Ann Thorac Surg 1997;63:246-247
© 1997 The Society of Thoracic Surgeons
Case Report
Transhiatal Closure of Right-Sided Esophageal Rupture After a Left Pneumonectomy
Lajos Kotsis, MD, PhD,
László Agócs, MD,
Judit Kovács, MD
Thoracic Surgical Clinic, Postgraduate Medical University, Budapest, Hungary
Accepted for publication July 27, 1996.
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Abstract
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Right-sided spontaneous esophageal rupture developed 2 days after left pneumonectomy and vomiting. To avoid contamination of the pneumonectomized left thoracic cavity as well as a contralateral thoracotomy, we used a transhiatal approach for primary repair of the rupture, combined with right-sided pleural and mediastinal drainage, gastrostomy, and feeding jejunostomy. The 7-day barium meal control showed healing of the rupture.
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Introduction
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Management of the spontaneous esophageal rupture is one of the most challenging problems in thoracic surgery. Since 1981, 6 esophageal ruptures have been treated at the Thoracic Surgical Clinic in Budapest. All but one were typical late (24 hours to 5 days) ruptures. We elected to use left transthoracic mediastinal decompression and reinforced (with diaphragmatic flap or fundoplication) two-layer closure. The pathologic circumstances in the last case were unusual.
Two days after left pneumonectomy for recurrent bronchial tumor and vomiting of a 68-year old patient, right-sided hydropneumothorax developed. Brownish gastric content (850 mL) was obtained through the thoracostomy tube drain (Sherwood Medical Argyle, Crawley, United Kingdom) (Fig 1
), whereas the esophagogram (Fig 2) showed a large communication with the right pleural cavity.
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Fig 1. . Chest roentgenographic finding of the emergently drained right pleural cavity for a right-sided hydropneumothorax that developed 2 days after left pneumonectomy and vomiting.
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Fig 2. . Contrast material swallowing showed a large communication with the right pleural space through an esophageal rupture.
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It was evident that transthoracic access would be disadvantageous for the esophageal wall repair attempt; therefore, we used a transhiatal Pinotti-type [1] approach. Through a midline laparotomy the esophageal hiatus (Fig 3) was enlarged by a vertical diaphragmatic incision (5 cm). After mediastinal decompression, debridement of the gastric juice, fibrin, and food (180 mL) in the right pleural space (through the ruptured right mediastinal pleura) was achieved by 3% povidone-iodine lavage. The two-layer suture of the 2.5-cm-long complete rupture situated 4 cm above the esophagogastric junction was carried out intramediastinally with interrupted Vicryl (Ethicon, Edinburgh, United Kingdom) stitches. The suture line was buttressed with omentum, and a previously introduced right-sided pleural drain was combined with a mediastinal drain, a gastrostomy, and a feeding jejunostomy.
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Fig 3. . Enlarged transhiatal approach by a vertical diaphragmatic incision for primary repair of the rupture.
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The mediastinal and pleural tubes were removed at 3 and 7 postoperative days, respectively. The 7-day barium meal swallowing showed healing of the rupture (Fig 4). Unfortunately the patient died 2 weeks later due to a "kissing" duodenal ulcer.
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Comment
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None of the conventional types of management [2–7], including the newest one [8], were available in this case. Previous indications for transhiatal access include removal of lower or high esophageal cancer or of an aperistaltic megaesophagus, lye esophageal necrosis, or perforated esophageal carcinoma, Merendino-type jejunal interposition, and diverticulectomy with myotomy of epiphrenic diverticula with associated achalasia.
It was mandatory that contamination of the pneumonectomized left thoracic cavity during rupture closure as well as a contralateral thoracotomy with its respiratory consequences had to be avoided by all means. Reconstruction of the esophageal wall combined with reinforcement was achieved without difficulties through this approach, although to avoid rupture of the left-sided mediastinal pleura, we did not mobilize the esophagus.
In the very particular circumstance when transthoracic primary repair of an esophageal rupture is contraindicated, transhiatal closure may be a useful alternative procedure.
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Footnotes
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Address reprint requests to Dr Kotsis, Pihenö út 1, H-1529 Budapest, Hungary.
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References
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- Pinotti HW. Esofagectomia subtotal por tunel transmediastinal sem toracotomia. Rev Assoc Med Bras 1977;23:395–9.
- Finley RJ, Pearson FG, Weisel RD, Todd RJ, Ilves R, Cooper J. The management of nonmalignant intrathoracic esophageal perforations. Ann Thorac Surg 1980;30:575–83.[Abstract/Free Full Text]
- Westaby S, Shepherd MP, Nohl-Oser HC. The use of diaphragmatic pedicle grafts for reconstructive procedures in the esophagus and tracheobronchial tree. Ann Thorac Surg 1982;33:486–90.[Abstract/Free Full Text]
- Kotsis L, Gondos T, Pénzes I. The modern treatment of the spontaneous esophageal ruptures. Orv Hetil 1983;124:1755–58.[Medline]
- Pate JW, Walker WA, Cole FH Jr, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689–92.[Abstract/Free Full Text]
- Urschel HC Jr, Razzuk MA, Wood RE. Improved management of esophageal perforations: exclusion and diversion in continuity. Ann Surg 1974;179:587–90.[Medline]
- Chang C-H, Lin PJ, Chang J-P, Hsieh M-J, Lee M-C, Chu J-J. One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation. Ann Thorac Surg 1992;53:617–20.[Abstract/Free Full Text]
- Akiyama H, Tsurumaru M, Ono Y, Udagawa H, Kajiyama Y. Mucosal stripping of the esophagus. Dis Esoph 1993;6:27–30.
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Eur J Cardiothorac Surg,
December 1, 2000;
18(6):
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Abstract
Introduction
