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Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 445, Houston, TX 77030-4009
(Email: whofstetter{at}mdanderson.org).
This article by Kotzampassakis and colleagues [1] provides more evidence that the management of spontaneous and iatrogenic esophageal perforations presenting with sepsis can result in excellent outcomes. Their results are impressive, considering where we have come from. When originally described, esophageal perforations were uniformly fatal, and in past decades, we applauded novel treatments that led to improvements away from high, double-digit mortality. Very low mortality is the current new standard, and this article reports 0% in-hospital mortality.
Substantial changes have occurred in the management trends for this type of high-risk visceral perforation. Early treatment attempts focused on observation and drainage, resulting in extraordinarily high mortality rates. Later, recommendations for a surgical approach with decortication, drainage, and primary closure of the esophageal defect improved outcomes [2], but it became clear that using this tactic in patients with a delayed diagnosis and sequelae of infection led to frequent failures.
The most recent studies advocate débridement of all necrotic tissue, followed by closure of the defect with a tension-free tissue transfer, when possible [3–6]. This latest trend has resulted in significant improvements in reported survival and has decreased the number of patients undergoing diversion. Another significant change in management has been the recommendation to perform operative intervention regardless of the interval from occurrence to recognition of an esophageal leak, when appropriate.
It is interesting that 5 of 19 patients in the series presented had undergone previous operations, presumably with attempts at closing the perforation. Potential reasons for failure to surgically close a leak are multiple; those that are common are implied but not explicitly addressed in this article. Specifically, choosing an inappropriate patch or no patch at all will often lead to reopening of a leak. We have also found that distal obstruction was often overlooked in patients referred to our center with recurrent esophageal fistula.
As described in the article, placing well-vascularized tissue with sealing sutures at the defect, and also around the area at risk of failure, seems critical. In a review of our management of intrathoracic leaks after esophagectomy, we found that early surgical correction, adequate nutrition, and the use of transferred tissue were important aspects of successful management [3–6]. Clearly, these results are supplemented by improvements in intensive care, antibiotics, interventional radiology, and nursing.
The authors' technique includes the transfer a large portion of the diaphragm along with the ensuing defect, and the surgical wound is left open for use of an internal-external vacuum system to seal the defects. The authors report excellent results, but my concern is for the long-term effects of an incomplete diaphragm and subsequent abdominal visceral translocation. We have used the serratus anterior muscle for high thoracic defects, latissimus dorsi for intermediate to lower defects, and omentum when it is available for any defect in the thoracic cavity. Most of the wounds in our patients are closed over drains. Moreover, I would be very comfortable replacing half of the esophageal wall with any of these tissues, but admit that in the case where the authors describe three-fourths of the anastomosis débrided, I would be tempted to redo the anastomosis and wrap it with well-vascularized transferred tissue.
Finally, I believe that the principles presented in this article and others like it can increase the number of appropriately preserved esophagi/esophageal conduits and lives saved. However, one must make careful comparisons among treatment options. The excellent outcomes described in this article reflect a selected group of 19 patients cared for in a highly specialized environment by experts in all aspects of managing esophageal perforations. Presented are only those patients that underwent surgical management with esophageal preservation. But, it is individualization of management that is paramount to successful results. Recognition of the patient who can be successfully repaired vs another who may require esophagectomy, diversion, or both, is a matter of significant experience.
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