Ann Thorac Surg 2007;83:1133
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Harold Urschel, Jr, MD
Cardiovascular and Thoracic Surgical Research, Education and Clinical Excellence, Baylor University Medical Center, 3600 Gaston Ave, Suite 1201, Dallas, TX 75246
(Email: drurschel{at}earthlink.net).
This review [1] of esophageal perforations presents satisfactory management for cervical and acute cases. However, the authors’ treatment of delayed thoracic perforations with an "infrequently used method" of a controlled fistula with a T tube placed through the perforation is not well supported by their data. The mortality of 8.7% is not significantly different from management of these patients with the "diversion and exclusion" technique; however, the length of stay of 47 days (average) and morbidity rate of 83% are much higher in the T-tube group. An additional advantage of the "diversion and exclusion" technique is that it usually does not require a second major invasive procedure.
Dr Richard H. Sweet described the technique of T-tube insertion, championed by Dr Osler A. Abbott, as a "complete travesty and the idea of placing a tube through a hole you are trying to heal doesn’t make any sense conceptually." I tend to agree with Dr Sweet, and for this "sicker group" prefer the "diversion and exclusion" technique, which allows the patient to leave the hospital much quicker and is associated with far less morbidity [2].
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References
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- Linden PA, Bueno R, Mentzer SJ, et al. Modified T-tube repair of delayed esophageal perforation results in a low mortality similar to that seen with acute perforations Ann Thorac Surg 2007;83:1129-1133.[Abstract/Free Full Text]
- Urschel Jr HC, Razzuk MA, Wood RE, Galbraith NF, Pockey M, Paulson DL. Exclusion and diversion in continuity for traumatic esophageal perforation Ann Surg 1974;179:587-596.[Medline]
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