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Ann Thorac Surg 1997;64:1606-1609
© 1997 The Society of Thoracic Surgeons
Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed.
Results. Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%).
Conclusions. In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a "normal" esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Intrathoracic esophageal perforation continues to be a formidable challenge for the thoracic surgeon. Disruption of the intrathoracic esophagus leads to extravasation of oral secretions and bacteria as well as refluxed gastric contents into the mediastinum. The mixture of digestive enzymes and bacteria bathes the tissue planes of the mediastinum and leads to a fulminate, rapidly progressive infection that is usually fatal without surgical intervention. Delays in diagnosis and treatment are associated with increased morbidity and mortality [1–5].
Given the devastating nature of this condition, a multitude of reports have focused on the acute management of patients with esophageal perforation [1–3, 6–9], and contemporary reports have reflected a reduction in mortality [1–5] using modern surgical techniques. With the mortality of esophageal perforation down to an acceptable level (approximately 10% to 15%), we began to evaluate the long-term sequelae of esophageal perforation and how various treatment regimens may affect swallowing function after recovery from the acute event. We chose to follow up those patients with benign disease and a reasonable life expectancy to obtain meaningful long-term follow-up data.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Follow-up (100% complete) was obtained by personal or telephone interview. The follow-up time was calculated as the period from diagnosis of the perforation to telephone contact, office visit, or death. Questions asked during the interview were those with respect to the ability to swallow, alterations or limitation in diet because of previous repair, need for further intervention or repeat dilatation or further operation, as well as symptoms of reflux or regurgitation and the need for medication or alteration in dietary habits to control symptoms. Data were collected on worksheets and entered into a database for statistical analysis (SPSS for Windows, Release 6.0, SPSS, Inc). Statistical differences were determined by 
2 analysis (nonparametrics tests) and by analysis of variance (means comparisons). Mean values are expressed as mean ± standard error throughout the article.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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) and consisted predominantly of motor disorders and gastroesophageal reflux disease (GERD). Most patients (28 of 42, 67%) had no previous history of esophageal procedures or instrumentation, whereas 10 (23.8%) had undergone dilations, 2 (4.8%) antireflux operations, and 2 (4.8%) sclerotherapy before the perforation.
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) with instrumental causes predominating over other causes. The perforation was contained to the mediastinum in 19 of 42 patients (45.2%), into the pleural space in 21 (50%), and into the peritoneal cavity in 2 (4.8%). The location of the esophageal perforation was midthoracic in 9 (21.4%) and distal in 33 patients (78.6%).
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), the extent of esophageal disease, or extent of damage at the time of exploration. Primary repair, with (19 of 25 patients) or without (6) pleural, intercostal, or gastric fundus reinforcement, was undertaken in 25 of 42 patients (59.5%). Ultimately, 5 of these patients required esophagectomy. Esophagectomy, with intrathoracic or cervical gastroesophageal anastomosis, was initially used in 15 patients (35.7%), whereas drainage alone was used in 2 patients (4.8%). One of the patients initially treated with drainage alone underwent successful delayed primary repair, whereas the other patient had a staged esophagectomy and reconstruction 3 months after cervical esophagostomy and drainage. Of note, the time from perforation to operation had no impact on the type of operation (primary repair versus esophagectomy with reconstruction) used (p = 0.67).
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Two empyemas developed late (3 and 6 months postoperatively). Both were treated effectively with tube thoracostomy drainage.
At least one postoperative dilation was required in 18 of 42 patients (42.8%). The indications for dilation were dysphagia without stricture (13 of 18, 72%), dysphagia with stricture (4, 22%), and postoperative esophagopleurocutaneous fistula (1 patient). It is informative to examine the need for postoperative dilation as a function of the initial treatment. Of the 15 patients treated with esophagectomy and esophagogastric anastomosis, 8 (53%) required dilations with complete resolution of their symptoms. It is out of practice to dilate the esophagogastric anastomosis at the bedside if the patient complains of dysphagia during the postoperative period. None required long-term dilations. In contrast, 10 of 25 patients (40%) who underwent primary repair required dilations. Three patients required operative dilations 10, 35, and 47 months after primary repair. Half of the patients (5 of 10) requiring dilation after primary repair ultimately underwent esophagectomy and reconstruction secondary to persistent stricture despite repeated dilations. Interestingly, all 5 of these patients had GERD (Table 2).
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). Although 8 patients were treated initially with esophagectomy and reconstruction at the time of their perforation, 14 (93%) had undergone esophagectomy by the time of last follow-up. The time from primary repair to esophagectomy averaged 21 months and ranged from 1 to 57 months after the initial primary repair.
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The mean follow-up time for the entire group was 3.7 ± 0.5 years (range, 0.2 to 12.8 years) and comprised 156 patient-years. Follow-up was completed in all patients surviving more than 1 year from their perforation. When questioned about their ability to swallow, 55.8% indicated that it was better than before the perforation, 33.3% the same, and 11.1% worse. Most patients were satisfied (33 of 36, 91.6%) with their current swallowing function, and 3 patients (all with primary repair) were not. Two patients complained of reflux symptoms. One patient had partial esophagectomy with intrathoracic gastroesophageal anastomosis and the other transhiatal esophagectomy with cervical esophagogastric anastomosis.
The mean weight change from diagnosis to follow-up was -1.1 ± 1.3 kg for the entire study group. There was no significant difference (p = 0.50) in weight change between the primary repair group (-0.7 ± 1.5 kg) and the esophagectomy and reconstruction group (-2.2 ± 1.4 kg).
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The majority of published reports on esophageal perforation focus on the acute management and the various techniques for repair. These reviews often fail to report any subjective or objective evaluation of swallowing function after repair or reconstruction. In the recent literature, we could only find one study that evaluated the long-term results after treatment for esophageal perforations [12]. Sawyer and colleagues [12] reported that 19 of 30 patients, the majority of whom were treated with primary repair, had persistent dysphagia, some requiring repeated dilations. Similarly, we found that the need for repetitive repair after dilations was significant and occurred predominately in patients who underwent primary repair for their esophageal perforation, the worst outcome being in patients with the combination of primary repair for GERD with stricture. In addition, further operative intervention was more common in the group having primary repair and a reflux stricture. Five of 6 patients eventually required esophagectomy.
An evaluation of the underlying disease that prompted the need for further operative intervention was undertaken to develop an algorithm to guide initial therapy (ie, which patients with perforation benefit most from primary repair and in which patients esophagectomy is the best initial approach). In our experience, a perforation in a patient with a moderately severe, fibrotic, distal esophageal reflux stricture is best treated with esophagectomy even if the stricture can be dilated. One must be cognizant that intraoperative assessment of a perforated reflux stricture can be difficult because the stricture may be fractured at the esophageal tear and the relative constriction may be difficult to appreciate at the time of perforation repair. Even when intraoperative dilation was believed to be satisfactory in 6 patients with reflux strictures, 5 ultimately experienced significant dysphagia that eventually required esophagectomy and reconstruction. In these patients, moderate resistance to passage of a 42F or larger Maloney dilator portends a poor prognosis and an esophagectomy should be carried out. In the achalasia patient with a perforation, our approach of primary repair, myotomy, and Belsey fundoplication is associated with good long-term swallowing function without the need for further operative interventions. This approach to iatrogenic perforations of motor disorders has been supported by Ferguson and colleagues [13], who found no difference in long-term outcome whether elective or emergent operation had been performed.
On the basis of these data, we have adopted a policy of primary repair whenever possible in all patients who have no intrinsic esophageal disease or uncomplicated (early) motor disorders. In those patients with a long-standing reflux stricture of the distal esophagus, esophagectomy with reconstruction provides the best overall satisfaction with swallowing function with fewer postoperative interventions. Patients without preexisting esophageal disease, and patients with motor disorders, can be expected to do well with primary repair alone.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Address reprint requests to Dr Iannettoni, Section of Thoracic Surgery, University of Michigan Medical Center, 1500 E Medical Center Dr, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109.
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References |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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