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Ann Thorac Surg 1996;62:1891-1892
© 1996 The Society of Thoracic Surgeons

Correspondence

Esophageal Perforation

Rafael Andrade-Alegre, MD

Thoracic Surgery, Department of Surgery, Santo Tomas Hospital, PO Box 8748, Panamá 5, Republic of Panamá

To the Editor:

I read with interest the fine article by Bufkin and associates [1] on esophageal perforation. There is no state of the art in the management of esophageal perforations, particularly late ones. Treatment of late esophageal perforations is controversial, and proof of this is the numerous options described in the medical literature [2–9]. The surgical decision will depend on several aspects: the patient's general condition, extent of damage, underlying esophageal disease, quality of tissues, and the surgeon's experience.

An individualized approach is recommended for esophageal perforation, and at this point I would like to make a comment on the sometimes criticized T-tube intubation of the esophagus. This is a very useful procedure for critically ill patients: it does not increase the length of the operation, preserves the esophagus, and converts a free perforation into a controlled fistula, avoiding further contamination of the mediastinum and pleural cavity. It is important to stress the fact that, contrary to Dr Urschel's opinion (expressed in the discussion of this article), the created fistula usually will close a few days after the removal of the T tube and will require no further operation. If the fistula does not close promptly, probably there is a distal obstruction and the indication to place a T tube was inadequate.

I have used the T tube twice in the last 4 years: once for a leakage of an esophagogastric anastomosis after operation for cancer and once for the management of a late esophageal perforation due to a gunshot wound [10]. Both patients did well. The patients were followed up for 10 months and 3 years, respectively. Neither of them required a further operation.

T Tubes should continue to be considered in the management of selected cases of esophageal perforations.

References

  1. Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation: emphasis on management. Ann Thorac Surg 1996;61:1447–52.[Abstract/Free Full Text]
  2. Urschel HC, Razzuk MA, Wood RE, Galbraith N, Pockey M, Paulson DL. Improved management of esophageal perforation: exclusion and diversion in continuity. Ann Surg 1974;179:587–91.[Medline]
  3. Grillo HC, Wilkins EW. Esophageal repair following late diagnosis of intrathoracic perforation. Ann Thorac Surg 1975;20:387–99.[Abstract]
  4. Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990;49:35–43.[Abstract]
  5. Gayet B, Breil P, Fekete F. Mechanical sutures in perforation of the thoracic esophagus as a safe procedure in patients seen late. Surg Gynecol Obstet 1991;172:125–8.[Medline]
  6. Bardini R, Bonavina L, Pavanello M, Asolati M, Peracchia A. Temporary double exclusion of the perforated esophagus using absorbable staples. Ann Thorac Surg 1992;54:1165–7.[Abstract]
  7. Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic esophageal rupture. Br J Surg 1994S;81:863–5.[Medline]
  8. Richardson JD, Tobin GR. Closure of esophageal defects with muscle flaps. Arch Surg 1994;129:541–8.[Abstract/Free Full Text]
  9. Tasdemir O, Kucukaksu DS, Karagoz H, Bayazit K. Beneficial effects of fibrin glue on esophageal perforation [Letter]. Ann Thorac Surg 1996;61:1589.[Free Full Text]
  10. Andrade-Alegre R. T-tube intubation in the management of late traumatic esophageal perforations: case report. J Trauma 1994;37:131–2.[Medline]
 

Reply

Kamal A. Mansour, MD

The Emory Clinic, 1365 Clifton Rd NE, Atlanta, GA 30322

To the Editor:

I thank Dr Andrade-Alegre for his supporting remarks on our T-tube management of late esophageal perforations. I have nothing else to add, but thank him also for responding to Dr Urschel's discussion of our article. This is particularly important as we did not solicit Dr Andrade-Alegre's help.





This Article
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Kamal A. Mansour
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Right arrow Articles by Mansour, K. A.

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