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Ann Thorac Surg 1998;65:1433-1436
© 1998 The Society of Thoracic Surgeons

The Role of Esophagectomy in the Management of Esophageal Perforations

^a Department of Surgery, Postgraduate Medical University, Budapest, Hungary

Accepted for publication December 12, 1997.

Address reprint requests to Dr Altorjay, Department of Surgery, Postgraduate Medical University, Károly krt 23, H-1075 Budapest, Hungary

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial.

Methods. Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied.

Results. Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints.

Conclusions. Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.

	Introduction

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In thoracic surgical practice, few acute conditions are associated with sequelae as serious as those that follow perforation of the thoracic esophagus. The mortality of intrathoracic esophageal perforations is almost three times that of cervical esophageal injuries [1]. Prolonged leakage of saliva, gastric digestive enzymes, oropharyngeal bacteria, and bile into the mediastinum is often fatal. In the majority of patients, a close correlation can be demonstrated between mortality and interval from onset of symptoms to institution of treatment [2–5].

In an effort to stop ongoing mediastinal contamination in patients with intrathoracic esophageal perforation, a variety of procedures for esophageal exclusion or diversion have been proposed. In sharp contrast to these approaches is the concept of one-stage esophageal resection and reconstruction as initially described by Hendren and Henderson [6] in 1968. This report reviews our results with one-stage esophageal resection and reconstruction in the treatment of thoracic esophageal perforations.

	Material and methods

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A retrospective review of the records of all patients undergoing esophagectomy for perforations at the Postgraduate Medical University of Budapest between January 1, 1985, and December 31, 1994, was carried out. A scoring scale developed by Elebute and Stoner [7] for grading the severity of sepsis was applied. This scale evaluates four factors: local effects of infection, pyrexia, secondary effects of sepsis, and laboratory data. The resulting score [0 to 25] indicates the severity of sepsis. It was determined in our patients at the time of admission and on every third postoperative day.

Surviving patients were followed up by physical examinations, radiologic study, and letter.

On follow-up, the quality of swallowing (able to eat solid, semisolid, or soft food or drink fluid only) and major symptoms (distending discomfort, dumping syndrome, "full" sensation, reflux, pain, and weight loss) were evaluated.

For statistical analysis, the Borland Quattro Plus 2.0 program was applied.

	Results

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In the Department of Surgery, Postgraduate Medical University of Budapest, between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus (Table 1). In 8 patients, the esophagectomy was transhiatal, and in 19, a transthoracic approach was used. In 25 patients, esophageal reconstruction was carried out at the same operation. Continuity of the alimentary tract was restored with a jejunal interposition in 10 patients and with stomach in 15. The stomach was positioned retrosternally in 11 patients and in the posterior mediastinum in the original esophageal bed in 4. In 2 patients, delayed reconstruction with left colon was carried out 6 months after subtotal esophagectomy.

Postoperative complications occurred in 11 patients (41%): cervical anastomotic leak in 2 patients, wound infection in 2, respiratory failure in 3, multisystem organ failure in 2, pulmonary embolism in 1, and renal failure in 1. There was one postoperative death, for an operative mortality rate of 3.7%. The patient, a 74-year-old man with a perforated esophageal cancer, died of a pulmonary embolism on the 12th postoperative day and at postmortem examination was found to have hepatic metastasis and evidence of a previous myocardial infarction.

The duration of the postoperative hospital stay ranged from 12 to 63 days (average duration, 19 days). On average, peroral nutrition was begun on the tenth postoperative day.

Patients have been followed up from 3 to 78 months (average follow-up, 40.5 months). Follow-up is complete for 22 patients (82%). Of the 22 patients, 16 (73%) have no complaints and can swallow freely. Periodic recurrent dysphagia occurred in 2 patients (9%) and early morning reflux, in 1 patient (4.5%); treatment with H2 blockers was almost completely effective in relieving the latter symptom. One patient frequently complained of a "full" sensation retrosternally. He underwent a pyloroplasty 9 months after retrosternal substitution with stomach and had relief from symptoms. Repeated postoperative anastomotic dilations were required in 2 patients, 1 with a jejunal interposition and the other with a retrosternal gastric interposition.

Analysis of the Elebute-Stoner sepsis scores in these patients undergoing esophagectomy for perforation indicated significant lowering of the mean sepsis score by the third postoperative day (Fig 1).

View larger version (17K): [in this window] [in a new window]   Fig 1. Elebute-Stoner [7] sepsis scores in patients with intrathoracic esophageal perforation treated conservatively (drainage, endoprosthesis, exclusion, or diversion) or by esophagectomy.

	Comment

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An esophageal perforation proximal to a reflux stricture that is diagnosed early can be successfully treated by intraoperative bougienage, closure of the perforation, and buttressing the suture line with an intercostal muscle flap or a pericardial or omental tissue patch. Similarly, a perforation resulting from pneumatic dilation of an esophagus with achalasia is generally successfully treated by esophagomyotomy and suturing the perforation. Michel and co-workers [2] reported a mortality rate of 23% for perforations associated with intrinsic esophageal disease compared with a 4% mortality rate for perforations occurring in an otherwise normal esophagus. Similarly, Whyte and coauthors [11] reported excellent results with meticulous primary repair of an intrathoracic esophageal perforation regardless of the duration of the injury in the absence of cancer or an irreversible distal obstruction.

Our data suggest that esophageal resection and reconstruction is reliable and safe even in patients with established sepsis from a perforated thoracic esophagus. Although it represents a major primary therapeutic intervention, this approach definitively eliminates the source of intrathoracic sepsis, the hole in the esophagus, and the esophagus, which is so often diseased. It is best in this setting to avoid procedures that divide and exclude the esophagus, as such methods merely complicate the reconstructive procedures required later. Orringer and Stirling [4] advocated a similar aggressive approach and emphasized that in a desperately ill patient with sepsis and thoracic esophageal disruption, closure of the perforation or exclusion may not control the sepsis adequately.

Clinicians have long attempted to better assess objectively the severity of an illness and to predict the outcome of therapy on the basis of quantitative changes in measurable physiologic variables. Numeric quantification of these variables in such a disparate group of patients with esophageal perforation resulting from a variety of causes and undergoing conservative (drainage alone, drainage plus endoprosthesis, exclusion, or diversion) or radical (resection or resection and repair at one time) surgical procedures is a challenge.

To date, we have evaluated retrospectively the clinical courses of 44 patients with esophageal perforation, 22 treated conservatively and 22 by resection, according to the sepsis score of Elebute and Stoner [7]. The results are of limited value because of the relatively small number of patients. However, they may be useful for cautious prognostication or for assessing in a future prospective study the elimination of the source of sepsis in patients treated for perforation of the esophagus.

The sepsis scores of our 44 patients treated conservatively (drainage, endoprosthesis, exclusion, or diversion) and by resection start essentially at the same level (see Fig 1). In the group undergoing esophagectomy, the mean sepsis score is significantly lower by the third postoperative day and continues to decrease. On the other hand, in the patients treated conservatively, it is not until the 18th postoperative day that the sepsis score is significantly lower. These data indicate that esophagectomy in these patients results in earlier resolution of sepsis.

In 14 of our patients, a primary intrathoracic esophageal anastomosis was performed in the bed of the excised esophagus (to jejunum in 10 and stomach in 4). There was no anastomotic leak in any of these patients. Orringer and Stirling [4] advocated a cervical anastomosis away from the infected mediastinum, but it would appear that anastomosing viable, well-vascularized tissues is more important for ultimate anastomotic healing than avoidance of some degree of adjacent mediastinal contamination.

Whether a transthoracic or transhiatal approach is more appropriate for resection of a perforated esophagus is influenced by the age of the perforation, the severity of the concomitant mediastinitis, and the presence of pleural contamination. Transhiatal esophagectomy is an excellent treatment for early esophageal rupture, when pleural contamination is minimal, or when the perforation is confined to the mediastinum only. After extraction of the esophagus, vigorous intraoperative mediastinal and pleural irrigation through the diaphragmatic hiatus and cervical incision as advocated by Orringer and Stirling [4] effectively cleanses the contaminated areas. With an older perforation, particularly in the presence of pleural contamination, the transthoracic approach is preferred because at the time of resection, cleansing of the thoracic cavity and decortication can be carried out.

During the past 10 years, we have resected the esophagus to treat thoracic esophageal perforations in 27 patients, and only 1 patient (3.7%) has died. In view of this experience, the following criteria for esophageal resection and reconstruction as treatment of thoracic esophageal perforation are recommended:

1. Concomitant obstructive esophageal disease is present.
   
2. There is an extensive injury, even one treated within 24 hours, associated with serious mediastinal or intrapleural contamination.
   
3. The viability of the esophageal tissue at the site of injury is even slightly questionable, and no adequate pedicled tissue flap can be mobilized to cover the suture line.
   
4. Primary repair would cause a 50% narrowing of the esophageal lumen.
   
5. There is a spontaneous perforation associated with substantial sepsis.
   
6. There is circumscribed extravasation caused by a neglected impacted foreign body.
   

On the basis of our experience, we believe esophageal resection with immediate substitution is the method of choice in the treatment of selected perforations of the intrathoracic esophagus, particularly when there is established intrinsic esophageal disease.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Sandrasagra F.A., English T.A., Milstein B.B. Esophageal intubation in the management of perforated esophagus with stricture. Ann Thorac Surg 1978;25:399-401.[Abstract]
2. Michel L., Grillo H.C., Malt R.A. Operative and nonoperative management of esophageal perforations. Ann Surg 1981;194:57-63.[Medline]
3. Sandrasagra F.A., English T.A. The management and prognosis of oesophageal perforation. Br J Surg 1978;65:629-632.[Medline]
4. Orringer M.B., Stirling M.C. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990;49:35-43.[Abstract]
5. Matthews H.R., Mitchell I.M. Emergency subtotal esophagectomy. Br J Surg 1989;76:918-920.[Medline]
6. Hendren W.H., Henderson B.M. Immediate esophagectomy for instrumental perforation of the thoracic esophagus. Ann Surg 1968;168:192-194.
7. Elebute E.A., Stoner H.B. The grading of sepsis. Br J Surg 1983;70:29-31.[Medline]
8. Finley R.J., Pearson F.G., Weisel R.D., Todd T.R.J., Ilves R., Cooper J. The management of nonmalignant intrathoracic esophageal perforations. Ann Thorac Surg 1980;30:575-583.[Abstract]
9. Imre J. Plastic tube prosthesis for the surgical treatment of perforations in esophageal strictures. Ann Thorac Surg 1973;15:275-280.[Medline]
10. Skinner D.B., Little A.G., DeMeester T.R. Management of esophageal perforation. Am J Surg 1980;139:760-764.[Medline]
11. Whyte R.I., Iannettoni M.D., Orringer M.B. Intrathoracic esophageal perforation. J Thorac Cardiovasc Surg 1995;109:140-146.[Abstract/Free Full Text]

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