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Ann Thorac Surg 1997;64:1609-1610
© 1997 The Society of Thoracic Surgeons
DR WILLIAM W. TAYLOR (Dallas, TX): I presume in most of these patients where you did an esophagectomy you only took out the lower third of the esophagus and not the entire esophagus. Is that correct?
Then, if you took out just the lower esophagus and brought the stomach up, do you favor hand-sewn or the end-to-end anastomosis, and could you comment on those aspects of it for us?
DR VLESSIS: Of the patients who had resection of their esophagus, only 2 had intrathoracic gastroesophageal anastomoses; the rest of the patients had their anastomoses performed in the neck. The reason for doing this is that the consequences of an anastomotic breakdown in the thoracic cavity are much more extensive than an anastomotic breakdown in the neck. A neck leak can simply be treated by opening the neck incision. An intrathoracic leak is devastating, requires reoperation, and carries a high mortality.
To summarize, only 2 of the 15 patients had intrathoracic anastomosis. The type of anastomosis we do varies somewhat depending on the surgeon, but all the anastomoses were hand sewn with absorbable suture.
DR RODNEY J. LANDRENEAU (Pittsburgh, PA): I enjoyed your presentation. I was wondering, however, how many of the patients who had benign reflux strictures in this series were primarily managed by the thoracic surgical team after their initial esophageal repair versus primary follow-up by an aggressive gastroenterologist who might have been more inclined to manage the patient with dilation and antisecretory therapy?
DR VLESSIS: I can say with confidence that all the patients were followed up by our service after their repairs. Some of them may have been followed up as well by a gastroenterologist.
DR LANDRENEAU: I would like to know who was making the decision toward resection? In our practice, we often see patients who are followed up long-term with repeated dilations by a gastroenterologist. If you look at the medical gastroenterology literature, there are those who believe many of these patients will obtain good control of symptoms with aggressive antisecretory management and repeated dilation. Many esophageal surgeons would disagree with this philosophy and would favor operative management in these difficult situations. I am just wondering who made the decision to operate. Were these patients medical failures from a gastroenterologist's viewpoint or failures from a thoracic surgeon's perspective?
DR VLESSIS: The decision to operate was made by us.
Maybe I should be a little more specific about the 5 patients in our series who were treated with primary repair and then went on to an esophagectomy. Two of those patients had a fistula with a stricture distal to the fistula, which progressed to a chronic fistula and would not heal even with repeated, frequent dilations. The other 3 patients in that group had continued difficulty swallowing to the point of weight loss. They could not maintain their weight or nutrition and, thus, went on to esophagectomy. All 3 did well after esophagectomy, I might add.
DR TONI E. LERUT (Leuven, Belgium): Do you add an antireflux procedure when you perform a primary repair?
DR VLESSIS: If the patient has a primary repair, it is our practice to perform a Belsey-type fundoplication, usually buttressing the perforation site.
DR SAFUH ATTAR (Baltimore, MD): I congratulate Drs Vlessis and Orringer and their associates on excellent results on a very tough problem.
I have a couple of questions. If by the end of therapy you ended with 93% esophagectomies for, I assume, mostly benign disease, that is a very high rate. There must be some reasons for this high rate of esophagectomy. Either you had a very high complication rate after the primary or secondary procedure, or you had leakage that necessitated further operations. If that is the case, why not do esophagectomy in the first place then, instead of putting the patients through all this harassment of multiple operations?
DR VLESSIS: Before performing this study we could find very little in the literature that documented the long-term results after primary repair of esophageal perforation. In this study, we identified a group of patients that had problems with swallowing after their primary repair. Most of those patients had reflux strictures predating their perforation. Therefore, given the new data, in a patient who comes in with a perforation and a long history of reflux stricture, we are now more inclined to do an esophagectomy the first time around rather than subject the patient to continued years of dilations and problems with swallowing.
DR RICHARD J. FINLEY (Vancouver, British Columbia, Canada): Thank you for identifying the value of esophagectomy in patients with perforations associated with esophageal strictures.
My questions relate to patients with esophageal perforations and achalasia. What percentage of your patients with perforations had achalasia? Under what circumstances would you consider resecting the esophagus in patients with achalasia and esophageal perforation?
DR VLESSIS: Approximately two thirds of the patients had primary repair if they had a motor disorder. There were only 2 patients with primary esophageal spasm, and 1 patient with scleroderma. All the other patients had achalasia.
The criteria for doing an esophagectomy in a patient with a perforation and achalasia is an esophagus approximately 6 cm in diameter. If it is enlarged to that extent, most of the time we will proceed with esophagectomy primarily. If it is less than that, we will do a primary repair, a myotomy, and a Belsey fundoplication.
DR ROY THOMAS TEMES (Albuquerque, NM): Have you had any experience with minimally invasive repairs in the patients without underlying esophageal disease who present early in their course?
DR VLESSIS: No, we have not had any experience approaching these patients with thoracoscopy or other minimally invasive procedures. Patients are approached through a left thoracotomy for distal perforations, a right thoracotomy for midesophageal perforations, and a cervical incision for proximal perforations.
Related Article
Ann. Thorac. Surg. 1997 64: 1606-1609.
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