Esophagectomy for Esophageal Disruption Mark B. Orringer, MD, and Mack C. Stirling, MD Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, Michigan
When esophageal disruption occurs in the presence of preexisting esophageal disease or is associated with sepsis or fluid and electrolyte imbalance, aggressive and definitive therapy often provides the only chance for patient salvage. Twenty-four adults (average age, 59 years) with intrathoracic esophageal perforations underwent esophagectomy: 15, transhiatal esophagectomy without thoracotomy; and 9, transthoracic esophagectomy. Restoration of alimentary continuity with an immediate cervical esophagogastric anastomosis was carried out in 13 patients. Eleven underwent a cervical or anterior thoracic esophagostomy, and 10 of them had a subsequent colonic (7) or gastric (3) interposition from 4 to 32 weeks (average time, 8.6 weeks) later. The perforations were due to esophageal instrumentation (9 patients), acute caustic ingestion (21, emesis (2), intrathoracic esophagogastric anastornotic disruption (21, and other causes (9). Preexisting esophageal disease in 20
patients included chronic strictures (10 patients), reflux esophagitis (3), esophageal cancer (31, achalasia (2), diffuse spasm (21, and monilial esophagitis (1 patient). Ten patients were operated on within 12 hours after the injury; 3, within 12 to 24 hours; and 11, within three to 45 days (average interval, 6.6 days). There were three hospital deaths (13%). Nineteen of the 21 survivors were able to swallow comfortably until the time of death or latest follow-up. Aggressive diagnosis and aggressive treatment of life-threatening esophageal perforations are advocated. Conservative procedures (repair, diversion, or drainage) for a perforation with preexisting esophageal disease often inflict more morbidity than esophageal resection, which eliminates the perforation, the source of sepsis, and the underlying esophageal disease. The decision to restore alimentary continuity in a single stage must be individualized. (Ann Thoruc Surg 2990;49:3543)
F
the necessity for eventual reoperation is inherent in most of these procedures. More recently, improved results with esophageal replacement, particularly using the stomach as the conduit of choice [5-71, have influenced our approach to patients with intrathoracic esophageal disruption in the presence of preexisting esophageal disease or severe consequences of the mediastinal sepsis. This report reviews our experience with 24 patients with esophageal disruption treated by esophagectomy and either primary or delayed esophageal reconstruction.
ew events encountered in the practice of thoracic surgery are associated with such devastating consequences as disruption of the intrathoracic esophagus, an event that carries a mortality rate nearly three times that of a cervical esophageal perforation [l].Prolonged extravasation into the mediastinum of oral salivary digestive enzymes and bacteria as well as refluxed gastric acid, enzymes, and bile is nearly uniformly fatal without surgical intervention. The longer treatment is delayed, the greater the increase in mortality, to 40% to 66% after 24 hours or with established hydropneumothorax and mediastinal sepsis [24]. The dilemma confronting the thoracic surgeon is compounded by the variability of factors influencing the clinical setting: the duration of time between the occurrence of the leak and its diagnosis, the age of the patient, associated systemic illness, the hemodynamic stability of the patient, associated pleural contamination with empyema, and the presence of underlying intrinsic esophageal disease. No rigid set of guidelines applies to every patient with esophageal disruption, a successful outcome often depending on the surgeon’s experience and ability to be flexible and innovative. The desirability of preserving the esophagus when primary repair of the leak is tenuous has fostered a variety of alternatives for diversion in continuity or establishment of a controlled fistula. A protracted hospital course with Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11-13, 1989. Address reprint requests to Dr Omnger, Section of Thoracic Surgery, The University of Michigan Medical Center, 1500 E Medical Center Dr, 2120 Taubman, Box 0344,Ann Arbor, MI 48109.
0 1990 by
The Society of Thoracic Surgeons
Material and Methods During the past 15 years, we have performed an esophagectomy in 24 patients with disruption of the intrathoracic esophagus, and a retrospective review of their clinical status influencing our choice of treatment, the operative approach, and the surgical outcome has been conducted. During the same period, an additional 27 patients with intrathoracic esophageal perforations were treated with either primary repair (22 patients) or drainage (5). Virtually all of these patients had little or no underlying intrinsic esophageal disease (eg, achalasia with minimal esophageal dilatation), and repair of endoscopic, early postemetic, or postoperative perforations diagnosed promptly was readily achieved. These patients are not analyzed in this report. Among our 24 patients with perforations treated by esophagectomy were 12 male and 12 female patients ranging in age from 27 to 88 years (average age, 59 years). The oldest patients were 78, 79, 86, and 88 years of age (Tables 1, 2). The causes of the esophageal disruptions 0003-4975/90/$3.50
36
ORRINGERAND STIRLING ESOPHAGECTOMY FOR ESOPHAGEAL DISRUPTION
Ann Thorac Surg 1990;49:3543
Table 1 . Esophagectomy for Esophageal Disruption: Single-Stage Resection and Reconstruction
Patient No.
Age (yr) Sex
Intrinsic Esophageal Disease
Cause of Disruption
1
69
M
Emesis
Reflux stricture
2
86
F
Barrett's ulcer
Reflux stricture
3
31
M
Endoscopy
Monilial esophagitis
4
65
F
Maloney dilation
5
60
F
Balloon dilation
6 7 8 9
78 88 79 69
F M F F
Maloney dilation Maloney dilation Maloney dilation Balloon dilation
10 11
69 65
F M
Emesis Maloney dilation
12
59
F
Sclerodermarelated reflux stricture Megaesophagus achalasia Reflux stricture Reflux stricture Reflux stricture Spasm, pulsion diverticulum Reflux stricture Reflux stricture, cancer None
13
41
F
Swallowed dental prosthesis Takedown of Thal Achalasia fundoplasty
CEG
=
cervical esophagogastrostomy;
Interval From Leak to Esophagectomy Operation 4 2h
THEKEG
20 days
THEKEG
7 days
THEKEG
Complications
Hospitalization After Esophagectomy (days)
Continued sepsis, death 3 wk postop Respiratory insufficiency, sudden death 9 days postop Anastomotic leak, sepsis, death 2 mo postop Aspiration, respiratory insufficiency
...
...
...
When esophageal disruption occurs in the presence of preexisting esophageal disease or is associated with sepsis or fluid and electrolyte imbalance, aggressive and definitive therapy often provides the only chance for patient salvage. Twenty-four adults (average age, 59 years) with intrathoracic esophageal perforations underwent esophagectomy: 15, transhiatal esophagectomy without thoracotomy; and 9, transthoracic esophagectomy. Restoration of alimentary continuity with an immediate cervical esophagogastric anastomosis was carried out in 13 patients. Eleven underwent a cervical or anterior thoracic esophagostomy, and 10 of them had a subsequent colonic (7) or gastric (3) interposition from 4 to 32 weeks (average time, 8.6 weeks) later. The perforations were due to esophageal instrumentation (9 patients), acute caustic ingestion (21, emesis (2), intrathoracic esophagogastric anastornotic disruption (21, and other causes (9). Preexisting esophageal disease in 20
patients included chronic strictures (10 patients), reflux esophagitis (3), esophageal cancer (31, achalasia (2), diffuse spasm (21, and monilial esophagitis (1 patient). Ten patients were operated on within 12 hours after the injury; 3, within 12 to 24 hours; and 11, within three to 45 days (average interval, 6.6 days). There were three hospital deaths (13%). Nineteen of the 21 survivors were able to swallow comfortably until the time of death or latest follow-up. Aggressive diagnosis and aggressive treatment of life-threatening esophageal perforations are advocated. Conservative procedures (repair, diversion, or drainage) for a perforation with preexisting esophageal disease often inflict more morbidity than esophageal resection, which eliminates the perforation, the source of sepsis, and the underlying esophageal disease. The decision to restore alimentary continuity in a single stage must be individualized. (Ann Thoruc Surg 2990;49:3543)
F
the necessity for eventual reoperation is inherent in most of these procedures. More recently, improved results with esophageal replacement, particularly using the stomach as the conduit of choice [5-71, have influenced our approach to patients with intrathoracic esophageal disruption in the presence of preexisting esophageal disease or severe consequences of the mediastinal sepsis. This report reviews our experience with 24 patients with esophageal disruption treated by esophagectomy and either primary or delayed esophageal reconstruction.
ew events encountered in the practice of thoracic surgery are associated with such devastating consequences as disruption of the intrathoracic esophagus, an event that carries a mortality rate nearly three times that of a cervical esophageal perforation [l].Prolonged extravasation into the mediastinum of oral salivary digestive enzymes and bacteria as well as refluxed gastric acid, enzymes, and bile is nearly uniformly fatal without surgical intervention. The longer treatment is delayed, the greater the increase in mortality, to 40% to 66% after 24 hours or with established hydropneumothorax and mediastinal sepsis [24]. The dilemma confronting the thoracic surgeon is compounded by the variability of factors influencing the clinical setting: the duration of time between the occurrence of the leak and its diagnosis, the age of the patient, associated systemic illness, the hemodynamic stability of the patient, associated pleural contamination with empyema, and the presence of underlying intrinsic esophageal disease. No rigid set of guidelines applies to every patient with esophageal disruption, a successful outcome often depending on the surgeon’s experience and ability to be flexible and innovative. The desirability of preserving the esophagus when primary repair of the leak is tenuous has fostered a variety of alternatives for diversion in continuity or establishment of a controlled fistula. A protracted hospital course with Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11-13, 1989. Address reprint requests to Dr Omnger, Section of Thoracic Surgery, The University of Michigan Medical Center, 1500 E Medical Center Dr, 2120 Taubman, Box 0344,Ann Arbor, MI 48109.
0 1990 by
The Society of Thoracic Surgeons
Material and Methods During the past 15 years, we have performed an esophagectomy in 24 patients with disruption of the intrathoracic esophagus, and a retrospective review of their clinical status influencing our choice of treatment, the operative approach, and the surgical outcome has been conducted. During the same period, an additional 27 patients with intrathoracic esophageal perforations were treated with either primary repair (22 patients) or drainage (5). Virtually all of these patients had little or no underlying intrinsic esophageal disease (eg, achalasia with minimal esophageal dilatation), and repair of endoscopic, early postemetic, or postoperative perforations diagnosed promptly was readily achieved. These patients are not analyzed in this report. Among our 24 patients with perforations treated by esophagectomy were 12 male and 12 female patients ranging in age from 27 to 88 years (average age, 59 years). The oldest patients were 78, 79, 86, and 88 years of age (Tables 1, 2). The causes of the esophageal disruptions 0003-4975/90/$3.50
36
ORRINGERAND STIRLING ESOPHAGECTOMY FOR ESOPHAGEAL DISRUPTION
Ann Thorac Surg 1990;49:3543
Table 1 . Esophagectomy for Esophageal Disruption: Single-Stage Resection and Reconstruction
Patient No.
Age (yr) Sex
Intrinsic Esophageal Disease
Cause of Disruption
1
69
M
Emesis
Reflux stricture
2
86
F
Barrett's ulcer
Reflux stricture
3
31
M
Endoscopy
Monilial esophagitis
4
65
F
Maloney dilation
5
60
F
Balloon dilation
6 7 8 9
78 88 79 69
F M F F
Maloney dilation Maloney dilation Maloney dilation Balloon dilation
10 11
69 65
F M
Emesis Maloney dilation
12
59
F
Sclerodermarelated reflux stricture Megaesophagus achalasia Reflux stricture Reflux stricture Reflux stricture Spasm, pulsion diverticulum Reflux stricture Reflux stricture, cancer None
13
41
F
Swallowed dental prosthesis Takedown of Thal Achalasia fundoplasty
CEG
=
cervical esophagogastrostomy;
Interval From Leak to Esophagectomy Operation 4 2h
THEKEG
20 days
THEKEG
7 days
THEKEG
Complications
Hospitalization After Esophagectomy (days)
Continued sepsis, death 3 wk postop Respiratory insufficiency, sudden death 9 days postop Anastomotic leak, sepsis, death 2 mo postop Aspiration, respiratory insufficiency
...
...
...
