The Annals of Thoracic Surgery, Vol 30, 575-583, Copyright © 1980 by The Society of Thoracic Surgeons
The management of nonmalignant intrathoracic esophageal perforations
RJ Finley, FG Pearson, RD Weisel, TR Todd, R Ilves and J Cooper
Eight patients with nonmalignant intrathoracic esophageal perforations
recognized more than 48 hours (48 hours to 14 days) after rupture were
treated at Toronto General Hospital between 1973 and 1978. Perforation was
due to postemetic rupture in 7 patients and to instrumentation in 1. The
patients were seen with pain (8), vomiting (7), fever (7), shock (4),
respiratory insufficiency (5), pleural effusion (7), pulmonary infiltrates
(7), and leukocytosis (6). All patients were managed with thoracotomy.
Direct suture closure of the perforation was carried out in 4 patients with
midesophageal perforations. Postoperative localized leaks developed in 2 of
these patients but healed with conservative management. Cervical
esophagostomy and esophageal diversion were used in 1 patient in whom a
severe empyema developed in the postoperative period. Direct suture
closure, reinforced with a gastric patch, was used to close three lower
esophageal perforations. None of these patients had a postoperative leak
but all developed subsequent reflux esophagitis. All 8 patients survived.
In patients with delayed recognition of a nonmalignant intrathoracic
esophageal perforation, elimination of continued chemical and bacterial
contamination can be achieved by a clear definition and closure of the
esophageal mucosal margins. The obliteration of potential pleural spaces by
good tube drainage, lung decortication, and the elective use of mechanical
ventilation with positive end-expiratory pressure decreases the incidence
of uncontrolled intrapleural sepsis.
