Ann Thorac Surg 2009;88:199. doi:10.1016/j.athoracsur.2009.05.006
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
John C. Kucharczuk, MD
Division of Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104
(Email: john.kucharczuk{at}uphs.upenn.edu).
Despite improvements in surgical technique and critical care, the morbidity and mortality associated with spontaneous esophageal perforation remains high. Traditional treatment plans have focused on five goals to improve outcome: (1) hemodynamically stabilizing the patient, (2) controlling sepsis, (3) stopping mediastinum soilage, (4) maintaining nutrition, and (5) reestablishing esophageal continuity. The surgical options to achieve these goals currently include primary repair with buttress, esophageal resection with immediate reconstruction, and esophageal exclusion with diversion.
The traditional surgical approaches represent relatively invasive operative procedures; thus, it is appropriate during this time of rapidly developing technology and less invasive surgical techniques to ask whether a new treatment paradigm for esophageal perforations is on the horizon. In this article, Freeman and colleagues [1] present a large series of patients with spontaneous esophageal perforation successfully treated using esophageal stenting as part of a hybrid treatment plan. This article actually represents the completion of a trilogy of reports by the same group evaluating the use of esophageal stents for the treatment of iatrogenic esophageal perforation [2] and for the treatment of postoperative esophageal anastomotic leaks [3].
The successful use of hybrid therapies for spontaneous esophageal perforation requires careful patient selection, sound surgical judgment, and experience. Although their article should generate lively discussion and further investigation, it should not be considered the sentinel report changing the treatment paradigm for spontaneous esophageal perforation. The authors should be commended for showing us what is possible; however, to advocate widespread application, specific criteria for patient and procedure selection must be formulated. Selecting the wrong patient or making a poor judgment will lead to local complications, continued sepsis, and potentially devastating outcomes. Because the stakes are so high, it must be recognized that traditional operative treatment remains the recommended approach to spontaneous esophageal perforations. Nevertheless, as the algorithm to treating spontaneous esophageal perforations develops, esophageal stenting and hybrid surgical procedures will likely play a major role.
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References
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- Freeman RK, Van Woerkom JM, Vyverberg A, Ascioti AJ. Esophageal stent placement for the treatment of spontaneous esophageal perforations Ann Thorac Surg 2009;88:194-199.[Abstract/Free Full Text]
- Freeman RK, Van Woerkom JM, Ascioti AJ. Esophgeal stent plancement for the treatment of iatrogenic intrathoracic esophgeal perforation Ann Thor Surg 2007;83:2003-2008.[Abstract/Free Full Text]
- Freeman RK, Ascioti AJ, Wozniak TC. Postoperative esophageal leak management with the Polyflex esophageal stent J Thorac Cardiovasc Surg 2007;133:333-338.[Abstract/Free Full Text]
Related Article
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Esophageal Stent Placement for the Treatment of Spontaneous Esophageal Perforations
- Richard K. Freeman, Jaclyn M. Van Woerkom, Amy Vyverberg, and Anthony J. Ascioti
Ann. Thorac. Surg. 2009 88: 194-198.
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