Ann Thorac Surg 2000;69:1609-1611
© 2000 The Society of Thoracic Surgeons
How to do it
Repair of esophageal perforation after treatment for achalasia
Moria Urbani, MDa,
Douglas J. Mathisen, MDa
a General Thoracic Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
Address reprint requests to Dr Mathisen, General Thoracic Surgical Unit, Massachusetts General Hospital, 32 Fruit St, Blake 1570, Boston, MA 02114
e-mail: dmathisen{at}partners.org
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Abstract
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Esophageal perforation after treatment for achalasia is a devastating complication. Successful closure of the perforation and relief of the obstruction from achalasia are paramount. This can be accomplished by careful closure of the mucosa. The mucosal closure is buttressed by a pedicled intercostal muscle carefully sewn to the edges of the muscular defect. This approach deals effectively with the perforation and maintains the myotomy for relief of esophageal obstruction from achalasia.
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Introduction
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Pneumatic balloon dilation of the esophagus for achalasia has become a popular method for treating this disorder. A major complication of this procedure is esophageal perforation. Most authors have recommended closure of the mucosa and reapproximation of the ruptured esophageal muscle [1–5]. The esophagus is then mobilized, and a Heller myotomy is performed on the opposite side of the perforation.
We have used a different approach to the management of these patients that treats the perforation, maintains the myotomy caused from the rupture by the pneumatic dilation, and has provided good long-term relief from symptoms.
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Technique
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The level of perforation is documented with a contrast study. If the perforation involves the distal esophagus, the site is explored through the seventh or eighth intercostal space. The intercostal muscle between the seventh and eighth ribs is carefully mobilized, preserving the vascular supply. The pedicle is based posteriorly and must be mobilized to the costal arch to have enough length to cover the entire length of the perforation. The lung is decorticated, necrotic esophageal muscle is debrided, and the entire length of the perforation is exposed (the mucosal tear invariably extends beyond the muscular tear). No additional mobilization of the esophagus is required.
If it is determined that the perforation crosses the gastroesophageal junction (it almost always does), the mucosa is closed with inverting simple 4-0 silk sutures with great care taken to "dunk" the last suture (Fig 1). The repair is checked by instilling methylene blue through a nasogastric tube positioned just proximal to the repair and applying gentle pressure. Alternatively, the repair is immersed in saline, and air is instilled instead of methylene blue. Any leaks should be repaired. The intercostal muscle is then carefully sutured to the edges of the ruptured esophageal muscle (Fig 1). This is performed with 4-0 silk sutures using a horizontal mattress technique. These sutures must be placed carefully around the entire defect to not allow any gaps. It is typical to use 15 to 20 sutures. The same care applied to an esophageal anastomosis must be applied to this repair.
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Fig 1. (A) Esophageal perforation usually crosses the gastroesophageal junction. (B) Any devitalized tissue must be debrided and extent of mucosal tear accurately identified. (C) The mucosa is carefully closed with interrupted 4-0 silk sutures with knots on the inside to invert the mucosa. (D) The mucosal closure should be checked for any leaks. (E) The pedicled intercostal muscle is carefully sewn to the muscular edge of the defect with interrupted 4-0 silk mattress sutures.
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Because the hiatus and esophagus are not deserted, we do not believe that an antireflux procedure is needed. The presence of the intercostal muscle would make the antireflux procedure technically more difficult. Appropriate chest tubes are placed, and a draining gastrostomy and feeding jejunostomy are always performed. A contrast study is routinely done on postoperative day 7 to check for any leaks.
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Results
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Case 1
A 55-year-old man was diagnosed with esophageal perforation 24 hours after pneumatic dilation for achalasia. Repair was accomplished. Barium swallow at day 7 revealed an asymptomatic thin wisp of barium, approximately 1.5 cm in length. Results from a repeat barium study 5 days later were normal. He has had good symptomatic relief from achalasia. He had a small hiatal hernia appreciated on postoperative contrast studies some years later. He experienced mild reflux symptoms about 5 years after perforation, but they were well controlled with medical regimens. He required dilation of a mild stricture on occasion, but otherwise remains well 13 years later.
Case 2
A 92-year-old woman was diagnosed with esophageal perforation 8 hours after pneumatic dilation. Esophageal repair was accomplished. The patient had an uneventful recovery and was discharged on day 10. She remains well with good relief of symptoms 3 years later.
Case 3
A 79-year-old woman underwent a Heller myotomy. She had a prior subtotal gastrectomy. A barium swallow on day 7 revealed free flow of barium from the distal esophagus into a 3-cm cavity from which she was asymptomatic. She was found to have a 4-cm perforation possibly related to ischemia. The remaining mucosa was healthy, and repair as described for balloon perforation was performed. She had an uneventful recovery and was discharged 10 days later. She maintains excellent relief from her achalasia many years later.
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Comment
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Esophageal perforation after therapy for achalasia is a devastating complication. When this follows pneumatic dilation, the recommendation is to close the mucosa and ruptured esophageal muscle in two layers, mobilize the esophagus, and perform a Heller myotomy on the side opposite the perforation. If it is determined that the rupture has crossed the gastroesophageal junction, this approach seems awkward and problematic relative to the completeness of the myotomy, and potentially dangerous because of the need to mobilize an edematous, inflamed esophagus.
We believe it is necessary to adhere to the following principles in managing esophageal perforation after treatment of achalasia. Foremost it is imperative to repair the perforation in a reliable fashion to avoid the devastating complications and possible death caused by esophageal perforation. A careful closure of the well-preserved esophageal mucosa can be accomplished with the technique described. Buttressing this repair with a pedicled intercostal muscle carefully sewn as described provides a secure two-layer closure. Furthermore, by inserting the intercostal muscle between the separated edges of the ruptured esophageal muscle, it maintains the myotomy created by the balloon dilation. The intercostal muscle prevents reapproximation providing long-term relief from symptoms of achalasia as well. We think a draining gastrostomy and feeding jejunostomy are essential to reduce acid reflux on the repair and provide early nutritional support.
This method avoids the need for extensive mobilization of the esophagus, which can be dangerous in this circumstance. A myotomy on the opposite side of the esophagus is awkward and often involves disrupting the esophageal hiatus predisposing to gastroesophageal reflux. If the esophageal muscle is dissected from the mucosa to avoid later reapproximation of the muscle, it could pose an additional hazard to the repaired perforation site.
This method has been successful in 3 patients to repair the esophageal perforation and provide lasting relief of symptoms of achalasia. This method of repair should be considered in patients treated for achalasia by pneumatic dilation who have an esophageal perforation.
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References
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McKinnon W.M.P., Ochsner J.L. Immediate closure and Heller procedure after Mosher bag rupture of the esophagus. Am J Surg 1974;127:115-118.[Medline]
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Miller R.E., Tiszenkel H.I. Esophageal perforation due to pneumatic dilation for achalasia. Surg Gynecol Obstet 1988;166:458-460.[Medline]
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Pricolo V.E., Park C.S., Thompson W.R. Surgical repair of esophageal perforation due to pneumatic dilation for achalasia. Is myotomy really necessary?. Arch Surg 1993;128:540-544.[Abstract/Free Full Text]
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Schwartz H.M., Cahow C.E., Traube M. Outcome after perforation sustained during pneumatic dilatation for achalasia. Dig Dis Sci 1993;38:1409-1413.[Medline]
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Slater G., Sicular A.A. Esophageal perforation after forceful dilatation in achalasia. Ann Surg 1982;195:186-188.[Medline]
Accepted for publication December 30, 1999.
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