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Ann Thorac Surg 1995;60:245-248
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Reinforced Primary Repair of Thoracic Esophageal Perforation

General Thoracic Surgical Unit, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Treatment of esophageal perforation, especially when diagnosed late, remains controversial.

Methods. Twenty-eight patients were treated for thoracic esophageal perforation with reinforced primary repair regardless of time of presentation.

Results. Fifteen patients were treated early (<24 hours) with no deaths. Two had contained postoperative leaks, which healed. Thirteen were treated late (mean, 5.5 days) with four deaths (3 with healed repairs). Postoperative leaks occurred in 7 patients; of the leaks, 4 healed, 2 became a controlled fistula, and 1 required reoperation. Primary healing with preservation of the native esophagus was achieved in 25 patients (89%). Among the 18 patients without evidence of sepsis preoperatively, postoperative leaks developed in 2 (11%). Ten patients had evidence of sepsis preoperatively, and postoperative leaks developed in 7 (70%).

Conclusions. Patients who present with sepsis have an increased risk of postoperative leak and therefore should have the repair buttressed. Overall mortality was 14% and no deaths were due to persistent leaks or mediastinal sepsis. Reinforced primary repair retains the native esophagus and avoids the need for later reconstructive operations. In the absence of a nondilatable stricture or cancer, reinforced primary repair should be performed for most thoracic esophageal perforations, early or late.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 248.

Controversy continues about treatment (repair, exclusion/diversion, or resection) of thoracic esophageal perforations, especially when treated late. Perforation of the thoracic esophagus remains a devastating illness with mortality rates approaching 25% despite aggressive modern surgical treatment [1]. Delay in diagnosis and treatment significantly influences outcome with mortality rates approximately doubling if treatment is delayed beyond 24 hours [1]. In the absence of esophageal cancer or distal obstruction many thoracic surgeons have favored primary repair, often with a tissue buttress for early (<24 hours) thoracic esophageal perforations [1]. However, some surgeons do not advocate primary repair for late perforations (>24 hours) based on time alone and instead advocate exclusion/diversion or resection [2, 3]. We have favored repair and retention of the native esophagus whenever possible without regard to time of perforation [4]. This obviates the need for a second major operation to restore continuity of the gastrointestinal tract. This report reviews our experience with reinforced primary repair of thoracic esophageal perforations over the past 15 years.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
From July 1979 to July 1994 we performed reinforced primary repair of a thoracic esophageal perforation in 28 patients on the General Thoracic Surgical Service. Hospital records and office charts were reviewed and the patients' clinical status and course analyzed. During the same period, 13 additional patients were treated for thoracic esophageal perforation by methods other than reinforced primary repair: esophageal resection, 8; exclusion/diversion, 2; nonoperative, 2; and T tube diversion, 1. These patients were not analyzed.

Fifteen patients were treated early (<24 hours) and 13 patients were treated late (>24 hours). The average age of the patients was 67 years; 19 were male and 9 were female. The cause of the perforation was postemetic in 14, dilation in 6, postoperative in 3, foreign body impaction in 2, esophageal intubation in 2, and esophagoscopy in 1. Preexisting esophageal disease was present in 13 patients: benign stricture in 10 and achalasia in 3. The average delay from perforation to treatment in the early group was 12 hours (range, 1 to 22 hours) whereas it was 5.5 days (range, 1 to 23 days) in the late group. The causes of delayed diagnosis and treatment appeared to be late referral by another hospital to our institution in 14 patients, a delay in diagnosis in 4, and delayed patient presentation in 3. Sepsis was defined by the presence at presentation of fever, tachycardia, and hypotension requiring volume or inotropic resuscitation. Three patients (20%) had evidence of sepsis preoperatively in the early group whereas 7 patients (54%) had sepsis in the late group.

Technique of Primary Repair and Buttressing
Thoracotomy is performed on the side of the perforation. Pleural debridement and decortication are performed if necessary. This allows complete reexpansion of the lung to eliminate potential spaces and the possibility of empyema. The mediastinum is widely opened and debrided of all necrotic debris and tissue. By eliminating dead space, possible empyema, and localized necrotic tissue the possibility of secondary breakdown of the esophageal repair is minimized.

Characteristically, the rent in the muscle of the esophagus is smaller than that of the mucosa so muscle must be opened to expose the full extent of the mucosal tear (Fig 1). Failure to do so will lead to persistent leaks and disruption of the repair. Esophageal muscle is debrided back to healthy tissue. The esophagus then is closed in two layers with fine 4-0 interrupted sutures. Occasionally, necrosis or induration of the muscle prohibits two-layer closure and only the mucosa can be closed. The mucosa, in contrast to the muscular layer, is usually in surprisingly good condition. The mucosal layer is closed with an inverting technique maintaining tension on the previously placed suture to facilitate mucosal inversion. The repair is tested by injection of air in a nasogastric tube with occlusion of the distal esophagus while under saline solution or by methylene blue injection.

View larger version (94K): [in this window] [in a new window]   Fig 1. . Technique of reinforced primary repair of thoracic esophageal perforations. (A) The mediastinal pleura is opened if necessary to fully expose the perforation site. Ragged, partially necrotic muscle at the border of the tear hides the full extent of the mucosal injury. (B) Necrotic muscle has been debrided back to fully expose the mucosal defect and the mucosal edge is trimmed to healthy tissue. (C) Inverting interrupted fine 4-0 sutures are placed and tied so that the knots remain inside. Inward traction on the previously placed suture facilitates proper mucosal inversion. Suturing is begun in each corner and finishes in the middle. (D) A second layer of interrupted fine 4-0 sutures are placed if possible in the muscle layer to cover the mucosal repair. (E) A previously harvested intercostal muscle flap with an intact vascular bundle is swung on its posteriorly based pedicle to cover and buttress the repair. This is sutured over the closure with interrupted mattress sutures in a circumferential fashion to make a third water-tight layer. All sutures are placed first before tying to facilitate an exact repair.

Chest drains are placed in the gutter, next to the repair and along the diaphragm. The chest cavity is thoroughly cleansed before closure. A small laparotomy then is performed and a draining gastrostomy and feeding jejunostomy are performed routinely. Enteral feeding by jejunostomy is begun as soon as bowel function returns. Adequate drainage of the stomach is important to avoid reflux of gastric contents on the repair. Broad-spectrum antibiotics are administered especially directed at mouth anaerobes and directed by culture results. A Gastrografin (Squibb Diagnostic, Princeton, NJ) swallow is obtained routinely on postoperative day 7 to 10 to check for leaks. An oral diet is resumed gradually once integrity of the esophagus is assured.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Twenty-eight patients were treated with reinforced primary repair. The repair was buttressed in all patients: intercostal muscle was used in 15, pedicled pleural flap in 13, omental flap in 4, stomach in 1, and pericardial fat pad in 1. Six patients had double buttressing of the esophageal repair. Fifteen patients were treated with reinforced primary repair within 24 hours with no deaths. Two of these patients (both with sepsis present preoperatively) had asymptomatic contained postoperative leaks, which healed within 1 week. Major complications occurred in 4 patients: Candida sepsis in 1, small bowel obstruction from the jejunostomy in 1, intraabdominal abscess requiring percutaneous drainage in 1, and respiratory failure along with myocardial infarction, sepsis, and pulmonary embolism in 1. None of these patients had postoperative leaks. The average hospital stay in these 15 patients was 23 days (range, 9 to 51 days). One patient required resection of a recurrent benign stricture 4 years after esophageal repair. All other patients have retained their native esophagus and are able to eat a normal diet.

Thirteen patients were treated after 24 hours with four deaths (31%). Postoperative leaks occurred in 7 patients: 4 were asymptomatic, contained, and healed; 2 became a controlled fistula; and 1 required reoperation. Seven patients had sepsis preoperatively, and postoperative esophageal leaks developed in 5 of them. Six patients did not have sepsis preoperatively, and 2 of these had postoperative esophageal leaks. Four patients died: 2 of multiorgan failure, 1 of stroke, and 1 of an aortoduodenal fistula after repair of a ruptured aneurysm. Three of these 4 patients died with a healed esophageal repair. Death was unrelated to persistent esophageal leakage or mediastinal sepsis. Esophagectomy ultimately was required in 2 patients for a persistent fistula in 1 and esophageal obstruction in another. This last patient was unique and was the only one who required reoperation. This patient was schizophrenic with psychogenic vomiting and underlying Barrett's esophagus with a mild stricture. His postemetic rupture was repaired and a barium swallow on day 9 was normal. On hospital day 13 just before discharge back to the psychiatric hospital he had another bout of psychogenic vomiting and ruptured his repair. Re-repair was successful but the residual lumen was too small too allow oral intake and therefore esophagectomy was performed. Major complications (other than leaks) occurred in 4 patients: respiratory failure in 3, hemothorax in 1, and pneumonia in 1. Only 1 of the patients with complications had a postoperative esophageal leak. The average hospital stay in the late patients was 47 days (range, 17 to 122 days). All surviving patients are able to eat a normal diet and have not required later operations or dilations.

Overall mortality was 14% in patients treated with reinforced primary repair. Primary healing with preservation of the esophagus was achieved in 25 patients (89%). Patients who present to the surgeon with sepsis preoperatively appear to have an increased risk of leakage after repair: 70% as opposed to only 11% if no evidence of sepsis is present. There were 9 postoperative leaks after buttressed repair; all were asymptomatic, 7 healed with observation only, and only 2 persisted as a fistula.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The management of thoracic esophageal perforation remains controversial in large part due to the variability in cause, underlying esophageal disease, treatment delays, and management strategies. Randomization of treatment has not been reported and therefore comparison of results of treatment of similar patients must suffice to judge the merits of a particular treatment approach. The majority of surgeons now agree that reinforced primary repair of an early esophageal perforation or resection of a perforated cancer or nondilatable stricture is an appropriate therapy [1]. Extension of the principle of primary repair of simple (postemetic or instrumental) perforations to those with achalasia or a soft benign stricture has been widely accepted as long as distal obstruction can be relieved [1]. This has been achieved by esophagomyotomy for achalasia or intraoperative dilation for a stricture [5, 6]. Controversy continues about treatment of late perforations. Strong advocates support exclusion/diversion or resection and advise against primary repair of late perforations [2, 3, 7]. We have had a long interest in primary repair of late perforations and believe our results support this view [4, 8].

Our overall mortality of 14% (0% early, 31% late) is relatively low and compares favorably with other series of perforations regardless of treatment [1]. Deaths after repair have been related to the sepsis syndrome with multiorgan failure (with healed repairs) or unrelated conditions (stroke, complication from ruptured abdominal aortic aneurysm) and are not due to failure of the repair. Complications are not increased in patients with contained postoperative leaks. Complications, death rates, and length of hospital stay all are increased in patients who have delayed treatment, as would be expected. These findings have been reported by others [1]. Early diagnosis and treatment of esophageal perforation remains the most important principle to reduce morbidity and mortality from this illness.

Repair of the perforated esophagus without a tissue buttress often fails, leading to a clinical leak rate of about 40% [9]. The rate exceeds 50% if the repair is delayed beyond 24 hours [10]. However, if the repair is buttressed, leak rates are reduced dramatically to about 10% [9]. Experimental studies also have documented markedly reduced leak rates after buttressed repair of esophageal perforation [11]. More importantly, the nature of a possible leak is changed from a potentially fatal free intrapleural leak to an asymptomatic, contained leak that will heal with observation. Seven of our nine leaks healed in this fashion. Only two fistulas developed for a ``clinical'' leak rate of only 7%. Careful technique, including buttressing the repair as if it were an anastomosis (as opposed to a few tacking sutures) as well as broad-spectrum antibiotics and aggressive enteral nutritional support contributed to these good results. Preoperative sepsis may be a risk factor for leak after repair and probably is a marker of severity of disease. The presence of preoperative sepsis mandates a buttressed repair to contain a leak. Primary healing with preservation of the esophagus was achieved in 25 patients (89%). Esophagectomy is rarely required in the absence of cancer or a nondilatable stricture.

Selection of treatment for thoracic esophageal perforation must remain individualized and take into account many variables including cause, duration, underlying esophageal disease, and condition of the patient. In the absence of cancer or an undilatable stricture, reinforced primary repair is the preferred treatment in most patients [1, 4, 8, 12, 13]. With the principles outlined, success can be achieved in the majority of patients. Surgeons should be familiar with other options of treatment (esophagectomy, exclusion/diversion, T tube drainage, nonoperative) to allow individualization of treatment.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 30--Feb 1, 1995.

Address reprint requests to Dr Wright, Massachusetts General Hospital, Warren 1212, Boston, MA 02114.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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10. Nesbitt JC, Sawyers JL. Surgical management of esophageal perforation. Ann Surg 1987;53:183–91.
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12. Ohri SK, Liakakus TA, Pathi V, Townsend ER, Fountain SW. Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave's syndrome. Ann Thorac Surg 1993;55:603–6.[Abstract]
13. Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation. The merit of primary repair. J Thorac Cardiovasc Surg 1995;109:140–6.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cameron D. Wright Douglas J. Mathisen John C. Wain Ashby C. Moncure Hermes C. Grillo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wright, C. D. Articles by Grillo, H. C. Search for Related Content PubMed PubMed Citation Articles by Wright, C. D. Articles by Grillo, H. C. Related Collections Related Article