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Diverticulectomy as treatment for traumatic perforation of pharyngoesophageal diverticulum
Diverticulectomy Perforation
as Treatment for Traumatic of Pharyngoesophageal Diverticulum
HOWARDJ. KESSELER, M.D. AND HERBERT C. MAIER,
M.D.,
New
A smaI1 instrumenta perforation of a normaI esophagus wiII usualIy cIose spontaneousIy when the surgeon mereIy drains the periesophagea1 space, provided there is no interference with passage of materia1 along the esophagea1 lumen. If there tends to be stagnation or retention of swahowed sahva or other esophagea1 contents at the site of perforation, the IistuIa wiI1 tend to persist. The chief reason why most instrumental perforations of the cervica1 esophagus cIosed foIIowing simple surgica1 drainage of the periesophagea1 spaces is that in most instances the injury had occurred through fairIy normaI tissue and there was no distaI esophagea1 obstruction. In the case of perforation of an esophagea1 diverticuIum, however, a very different situation exists. The foIIowing case forcibIy demonstrates why surgica1 excision of the perforated diverticulum as the initiaI emergency operation would be the procedure of choice. Primary suture of an esophagea1 perforation may no Ionger be feasibIe if operation is deIayed unti1 a marked inflammatory reaction has deveIoped.
RAUMATICperforation of the esophagus foIIowing instrumentation is 0ccasionaIIy encountered. SeyboId, Johnson and Leary’ found that among fifty cases of esophagea1 perforation seen at the Mayo CIinic, 68 per cent were manifest foIIowing instrumentation
T
CASE
FIG. I. Esophagram diverticuIum.
shows
smal1
rounded
York, New York
REPORT
A middIe-aged man compIained of a diffrcuhy in swaIIowing soIid foods of four months’ duration. Roentgenograms showed a smaI1 pharyngoesophagea1 diverticuIum. (Fig. I .) Esophagoscopy was performed under IocaI anesthesia. encountered diffrcuIty in The endoscopist passing the esophagoscope through the area of the cricopharyngeus. He thought that the tip of the instrument might have been in the diverticuIum. After endoscopy the patient was given nothing by mouth, and peniciIIin and streptomycin were administered. Four hours Iater the patient compIained of substernal heaviness and pain, and physica examination reveaIed evidence of subcutaneous emphysema
cervical
of the esophagus or gastroscopy. The earIy recognition and prompt treatment of such perforations is of greatest importance in reducing the morbidity and mortahty. AIthough the earIy use of antibiotics may lower the mortaIity considerabIy, immediate surgica1 intervention is a1s.o usuahy advisabIe. Recent experience has demonstrated that the surgica1 procedure shouId preferabIy aim at the cIosure of the perforation, rather than merely institute externa1 drainage. 994
Traumatic
Perforation
of PharyngoesophageaI
Diverticdum
2B
2A
FIG. 2. A, postero-anterior roentgenogram after patient swallowed a small amount of Iipiodol. Arrows point B, Iateral roentgenogram with arrows indicating extravasation of to pocket of Iipiodol in mediastinum. IipiodoI in the mediastinum far beIow original cervical drainage site.
pendent. Therefore, a right posterior mediastinotomy was performed under 10~1 anesthesia. The fifth rib was resected subperiosteaI1-y and the mediastina1 abscess cavity opened without entering the pIeura, and thereby dependent drainage was established. A smaI1 poIyethyIene nasogastric catheter was passed under fluoroscopic controi and feedings of the concentrated sustagen formula given through it. Fever subsided by the third postoperative day. The cervica1 Lvound was aIlowed to cIose. Profuse drainage of mucoid green fouI-smeIIing materia1 was evident at the thoracic wound. Cultures revealed the presence of BacilIus proteus and non-hemofytic enterococcus sensitive to chIoramphenico1. Therefore, this medication was begun without evident change in the amount or character of the drainage. Study of the esophagus two weeks later confirmed the clinica impression that the fistuIa was stiI1 present. Radiographic examination repeated ten days Iater showed no further tendency for the IistuIa to close, and it became evident that aIthough the perforation was smaI1, it did not cIose because it -\-as in the most dependent portion of the diverticuIum. (Fig. 3.) The cervical esophagus was expIorec1 under
on the right side of the neck. A diagnosis of perforation of the esophagus was made. Immediate operation was recommended. Consideration was given to the advisab Iity of immediately resecting the diverticuIum but since the exact site of perforation had not been established, it was decided mereIy to drain the prevertebral space in the region of the perforation. Under IocaI anesthesia a right cervica1 mediastinotomy was performed and drainage of the prevertebra1 space in the Iower portion of the neck was estabIished. The diverticulum was not exposed. PostoperativeIy the patient was given nothing by mouth, and alimentation was accomplished parenterally. The temperature varied between IOO and 102'F. for the next three days. Radiographs of the chest at this time reveaIed slight widening of the superior mediastinum. The drainage from the cervica1 wound was thin and seropuruIent. On the sixth postoperative day radiographic studies with IipiodoI taken by mouth revealed extravasation into the right side of the superior mediastinum .to the level of the top of the arch of the aorta. that the (Figs. 2A and B.) This indicated origina drainage site was not sufficiently de99s
KesseIer
FIG. 3. Arrows point to diverticuIum which is filled with barium. A very tiny stream of barium leaves the dependent portion of the diverticuIum to enter the large drained posterior mediastina1 abscess.
endotrachea1 anesthesia. The right cervica1 wound was reopened and the frstutous tract was entered. The diverticuIum was demonstrated, and the perforation noted to be at the most dependent portion. The neck of the diverticuIum was about 2 cm. in diameter and was resected using interrupted No. oooo chromic catgut for mucosa, and interrupted No. oooo siIk for muscuIaris. A drain was pIaced IateraI to the area and the wound was cIosed in Iayers. The postoperative course was uneventful. Drainage from the thoracic wound became minima1 and was no Ionger fouI-smeIIing. OraI feedings were begun on the sixth postoperative day, and by the tenth day the patient was eating a fuI1 soft diet. Both wounds heaIed, and radiographic examination of the esophagus one month Iater reveaIed no evidence of the stenosis or diverticulum. COMMENTS
The treatment of traumatic perforation of the esophagus has undergone considerabIe change in the last two decades. Before 1935 uncontroIIabIe mediastinitis and death foIIowed esophagea1 perforation in 70 per cent of the patients unIess surgical drainage was instituted. Pearse,2 and PhiIIip9 were among those to advocate prophyIactic cervical or posterior mediastinotomy folIowing perforation of the esophagus. They were abIe to achieve a
md Maier reduced mortality of 27 per cent following these principIes. With the advent of chemotherapeutic agents, the antibiotics and better genera1 supportive measures, a method of conservative therapy was evoIved. However, Lederer et aI. caIIed attention to the fact that peniciIIin and suIfa drugs were not substitutes for adequate dependent surgical drainage. Bisgard and Kerr,5 Dorsey,6 Kernan,’ and Striede6 have reviewed the surgica1 management of perforations of the esophagus. Emphasis was pIaced on earIy diagnosis, adequate dependent drainage of the mediastinum and drainage of the empyema space if present. Greater success in treatment was noted; and it became apparent that “conIay in earIy adequate servative therapy” drainage procedures along with antibiotics and supportive measures. Surgical concepts were evolved further when primary suture of the esophagus was advocated and performed successfuIIy in postemetic ruptures of the esophagus. WeiseI and Raineg extended the concept of immediate suture of esophagea1 perforations to those other than the postemetic type. They reported seven cases of traumatic perforation which were a11 treated by immediate suture and foIIowed by primary union of the esophagus. Lindskog and SternlO reported a case of primary excision of a ruptured pharyngoesophagea1 diverticuIum foIIowing instrumentation. Attendant to this form of therapy was decreased morbidity and earIy rehabiIitation of the patient. It is apparent that any procedure foIIowing earIy perforation of the esophagus that is directed toward drainage onIy is not compIete. Drainage operations do not take into account the size of the opening or the site of the perforation, whether it be in the esophagus, a diverticuIum or proxima1 to some obstructing Iesion. KnowIedge of the physica characteristics of the perforation may be of considerable import in the eventua1 progress of the case. If the perforation does not hea rapidly, many weeks of hospitalization and multipIe surgical procedures may foIIow. This chain of events occurred in the aformentioned case; for had the esophagus and the diverticuIum been expIored, the unfavorabIe perforation would have been appreciated and managed definitely at that time. The site of a perforation can sometimes be Iocated by radioscopic examination during
996
Traumatic
Perforation
of Pharyngoesophageal
Diverticulum REFERENCES
the swallowing of a smaI1 amount of lipiodol. If this study had been done as soon as the perforation was suspected, the wisdom of immediate diverticulectomy might have been obvious. Failure to demonstrate extraversation of the lipiodol however would not rule out a perforation. Barium should not be employed. Exploration of the site of perforation with the view toward immediate suture should be reserved for those early cases when the tissues are not too infIamed and when primary union can be anticipated.
I. SEYBOLD, W. D., JOHNSON, M. A., III and LEAKY,
2. 3. 4.
5.
6.
SUMMARY
A perforated esophageal diverticuIum shouId be treated by immediate diverticulectomy if operation can be performed within a few hours of perforation before an acute inflammatory process interferes with the esophagea1 repair. Although small traumatic perforations of the esophagus may respond to antibiotics and drainage, the advisabiIity of immediate surgica1 closure of the perforation should beconsidered.
7.
8. 9.
IO.
997
W. V. Perforation of the esophagus. S. Clin. Nortb America, 30: I 155, 1950. PEARSE, H. E., JR. Mediastinitis folIowing cervical suppuration. Ann. Surg., 108: 588, 1938. PHILLIPS, C. E. Mediastinal infection from esophageal perforation. J. A. M. A., I I T: 998, 1938. LEDERER, F. L., GROSSMAN, A. A. and DONNELLY, W. A. Present day concepts on treatment of esophageat perforations. Ann. Otol., Rbin. P Laryng., 56: 867, 1947. BISGARD, J. D. and KERR, H. LV. SurgicaI management of instrumental perforation of the esophagus. Arch. Surg., 58: 739, 1949. DORSEY, J. M. Symposium on gastroesophageal surgery; perforations and ruptures of the esophagus. S. C&n. Nortb America, 3 I : I I 7, 195 I. KERNAN, J. D. Perforation of the esophagus as a surgical emergency. S. C&n. North America, 30: 405, 1950. STRIEDER, J. W. Surgery of the esophagus. New England J. Med., 243: 445, r95o. WEISEL, W. and RAINE, F. Surgical treatment of traumatic esophageal perforation. Surg., Gynec. c’+ Obst., 94: 337, 1952. LINDSKOG,G. E. and STERN, H. DiverticuIum of the esophagus. Yale J. Biol. P Med., 26: 285, 1954.
as Treatment for Traumatic of Pharyngoesophageal Diverticulum
HOWARDJ. KESSELER, M.D. AND HERBERT C. MAIER,
M.D.,
New
A smaI1 instrumenta perforation of a normaI esophagus wiII usualIy cIose spontaneousIy when the surgeon mereIy drains the periesophagea1 space, provided there is no interference with passage of materia1 along the esophagea1 lumen. If there tends to be stagnation or retention of swahowed sahva or other esophagea1 contents at the site of perforation, the IistuIa wiI1 tend to persist. The chief reason why most instrumental perforations of the cervica1 esophagus cIosed foIIowing simple surgica1 drainage of the periesophagea1 spaces is that in most instances the injury had occurred through fairIy normaI tissue and there was no distaI esophagea1 obstruction. In the case of perforation of an esophagea1 diverticuIum, however, a very different situation exists. The foIIowing case forcibIy demonstrates why surgica1 excision of the perforated diverticulum as the initiaI emergency operation would be the procedure of choice. Primary suture of an esophagea1 perforation may no Ionger be feasibIe if operation is deIayed unti1 a marked inflammatory reaction has deveIoped.
RAUMATICperforation of the esophagus foIIowing instrumentation is 0ccasionaIIy encountered. SeyboId, Johnson and Leary’ found that among fifty cases of esophagea1 perforation seen at the Mayo CIinic, 68 per cent were manifest foIIowing instrumentation
T
CASE
FIG. I. Esophagram diverticuIum.
shows
smal1
rounded
York, New York
REPORT
A middIe-aged man compIained of a diffrcuhy in swaIIowing soIid foods of four months’ duration. Roentgenograms showed a smaI1 pharyngoesophagea1 diverticuIum. (Fig. I .) Esophagoscopy was performed under IocaI anesthesia. encountered diffrcuIty in The endoscopist passing the esophagoscope through the area of the cricopharyngeus. He thought that the tip of the instrument might have been in the diverticuIum. After endoscopy the patient was given nothing by mouth, and peniciIIin and streptomycin were administered. Four hours Iater the patient compIained of substernal heaviness and pain, and physica examination reveaIed evidence of subcutaneous emphysema
cervical
of the esophagus or gastroscopy. The earIy recognition and prompt treatment of such perforations is of greatest importance in reducing the morbidity and mortahty. AIthough the earIy use of antibiotics may lower the mortaIity considerabIy, immediate surgica1 intervention is a1s.o usuahy advisabIe. Recent experience has demonstrated that the surgica1 procedure shouId preferabIy aim at the cIosure of the perforation, rather than merely institute externa1 drainage. 994
Traumatic
Perforation
of PharyngoesophageaI
Diverticdum
2B
2A
FIG. 2. A, postero-anterior roentgenogram after patient swallowed a small amount of Iipiodol. Arrows point B, Iateral roentgenogram with arrows indicating extravasation of to pocket of Iipiodol in mediastinum. IipiodoI in the mediastinum far beIow original cervical drainage site.
pendent. Therefore, a right posterior mediastinotomy was performed under 10~1 anesthesia. The fifth rib was resected subperiosteaI1-y and the mediastina1 abscess cavity opened without entering the pIeura, and thereby dependent drainage was established. A smaI1 poIyethyIene nasogastric catheter was passed under fluoroscopic controi and feedings of the concentrated sustagen formula given through it. Fever subsided by the third postoperative day. The cervica1 Lvound was aIlowed to cIose. Profuse drainage of mucoid green fouI-smeIIing materia1 was evident at the thoracic wound. Cultures revealed the presence of BacilIus proteus and non-hemofytic enterococcus sensitive to chIoramphenico1. Therefore, this medication was begun without evident change in the amount or character of the drainage. Study of the esophagus two weeks later confirmed the clinica impression that the fistuIa was stiI1 present. Radiographic examination repeated ten days Iater showed no further tendency for the IistuIa to close, and it became evident that aIthough the perforation was smaI1, it did not cIose because it -\-as in the most dependent portion of the diverticuIum. (Fig. 3.) The cervical esophagus was expIorec1 under
on the right side of the neck. A diagnosis of perforation of the esophagus was made. Immediate operation was recommended. Consideration was given to the advisab Iity of immediately resecting the diverticuIum but since the exact site of perforation had not been established, it was decided mereIy to drain the prevertebral space in the region of the perforation. Under IocaI anesthesia a right cervica1 mediastinotomy was performed and drainage of the prevertebra1 space in the Iower portion of the neck was estabIished. The diverticulum was not exposed. PostoperativeIy the patient was given nothing by mouth, and alimentation was accomplished parenterally. The temperature varied between IOO and 102'F. for the next three days. Radiographs of the chest at this time reveaIed slight widening of the superior mediastinum. The drainage from the cervica1 wound was thin and seropuruIent. On the sixth postoperative day radiographic studies with IipiodoI taken by mouth revealed extravasation into the right side of the superior mediastinum .to the level of the top of the arch of the aorta. that the (Figs. 2A and B.) This indicated origina drainage site was not sufficiently de99s
KesseIer
FIG. 3. Arrows point to diverticuIum which is filled with barium. A very tiny stream of barium leaves the dependent portion of the diverticuIum to enter the large drained posterior mediastina1 abscess.
endotrachea1 anesthesia. The right cervica1 wound was reopened and the frstutous tract was entered. The diverticuIum was demonstrated, and the perforation noted to be at the most dependent portion. The neck of the diverticuIum was about 2 cm. in diameter and was resected using interrupted No. oooo chromic catgut for mucosa, and interrupted No. oooo siIk for muscuIaris. A drain was pIaced IateraI to the area and the wound was cIosed in Iayers. The postoperative course was uneventful. Drainage from the thoracic wound became minima1 and was no Ionger fouI-smeIIing. OraI feedings were begun on the sixth postoperative day, and by the tenth day the patient was eating a fuI1 soft diet. Both wounds heaIed, and radiographic examination of the esophagus one month Iater reveaIed no evidence of the stenosis or diverticulum. COMMENTS
The treatment of traumatic perforation of the esophagus has undergone considerabIe change in the last two decades. Before 1935 uncontroIIabIe mediastinitis and death foIIowed esophagea1 perforation in 70 per cent of the patients unIess surgical drainage was instituted. Pearse,2 and PhiIIip9 were among those to advocate prophyIactic cervical or posterior mediastinotomy folIowing perforation of the esophagus. They were abIe to achieve a
md Maier reduced mortality of 27 per cent following these principIes. With the advent of chemotherapeutic agents, the antibiotics and better genera1 supportive measures, a method of conservative therapy was evoIved. However, Lederer et aI. caIIed attention to the fact that peniciIIin and suIfa drugs were not substitutes for adequate dependent surgical drainage. Bisgard and Kerr,5 Dorsey,6 Kernan,’ and Striede6 have reviewed the surgica1 management of perforations of the esophagus. Emphasis was pIaced on earIy diagnosis, adequate dependent drainage of the mediastinum and drainage of the empyema space if present. Greater success in treatment was noted; and it became apparent that “conIay in earIy adequate servative therapy” drainage procedures along with antibiotics and supportive measures. Surgical concepts were evolved further when primary suture of the esophagus was advocated and performed successfuIIy in postemetic ruptures of the esophagus. WeiseI and Raineg extended the concept of immediate suture of esophagea1 perforations to those other than the postemetic type. They reported seven cases of traumatic perforation which were a11 treated by immediate suture and foIIowed by primary union of the esophagus. Lindskog and SternlO reported a case of primary excision of a ruptured pharyngoesophagea1 diverticuIum foIIowing instrumentation. Attendant to this form of therapy was decreased morbidity and earIy rehabiIitation of the patient. It is apparent that any procedure foIIowing earIy perforation of the esophagus that is directed toward drainage onIy is not compIete. Drainage operations do not take into account the size of the opening or the site of the perforation, whether it be in the esophagus, a diverticuIum or proxima1 to some obstructing Iesion. KnowIedge of the physica characteristics of the perforation may be of considerable import in the eventua1 progress of the case. If the perforation does not hea rapidly, many weeks of hospitalization and multipIe surgical procedures may foIIow. This chain of events occurred in the aformentioned case; for had the esophagus and the diverticuIum been expIored, the unfavorabIe perforation would have been appreciated and managed definitely at that time. The site of a perforation can sometimes be Iocated by radioscopic examination during
996
Traumatic
Perforation
of Pharyngoesophageal
Diverticulum REFERENCES
the swallowing of a smaI1 amount of lipiodol. If this study had been done as soon as the perforation was suspected, the wisdom of immediate diverticulectomy might have been obvious. Failure to demonstrate extraversation of the lipiodol however would not rule out a perforation. Barium should not be employed. Exploration of the site of perforation with the view toward immediate suture should be reserved for those early cases when the tissues are not too infIamed and when primary union can be anticipated.
I. SEYBOLD, W. D., JOHNSON, M. A., III and LEAKY,
2. 3. 4.
5.
6.
SUMMARY
A perforated esophageal diverticuIum shouId be treated by immediate diverticulectomy if operation can be performed within a few hours of perforation before an acute inflammatory process interferes with the esophagea1 repair. Although small traumatic perforations of the esophagus may respond to antibiotics and drainage, the advisabiIity of immediate surgica1 closure of the perforation should beconsidered.
7.
8. 9.
IO.
997
W. V. Perforation of the esophagus. S. Clin. Nortb America, 30: I 155, 1950. PEARSE, H. E., JR. Mediastinitis folIowing cervical suppuration. Ann. Surg., 108: 588, 1938. PHILLIPS, C. E. Mediastinal infection from esophageal perforation. J. A. M. A., I I T: 998, 1938. LEDERER, F. L., GROSSMAN, A. A. and DONNELLY, W. A. Present day concepts on treatment of esophageat perforations. Ann. Otol., Rbin. P Laryng., 56: 867, 1947. BISGARD, J. D. and KERR, H. LV. SurgicaI management of instrumental perforation of the esophagus. Arch. Surg., 58: 739, 1949. DORSEY, J. M. Symposium on gastroesophageal surgery; perforations and ruptures of the esophagus. S. C&n. Nortb America, 3 I : I I 7, 195 I. KERNAN, J. D. Perforation of the esophagus as a surgical emergency. S. C&n. North America, 30: 405, 1950. STRIEDER, J. W. Surgery of the esophagus. New England J. Med., 243: 445, r95o. WEISEL, W. and RAINE, F. Surgical treatment of traumatic esophageal perforation. Surg., Gynec. c’+ Obst., 94: 337, 1952. LINDSKOG,G. E. and STERN, H. DiverticuIum of the esophagus. Yale J. Biol. P Med., 26: 285, 1954.