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Ann Thorac Surg 2007;83:1129-1133
© 2007 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Modified T-Tube Repair of Delayed Esophageal Perforation Results in a Low Mortality Rate Similar to That Seen With Acute Perforations

Philip A. Linden, MD*, Raphael Bueno, MD, Steven J. Mentzer, MD, Lambros Zellos, MD, Abraham Lebenthal, MD, Yolonda L. Colson, MD, PhD, David J. Sugarbaker, MD, Michael T. Jaklitsch, MD

Division of Thoracic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

Accepted for publication November 3, 2006.

* Address correspondence to Dr Linden, Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (Email: plinden{at}partners.org).


General thoracic surgery: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Esophageal perforation carries a high mortality and morbidity rate, especially if treatment is delayed more than 24 hours. We present a large series of patients requiring operative treatment of esophageal perforations with attention to an infrequently used method of dealing with delayed intrathoracic perforations.

Methods: All patients undergoing operative treatment for intrathoracic esophageal perforation at the Brigham and Women’s hospital between 1989 and 2003 were reviewed. Mortality, morbidity, length of stay, nature of esophageal injury, type of repair, and outcome were reviewed.

Results: Forty-three operations for perforation of the thoracic esophagus were performed. Overall 30-day or in-hospital mortality was 7.0%, and overall morbidity was 47%. Most acute thoracic esophageal perforations were treated with primary repair and had a mortality rate of 5%, whereas most delayed perforations were treated with T-tube repair and had a mortality rate of 8.7%. The complication rate in the group repaired within 24 hours was 20%, whereas it was 61% in the group repaired after 24 hours. The complication rate in the group repaired within 72 hours was 42%, and it was 82% in the group repaired after 72 hours.

Conclusions: Treatment of delayed (more than 24 hours) thoracic esophageal perforations with a controlled fistula through T-tube results in a very low mortality similar to that seen with acute perforations (less than 24 hours). Morbidity and length of stay remain high. Delay in treatment of intrathoracic esophageal perforations beyond 24 and 72 hours results in a doubling of morbidity at each interval.

Esophageal perforation is a devastating illness associated with a prolonged hospitalization and significant mortality. Several factors are associated with the increased morbidity and mortality of this disease, including time to operation, location of perforation (cervical versus thoracic versus abdominal), associated esophageal disease, and operative approach. The time from onset of symptoms to definitive treatment is perhaps the strongest independent predictor of mortality and morbidity [1], with perforations treated within 24 hours carrying mortality rates of 10% to 15% and perforations treated after 24 hours associated with mortality rates of 30% to 60% [2–4].

It is generally accepted that intrathoracic esophageal perforations diagnosed within 24 hours are best treated by primary repair. Beyond 24 hours, primary repair is more likely to fail as the patient’s physiologic condition may deteriorate, and progression of local inflammation results in tissues that are less able to hold sutures. A variety of approaches have been recommended for intrathoracic perforations diagnosed after 24 hours, including exclusion with diversion, esophagectomy, and primary repair.

The use of a T-tube to treat delayed esophageal perforations by creating a controlled fistula has infrequently been described in the literature [5–8]. Creation of a controlled fistula, using a T-tube, may be ideally suited to delayed esophageal perforation as the incidence of repair breakdown and recurrent leak is high, and undrained collections are a major contributor to sepsis and death.

We reviewed our experience in treating patients with thoracic esophageal perforations between 1989 and 2003 with particular attention to the treatment of delayed perforations of the thoracic esophagus. The majority of these patients were treated with a previously described, but uncommonly used, esophageal T-tube.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
The Department of Surgery operative database at Brigham and Women’s Hospital was queried for all operations performed between 1989 and 2003 carrying the International Classification of Diseases (ICD-9) diagnosis of esophageal perforation (530.4). Cervical and intra-abdominal perforations were excluded. Only patients with perforations of the native esophagus were included. Patients found to have leaks secondary to esophageal resection with anastomosis were excluded. Gastric leaks into the chest in patients with hiatal hernias were excluded. Patients with tracheoesophageal fistulas were excluded.

Forty-three patients with the diagnosis of perforation of the thoracic esophagus underwent surgical treatment. All patients were evaluated with flexible esophagoscopy in the operating room before incision to determine the correct operative approach and to rule out any associated abnormalities. The time from perforation to operation was generally noted by the surgeon in the operative report. If not mentioned in the operative report, these times were estimated by examination of other notes in the medical record. Patients brought to the operating room after 24 hours of perforation were considered to have delayed treatment of their perforation. Hospital lengths of stay, as well as perioperative complications, were recorded. Barium swallows were surveyed to document persistent leaks. Additional surgeries and procedures were recorded.

The modified T-tube method of repair included decontamination of the pleural space, decortication of all lung surfaces, and identification of the site of perforation. A T-tube, consisting of either a large bore (16 F) soft biliary T-tube (Fig 1), or a trimmed percutaneous endoscopic gastrostomy (PEG) tube (Fig 2) was inserted into the esophagus, and the adjacent esophagus was closed in one or two layers. Muscle flap reinforcement was occasionally employed. The pleural space was extensively drained. The T-tube was placed through the most direct route possible out the chest wall, with care to secure the tube away from the aorta and other vital structures. Abdominal feeding tubes were inserted.


Figure 1
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  		Fig 1. Repair of a distal esophageal perforation over a T-tube. The tube is tacked to the diaphragm and lies away from the aorta.

 

Figure 2
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  		Fig 2. Repair of a distal esophageal perforation over a percutaneous endoscopic gastrostomy tube whose button has been trimmed. The tube is tacked to the diaphragm and lies away from the aorta.

 
The study was approved by the Institutional Review Board of the Brigham and Women’s Hospital. The requirement for individual patient consent was waived.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Between 1989 and 2003, 43 patients underwent operative treatment of perforations of the thoracic esophagus. There were three 30-day or in-hospital deaths, for an overall mortality of 7.0%. Twenty of the patients (47%) had one or more complication. Further analysis of etiology, interventions, and outcome are made according to region of perforation.

Etiology and Operative Procedures
The average age of patients presenting with perforation of the thoracic esophagus was 63 years (±31). Forty-three patients presented with thoracic perforations: 20 (47%) were treated within 24 hours of injury, and 23 (53%) were treated after 24 hours of injury. The majority (22) of thoracic perforations were spontaneous, whereas 15 were iatrogenic (Table 1).


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  		Table 1 Etiology of Thoracic Esophageal Perforations (n = 43)
 
Most patients who presented within 24 hours of the onset of symptoms were treated with primary repair (11 of 20), and 5 were treated with a T-tube. The majority of patients who presented after 24 hours were treated with T-tube repair (12 of 23). A unified algorithm for treating esophageal perforations has not been adopted by our group. Review of the operative notes revealed that the most important consideration in the use of a T-tube was the determination that the tissues were inadequate to hold sutures, either as a result of prolonged inflammation, from necrosis, or owing to overwhelming contamination. Muscle flaps were frequently added to buttress the repair in instances of delayed perforations. Certain patients with sealed perforations were treated by drainage or feeding tube placement without repair, or both. The primary operative procedures are listed in Table 2 (reoperations are listed in Table 4).


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  		Table 2 Operative Treatment of Thoracic Esophageal Perforations (n = 43)
 

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  		Table 4 Thoracic Perforations Requiring Reoperation
 
Length of Stay, Complications, and Mortality
The average length of stay for patients with intrathoracic esophageal perforations was 63 days (±31). Excluding outliers (4 patients with a length of stay longer than two standard deviations), the average length of stay was 26 days. Six of 20 patients (30%) with early (less than 24 hours) perforations suffered complications, and 14 of 23 patients (61%) with delayed perforations (longer than 24 hours) had complications. Further delay in repair increased the incidence and severity of complications. For patients treated within 72 hours of perforation, the complication rate was 5 of 12 (42%). Only 1 of these could be termed serious (mechanical ventilation more than 24 hours). Among patients whose treatment was delayed for more than 72 hours, the complication rate was 9 of 11 (82%). Eight were serious complications (myocardial infarction, death, prolonged ventilation, or empyema). A complete list of complications is found in Table 3.


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  		Table 3 Complications of Thoracic Perforations
 
Overall mortality for patients with thoracic perforations was 7.0% (3 of 43). The mortality rate for patients with perforations treated within 24 hours was 5% (1 of 20), whereas the mortality rate for the delayed group was 8.7% (2 of 23). When analyzed by treatment group, none of the 11 patients with acute perforations treated with primary repair died, and only 1 of the 12 patients with T-tube repair of delayed perforation died. Four of 11 (36%) of the acute perforation patients undergoing repair had one or more complications. The average length of stay in this group was 22 days. Ten of 12 (83%) of the delayed perforation patients undergoing T-tube repair had complications. The average length of stay in this group was 47 days. The average length of stay for the 5 patients in the acute perforation group undergoing T-tube repair was 46 days.

Barium Swallow Follow-Up and Additional Procedures
Seven patients did not undergo postoperative barium swallow. including the 3 patients who died. Thirty-six patients did have a postoperative barium swallow. Twenty-five were found to have no leak, and 11 had a leak. There were no deaths among the 11 patients who were found to have a postoperative leak. Those with a contained leak or a leak controlled by a drain did not undergo reoperation. Only 2 patients with leaks required intervention (exclusion). One patient with a controlled leak required repair of an aortoesophageal fistula 38 days after T-tube repair and survived. The fistula was due to erosion into the aorta by an adjacent Jackson-Pratt pleural drain. Overall, 16 patients required additional procedures related to the treatment of their perforation. Eight of these procedures were reoperations on the esophagus, and the remaining procedures were dilations, stent placement, or tracheostomy. Only a single T-tube patient in either the acute or delayed group required dilation of the esophagus. The repeat operative procedures are listed in Table 4.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Primary repair of acute (less than 24 hours) esophageal perforations is the preferred therapy and is associated with a low incidence of leak and a mortality rate of approximately 10% in the current literature [9]. Most papers describe a dramatic increase in perioperative mortality for perforations repaired beyond 24 hours with a mortality rate approaching 30% to 40% [1–3, 9]. Patients with delayed presentation of thoracic esophageal perforations present unique challenges. These patients are commonly septic with inadequate end-organ perfusion. The release of bacteria and enzymes from the perforation results in tissue destruction, edema, and local infection that interfere with repair.

A variety of treatments have been proposed for treatment of delayed thoracic esophageal perforations. Esophagectomy may be employed in instances of esophageal necrosis, end-stage benign esophageal disease, and resectable esophageal malignancy in patients who are hemodynamically stable. With a transthoracic approach, pleural drainage and decortication of the lung can be performed at the same time. The anastomosis is best placed in the neck, outside of the contaminated field. In a review of 24 patients with esophageal perforation treated with esophagectomy, the mortality rate was 13%, with 19 of the 21 survivors able to swallow comfortably [4]. In another study of 34 patients with delayed presentation of esophageal perforation, the 15 treated with resection had a mortality of 13%, whereas the 19 treated with primary repair had a mortality of 68% [10].

In unstable patients presenting late with esophageal perforation, exclusion and diversion, as popularized by Urschel and colleagues [11], is most prudent. A side neck esophagostomy (excluding the distal stream) along with ligation of the distal esophagus beyond the perforation (by stapler or large suture), feeding tube placement, and drainage of the pleural space is usually the most definitive method of draining infection and preventing further contamination. Exclusion and diversion commits the patient to a second operative procedure to restore intestinal continuity, although the procedure can be done with minimal invasiveness [12].

Primary repair is possible in some stable patients presenting with late perforation. A variety of recent papers advocate selected, reinforced primary repair of thoracic esophageal perforations. The postoperative leak rates, however, in three series are 17%, 70%, and 80%. The mortality rates in these series range between 1.5% and 30% [13–16]. The discrepancy between high recurrent leak rate and low mortality rate can be explained by the overwhelming importance of adequately drained leaks and intensive supportive care. Provided that all leaks are completely and externally drained, the patient can be nourished by feeding tube and allowed to heal and recover.

We have adapted this philosophy to the use of T-tubes for perforations where repair is likely to fail. This use is most common in delayed perforations, but has also been used by surgeons in our group for several acute perforations with severe inflammation of the tissues or massive contamination. At the time of operation, the pleural space is evacuated, the lung decorticated, and either a large bore soft T-tube, or trimmed PEG tube is inserted into the esophagus with repair of the surrounding esophagus. Muscle flaps may be used to reinforce the repair. The pleural space is widely drained. All drains and tubes are positioned away from vital structures such as the aorta, heart, and trachea. Provided the postoperative swallow shows no leakage other than that through the T-tube, the patient is allowed to advance to a liquid diet. After 4 to 6 weeks, the T-tube is withdrawn gradually in an outpatient setting.

Using this strategy, our mortality rate from delayed thoracic perforations is not much different than that seen with acute perforations, and is much better than the reported 30% to 40% mortality. The lengths of stay and morbidity rate remain much higher in our delayed group managed by T-tube (47 days and a morbidity rate of 83%) than in our acute group managed by primary repair (22 days and a morbidity rate of 36%). Thus, while most patients with a delayed perforation treated with T-tube can be expected to recover, complications and a prolonged hospitalization should be expected.

Likewise, the lengths of stay for the five acute perforations managed by T-tubes (46 days) is longer than in the acute group managed by repair (22 days). That is not necessarily due to the increased complexity of care of the T-tube patient, but may be simply a reflection of patient selection. In general, acute patients who were sicker, with more local inflammation and contamination, underwent T-tube repair.

Since the initial series by Abbott and associates [17] in 1970, of 10 patients with esophageal perforation treated by T-tube, there have only been a handful of publications describing use of the T-tube method, each with fewer than 5 patients [5, 6, 8, 18, 19]. A single report of 10 patients treated by Naylor and colleagues [5] offered no comparison to contemporary patients treated by alternate methods. In this series, use of the T-tube method of repair for chronic perforations resulted in a mortality rate as low as that for repair of acute perforations, and represents a modern assessment of risk and length of stay.

Advances in endoscopic techniques and devices may allow for future treatment of esophageal perforations with a combination of endoscopic and drainage procedures. Expandable metallic stents are now routinely used for nonoperative patients with obstruction or perforation due to esophageal cancer. Concerns over long-term complications have generally precluded their use in benign disease. A recent publication describes the use of expandable metallic stents for both benign and malignant esophageal perforations [20]. In patients with benign disease, the stents were removed or replaced after three weeks. Self-expanding silicone stents, which are considered easier to remove, have been used in the treatment of esophageal anastomotic leaks [21]. It is conceivable that a combination of endoscopic stents and either open, video-assisted thoracic surgery, or even computed tomography–guided pleural drainage could eventually be used to achieve the same endpoints as T-tube or primary reinforced repair: that is, the sealing of the majority of the esophageal perforation with the drainage of infected pleural fluid with controlled drainage of any residual leak.

In conclusion, delayed thoracic esophageal perforation can be managed safely and effectively through a modified T-tube repair. While morbidity and length of stay remain high, the mortality approximates that seen with repair of acute perforations. Delay in treatment of intrathoracic esophageal perforations beyond 24 and 72 hours results in a doubling of morbidity at each interval.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Jones II WG, Ginsberg RJ. Esophageal perforation: a continuing challenge Ann Thorac Surg 1992;53:534-543.[Abstract]
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  7. Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus Ann Surg 1989;209:612-619.[Medline]
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  9. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation Ann Thorac Surg 2004;77:1475-1483.[Abstract/Free Full Text]
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