented, and I believe the data are fine.
Doctor Mansour was kind enough to supply me with the manuscript yesterday, and your series is very similar to the one that we presented some years ago at this meeting. We had 64 patients at that time: 20 with perforation in the cervical region, 43 in the thoracic region, and 1 abdominal.
Our series is a bit different from yours in that we had a large number of traumatic lesions: There were 30 due to gunshots, three were traumatic lesions due to blunt trauma, and one was due to a stab wound. Nineteen patients had iatrogenic causes, or about 27% of the total series. At the time we presented our series, Dr Mansour commented that we had a 27% iatrogenic rate, and he asked how many of these Dr Attar and I had perforated. I noticed today that you had a 70% iatrogenic rate. I will not ask you about that, but I will ask Dr Mansour, as such a turnabout is fair play. Sixteen of ours were spontaneous.
We treated 30 of these patients by primary repair, and 9 by primary esophagectomy at the primary operation. Three or 4 of these had reconstruction at a later date. We drained 17 patients with late perforations who were sick and had other problems. We also used exclusion and diversion in 5 of these. Most of these people died. We used the Thal procedure in just 1 patient. There were two nonoperative cases: One man with cancer died later on, and the other got well.
We agree with your individualized approach to dealing with this problem. It is a terrible problem, and the mortality rate is high. Although we will do a primary closure after 24 hours if the tissues look good, often this simply is not the case. And in our series, there was a marked difference between those patients who we operated on early and those patients we operated on late. When operation was done in less than 24 hours and in the cervical region, 91% survived. After 24 hours, many of these patients had mediastinitis, pleuritis, and empyema, and only 60% survived. In the thoracic patients, 83% survived if we reached them in the first 24 hours. These are mostly primary repairs. We patch them. Only half of the patients survive if it is greater than 24 hours.
I have a couple of questions. I notice that the time you gave is in terms of means. Perhaps your numbers would be different if you looked at the mode. Did you calculate the mode?
Second, was there a correlation between that mode, which I assume you calculated, and survival? And if the cause was iatrogenic, why was there such a long time before identification? Most of the cases we see who we perforate, or our gastrointestinal colleagues perforate, we get pretty early. It seemed to me that the time lapse was quite long.
Finally, I am curious about the use of T tubes. It seems to me this is a very worthwhile thing, although we have not used these in this circumstance. I wondered whether these patients have late sequelae from these T tubes. If you take the mucosa out of something, it forms strictures; do these patients end up later on with strictures? Do you have to reoperate on them? Have you got a good follow-up?
DR BUFKIN: In answer to your last question, our T-tube patients have not had problems with late esophageal strictures. Reports on esophageal T-tubes from across the Atlantic, a total of 15, did not report stricture as a major finding postoperatively [1, 2].
Most of our patients, in fact two thirds of them, were diagnosed within 24 hours of the injury, and that was the case in all groups-the spontaneous, the iatrogenic, and others. The majority of patients, both those that died and those that survived, were diagnosed within 24 hours. Approximately half of the deaths occurred in patients diagnosed within the first 24 hours. An important fact that was not evident in the presentation but is in the paper is that our operative group included a set of 7 patients that were managed on their deathbeds, and 6 of these 7 patients died. All of these patients were diagnosed late, after 24 hours. As you point out, time to diagnosis remains an important predictor of survival; however, the degree of tissue injury and physiologic status of the patient are the final determinants of survival. Unfortunately, unlike time to diagnosis, these are subjective measurements that require long experience to quantitate.
With regard to iatrogenic esophageal perforation, 4 of the 48 patients had intraoperative perforations: 2 during cervical procedures and 2 with intraoperative esophagoscopy that preceded an elective esophageal operation. Our iatrogenic injuries occurred mostly during endoesophageal procedures performed by nonsurgeons. A high rate of iatrogenic injuries has been observed in other series as well.
DR WATTS R. WEBB (New Orleans, LA): I have a couple of quick points. For upper esophageal perforations, we always perform closure; we do not just drain them. We believe there is no reason not to close them and reinforce them with a strap muscle or something else at the same time.
Not enough has been said, I think, about the obstructive lesions, whether they be carcinoma or benign. I think that any time you have a perforation with a distal obstruction, you must take care of that at the time you first do your operation. If it is malignant, early or late, we resect it. We may or may not put the esophagus back together; that is, we may not do a gastric pull-up until later. But you have to get rid of the tumor then because it is your only chance of cure. If it is benign, you must take care of the obstruction at that point. We frequently have done a Thal procedure, myotomy, or something else to get rid of the obstruction and close the perforation at that time, and to make sure we have good drainage and good support.
DR BUFKIN: We would agree with those principles.
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