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S.G. IYER
Department of General Surgery, Sir JJ Hospital, Mumbai, India
Keywords: Oesophageal perforation, primary repair, single stage bipolar exclusion
Perforation of the thoracic oesophagus is a serious clinical problem, associated with a high morbidity and mortality, especially if treated late. Primary repair with or without reinforcement is commonly recommended, if the patient presents within 24 hours. As the time to treatment increases, primary repair has a high rate of leakage and complications. A useful technique of temporary oesophageal exclusion and diversion with spontaneous recanalisation is presented. The technique obviates the need for thoracotomy and preserves the native oesophagus
J.R.Coll.Edinb., 47, August 2002, 623 - 625
Oesophageal perforation is an emergency requiring early diagnosis and immediate treatment. The mortality and morbidity rises sharply as the time to treatment increases.1-3 Primary repair with or without reinforcement is an attractive option because it is simple and preserves the oesophagus. The frequent failure of primary closure has led to attempts at buttressing the suture line by various techniques. The plethora of techniques described in the literature suggests that the treatment needs to be individualized. This article presents a simple method to tackle this problem.
A technique of bipolar exclusion and diversion of the oesophagus without entering the thoracic cavity is described below. The neck is entered through an incision along the anterior border of lower half of the left sternomastoid muscle. Subplatysmal flaps are raised and the sternomastoid muscle is retracted laterally to expose the underlying structures. The sternomastoid muscle, carotid artery and the internal jugular vein are retracted laterally after ligating the middle thyroid vein. The oesophagus is mobilized and a lateral cervical oesophagostomy is made through a separate incision. (Figure 1) The oesophageal opening is sutured to the skin using catgut. An occluding No. 1 catgut ligature placed distal to the oesophagostomy. (Figure 1), achieves a complete oesophageal diversion.
A midline upper abdominal incision is made and a minilaparotomy performed. The vagii are isolated and the abdominal oesophagus is ligated using No. 1 catgut. (Figure 2) A jejunostomy is done for post-operative nutritional support. The thoracostomy tube drainage decreases after the procedure facilitating its removal in a few days. A period of two to three weeks of exclusion-diversion and the expansion of the lungs allows the oesophagus to heal. Spontaneous recanalisation of the oesophagus, following the absorption of the suture material, restores the anatomic continuity.
We used the technique in two patients with failed primary reinforced closure of the oesophagus. One of our patients required closure of the oesophagostomy under local anaesthesia while spontaneous closure of the oesophagostomy occurred in the other. Contrast studies done 10 weeks post-surgery revealed a well-healed oesophagus. Both patients were followed-up for more than two years with periodic contrast studies and oesophagoscopy and neither of them developed an oesophageal stricture.
The mortality and morbidity of late diagnosed and treated cases of thoracic oesophageal perforation rises sharply, the major reason being the rapid development of mediastinitis.1-3 Primary closure, if attempted on an oedematous and fragile oesophagus, is likely to fail and result in a leak. Surgeons have tried various procedures to reinforce the suture line with autologous tissue flaps, absorbable mesh and fibrin glue.4-7
The principle of exclusion and diversion has long been used for the treatment of oesophageal perforation. Johnson et al (1956) proposed dividing the stomach at its junction with the oesophagus.8 Urschel et al (1974) described ligating the oesophagus distal to the perforation with umbilical or teflon tape.9 Various other methods have been described in the literature including a `T` tube diversion use of absorbable linear vascular stapler, single stage exclusion and diversion.10-12 The surgeon often faces the challenge of making a decision of primary or reinforced closure versus an oesophageal exclusion or diversion. Chang et al (1992) successfully salvaged seven consecutive patients with a single stage operation using wide mediastinal drainage, `T` tube oesophagostomy, occluding absorbable ligature on cervical oesophagus and esophagogastric junction.
Failure of primary or reinforced closure, albeit uncommon, is known to occur and is associated with signficant morbidity and mortality.13,14 We used the technique described above in two patients with failed primary reinforced closure of oesophageal perforation. One patient had accidentally swallowed his denture and presented to the hospital after 36 hours with chest pain and fever. The other patient had a gunshot injury to the chest and presented with a haemo-pneumothorax, a bullet lodged in the chest and oesophageal injury. Both patients underwent thoracotomy, removal of the foreign body and closure of the oesophageal perforation with pleural flap reinforcement. Postoperatively, both patients developed a leak with persistent drainage through the thoracostomy tube.
The method described above provides a simple alternative in such a situation. The advantages of the procedure are that a re-thoracotomy is not required in an already physiologically challenged patient, the native oesophagus is preserved, and the use of absorbable occluding material obviates the need for further surgery subsequently, either to replace the oesophagus or to remove the occluding material. Minimally invasive techniques such as naso-mediastnal drainage followed by endoscopic clip closure of the oesophagus and combined percutaneous-endoscopic treatment has been described in the literature.15, 16 We emphasise that, although the approach to each case of a perforated oesophagus needs to be individualised, there are very few options for a failed primary closure. We advocate the technique described above for the failed primary closure as it achieves complete oesophageal exclusion and diversion.
In conclusion, temporary exclusion and diversion using a catgut ligature at the cardia and below a lateral cervical oesophagostomy is an attractive option for patients with failed primary repair of the thoracic oesophagus.
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Copyright: 10 June 2002
Correspondence: Mr S.G. Iyer, Department of Surgery, #02-813, Main Building, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074