Multimodality Treatment of Esophageal Disruptions

Multimodality Treatment of Esophageal Disruptions* Lajos Kotsis, MD, PhD; Szilard Kostic, MD; and Kornelia Zubovits, MD

The treatment of esophageal disruptions has changed since 1981. The value of a more selective assessment in six spontaneous ruptures and 30 mostly intrathoracic (83.4%) esophageal perforations is evaluated in this study. Based on the previous state of the esophagus, the time factor, and type and site of the disruption, reinforced primary repair (by diaphragmatic, muscular, pleural flap, or fundoplication), transhiatal closure, resection, intubation, suture combined with myotomy and fundoplication, esophageal diversion, and transhiatal mediastinal drainage were employed. The overall 30-day hospital mortality was 19.4%. Although these operations were mostly used in late (24 h to 7 months) perforations and ruptures, none of the patients with reinforced repair by autogenous diaphragmatic, muscular, or pleural flaps or fundoplication had fatal outcome for breakdown of the closure. Only patients with renal, cardiac, or multiorgan failure as a consequence of sepsis due to time elapsed before hospital admission died. The key to improve the prognosis of this life-threatening emergency is the more appropriate selection of the primary employed procedure. (CHEST 1997; 112:1304-09) Key words: esophageal disruptions; importance of the primary employed procedure; multimodality management

results following conventional treatment T heof poor esophageal disruptions-including even primary closure without reinforcement 1 •2-incited us 15 years ago to introduce a multimodality assessment in this major surgical emergency.3,4 The value of this more selective management of six spontaneous ruptures and 34 mostly intrathoracic (87.5%) esophageal perforations is evaluated in this retrospective study.

inoperable perforated esophageal malignancies (Fig 1) and in a 10-day-old instrumental perforation of a middle third caustic stri cture. In an instance of a lower mediastinal abscess of a similar etiology and origin, transhiatal mediastinal drainage (discussed by Krisar et al 5 ) in 1969 for suction lavage combined with decompressive gastros tomy was performed (Fig 2). In a 7-day-old iatrogenic perforation of a peptic stenosis-in

Table !-Esophageal Disruptions: Thoracic Surgical Clinic, Budapest, 1981 to 1996 No. of patients (n=36)

MATERIALS AND METHODS Forty patients, the majority (83.4%) with ruptures or perforations of the thoracic esophagus, were treated at the Thoracic Surgical Clinic in Budapest between 1981 and 1996. The nature of the disruptions, the types of procedure used, and the underlying esophageal diseases are shown in Tables 1-3.

Spontaneous rupture Spontaneous malignant perforation Instrumental Traumatic Foreign body

6

22 2

5

Perforated Obstructing Diseases Among th e patients with preexistent obstructive esophageal disease (Table 4), suture with Heller myotomy and Dor (two patients) or Thai and Belsey fundoplication (three patients) were carried out in early perforated achalasia. Traction intubation with a personally designed cuffed funnel tube-providing a watertight and reflux-free exclusion- was used in six *From the Postgraduate Medical University, Thoracic Surgical Clinic, Budapest, Hungary. Manuscript received August 2, 1996; revision accepted March 29, 1997. Reprint requests: Lajos Kotsis, MD, PhD, H-1529 Budapest, Piheno ut 1, Hungary 1304

Table 2-Types of Procedures Used* Procedures Nonoperative, collar mediastinotomy Reinforced primary closure Transhiatal suture or mediastinal drainage Surgical intubation Suture \\~th intubation or exclusion Suture+ myotomy+ fundoplication Woodward operation, exclusion-diversion with pleural drainage, coverage with serratus muscle flap *(n = l2). Clinical Investigations

Table 3-Underlying Esophageal Diseases No. of Patients (n=l6) Achalasia Malignant tumor Caustic stricture Peptic stricture

5 6 3 2

spite of th e localized empyema- breakdown of th e closure has bee n avoided by reinforcement of the suture line with a pedicl ed diaphragmatic flap. In a 7-month-old instrume ntal cervical perforation of a high intrathoracic lye stricture with related 10-cm-long mediastinal fistula, suture, fistulectomy accompanied by one-stage temporary intubation was successful. Spontaneous Ruptures In four late (24 h to 5 days ) spontaneous ruptures (Table 5) through left thoracotomy, mediastinal deco mpression and twolayer closure were performed r einforced by transhiatal Thai fundoplicat ion (two patients) or diaphragmatic flap (two patients ). In a right-side rupture follovvin g left pneumonectomy (for recurrent bronchial cancer) and vomiting on the second postope rative day, a transhiatal primmy closure was don e and reinforced by the omentum and combined with transhiatal and right-side pleural (previously introduced) drainage gastrostomy and feeding jejunostomy. In instances of bilateral ruptures of the mediastinal pleura (two cases), the contralateral hydrothorax was drained through the left thoracic cavity. Only a nasogastric tube was used for Gl deco mpression in all but one case. Perforated Healthy Esophagus The follmving treatm ent was adopted in case of mostly instrumental pe rforations of the healthy esophagus (Table 6). Nonoperative assessment was used in two early small cervical perforations and collar mediastinotomy in two subsequent upper mediastinal abscesses. In case of lower third mediastinal lesions (24 to 48 h), the suture was covered either with adiaphragmatic (Fig 3) or with a modified, better vascularized, vertical fashioned, pleural flap. In late (48 h, 7 day, and 6 week) intrathoracic perforations, recovery was obtained by Woodward operation or in a long (15em) 9-day tear by suture and Urschel-type 6 esophageal diversion. In a 6-week-old iatrogenic (by sclerotherapy) perfora-

tion with right-side empyema, a similar distal and also cervical banding (Fig 4) with Petzer tube esophagostomy, gastrostomy, and tube thoracostomy for suction lavage was successful. Resection was used only for an ischemic esophagus developed at the end of a left radical pneumonectomy and extended lymphadenectomy. In a small middle third esophageal perforation developed 4 months after right pneumonectomy for recurrent bronchial tumor and subsequent empyema, coverage \vith serratus ante rior muscle flap, combined with Schede-type thoracoplasty, proved to be useful.

RESULTS

The overall 30-day hospital mortality was 19.5%. The postoperative fatal complications related to pathologic conditions are summarized in Table 6. Although these operations were mostly used in late (24 h to 7 months) perforations and ruptures, in all but one instance the leakage was controlled. In our series, none of the patients with reinforced repair of early or late esophageal disruptions by autogenous pleural, diaphragmatic, muscular (serratus anterior, sternocleidomastoideus) flaps , or fundoplication had fatal outcome for breakdown of the closure. Only patients with renal, cardiac, or multiorgan failure in consequence of sepsis due to time elapsed before hospital admission died. The patient operated on for right-side postpneumonectomy spontaneous esophageal rupture died 3 weeks later for "kissing" duodenal ulcer. Neither stricture nor need for a late dilation was necessary after removal of the bandings on the lOth and 21st postoperative days, respectively, after esophageal exclusion by Urschel et al 6 technique, although in one case, only the anterior part of the distal banding was resected for deep tissue ingrowth. The site of the removed cervical banding and esophagostomy closed in 6 days following suture closure supported by a sternocleidomastoideus muscle flap in one patient and spontaneously in the other one.

Table 4-Peiforated Preexistent Obstructing Diseases (n=15) * Etiology Early perforated (instrumental) Achalasia Achalasia Inoperable tumors Late instru mental perforations Peptic stricture Caustic stricture Caustic st1icture High intrathoracic caustic stricture

No. of Patients

Time Elapsed

2 3 6

< lh < lh < l h-12 h

1

7d 24 h 10 d 7 mo

1

Treatment

Outcome

S + Heller myotomy+ Dor fundoplication S+ Heller+ Thal+ Belsey operation

Alive Alive Alive

I

s+ reinforcement with diaphragmatic nap Transhiatal mediastinal D I S+I

Alive Alive

*S=suture; ! = intubation; D = drainage. CHEST I 112 I 5 I NOVEMBER, 1997

1305

FIGURE l. Chest radi ograph finding of a right-side hydropneum othorax caused by a perforated, inoperable esophageal tumor (left). Exclusion of pe rforation b y surgically inse rted cuffed funn el tube (right) .

FIGURE

2. Ill ustration of th e transhiatal mediastinal drain age.

DISCUSSION

Once the diagnosis of esophageal leak is made, the most c1itical decision is the choice of the most appropriate management. Large comparative or international studies7 •8 of the current surgical techniques could not validate their real value in instances of esophageal di sruption. On the contrary, in our treatment protocol, the first choice and alternative procedures were selected on the basis of underlying esophageal diseases, the nature, site, and magnitude of the disruption, and th e time elapsed after onset of perforati on. 1306

The presence of surrounding mediastinal fibrosis in caustic strictures creates particular conditions in instrumental perforations. 5 The injury and also the contamination often r emain intramediastin al. Nonope rative treatm ent or gastrostomy (to minimize GI reflux ) should be used in early small cervical or intramural perforations and early mediastinitis. For intrathoracic instrumental perforations within 24 h, primary conventional resection with or without replace ment (with jejunum or colon, dependent on the level of perforation ) should be recommended. Endoprosthesis insertion9·10 proved to control the intramediastinal perforations (48 h ). Transhiatal mediastinal drainage (Fig 2) with suction lavage and gastrostomy and tube thoracostomy for associated empyema is the most useful kind of mediastinal drainage for lower or middle third mediastinal abscess. 5 Conventional collar mediastinotomy is preferred only in upper m ediastinal abscess. Underlying stenosing lower esophageal diseases compromise healing of suture repair of the perforation. As a rule, in early cases, obstruction should b e relieved together with the suturing and support of the closure.11 The antireflux procedures buttress both the suture line and formal operation. In late cases, resection, diversion,6 or intubation should be instituted. Transhiatal resection is indicated in perforated r esectable carcinoma. Endoprosthesis insertion is the unique real possibility to exclude a Clinical Investigations

Table 5-Spontaneous Ruptures* Etiology

No. of Patients (n=6)

Time Elapsed

2

< 24 h <24 h-5 d < 24 h-30 d

Late, typical

Atypical right side after left pneumonectomy

2 1

Treatment

Outcome

MD+S+distal exclusion prolonged pleural D 1 MD+S+diaphragmatic flap buttress MD+ S + fundoplication Transhiatal MD+S+mediastinal+right pleural D +gastrostomy+ jejunostomy

Alive Alive 1 Alive

*MD=mediastinal decompression ; S=suture; D = drainage. 1 Recurrent leak.

FIGURE 4. Illustration of Urschel-Ergin type esophageal exclusion diversion.

FIGURE 3. Aspect of the pedicled diaphragmatic flap for esophageal sutu re lin e buttress.

perforation of unresectable esophageal malignances (p1imary or secondary), especially if a cuffed funnel tube will be used. Conservative treatment 12 may be sufficient in small intramediastinal (documented) spontaneous ruptures. Recovery even after primary closure of these ruptures within 24 h has been found uncertain by many authors.l·2·13- 16 The patch procedures with well-vascularized diaphragmatic flap 15·17 or gastiic

fundus 3 ) 4 ,16 ensure a more secure healing of the primary suture repair than other (pleural, 18 intercostal muscle) applied flaps . If the transthoracic primary closure is contraindicated-as in our case with a right -side rupture after left pneumonectomy-transhiatal primary closure seems to be the procedure of choice. Large lacerations at the typical level should be dealt with by Woodward operation or resection. 19 Failure after initial repair or severe sepsis calls especially for Urschel-type esophageal diversion6·20·21 or mucosal stripping. 26 Injuries of the healthy esophagus demand a complex procedure for salvage of the organ. In early cases, primary closure with reinforcement (pleuraP 8 CHEST I 112 I 5 I NOVEMBER, 1997

1307

Table 6-Peiforation of the Healthy Esophagus* Etiology

No. of Patients (n= l5 )

Time Elapsed

2 2 1 2

12-24 h 24 h

Early ce1vical (instrumental ) Intramediastinal by foreign body Left pneumon ectomy Late ce1vical (instrumental) Intrathoracic by foreign body extraction Traumatic Foreign body extraction Traumatic Foreign body extraction Miscellaneous Sclerotherapy Postpenumonectomy

1

24-36 h 24 h 48 h 3d 7d 9d 7 d 6 wk 4 mo

Treatm ent

Outcome

Conse!Vative S +buttress with diaphragmatic or pleural flap Torek operation Collar mediastinotomy S+buttress with polyglactin suture (Vicryl ) mash Woodward operation S+buttress with omentum+pleural and mediastinal D S+buttress with pleural flap+pl eural D S+Urschel diversion+pleural D Johnson-type diversion, pleural D Diversion (Urschel)+ thoracostomy suction lavage Coverage with serratus ante1ior muscle flap+Schede thoracoplasty

Alive Alive Alive Alive Alive Alive

Alive Alive Alive

*See Table 4 footnotes.

Table 1-Relationship of Fatal Complications With the Underlying Diseases and Time Factor* Etiology Spontaneous rupture Dilation of a yl e shicture Overlooked traumatic leak Iatrogenic perforation of a p eptic stricture Miscellaneous Right-side spontaneous rupture following left pneumonectomy Foreign body extraction

Time Elapsed, d 5 10 7 7 3

3

Treatment

Cause of Death

S + DFLb Intubation S + PFLb S+ DFLb Exclusion (Johnson ) Transhiatal S+ pleural and mediastinal D+G+J S+coverage with omentum

Contralateral aspiration, sepsis, renal failure Lung abscess, perforated duodenal ulcer, sepsis Purulent pericarditis, mediastinitis, empyema, sepsis Renal failure Cardiac failure "Kissing" duodenal ulcer Purulent mediastinitis, sepsis+pleural+mediastinal D

*(n= 7); S= suture; b = buttress; D = drainage; G=gastrostomy; }=jejunostomy; DFL=diaphragmatic flap; PFL=pleural flap.

diaphragmatic, extrathoracic muscle flaps [romboideus22, pectoralis major, sternocleidomastoideus 23 ] is valuable. In late cases, intrathoracic tears, Woodward operation , and especially the organ-preserving U rschel-type diversion, performed simultaneously with the primary repair6·20 or after the failure of the initial attempt of the esophageal closure, 4 are of particular value. To avoid reoperation and hazard of removal of the distal banding with heavy tissue ingrowth, Urschel (cit 18) had ulteriorly modified his original technique by exteriorizing polypropylene (Prolene) suture through Rumel plastic tourniquet alongside of the gastrostomy. Mucosal stripping, introduced recently by Akiyama et al,26 is a new interesting alternative of esophageal exclusion. In esophageal disruptions due to operations (vagotomy, hiatal hernia repair, leiomyoma enucleation, Heller myotomy, pneumonectomy, etc), suture closure supported by fundoplication (Dor or Belsey type) or previously mentioned muscle flaps should be performed. In early detected postpneumonectomy esophageal perforation, we recommend primary suture but1308

tressed with serratus anterior or latissimus dorsi muscle flaps. Its value has been demonstrated in our patient having a similar a but delayed perforation.

CONCLUSION

Our 15-year experiences suggest that the key to improve the prognosis of this life-threatening emergency is the more appropriate selection of the primary applied procedure. Initial treatment should always be correlated with the previous state of the esophagus. Nonoperative assessment is rarely indicated. Only reinforced primary closure is justified today. Failure of the first procedure demands exlusion or resection.

REFERENCES 1 K eiglhley MRB , Girwood RW, Jonescu Ml, e t a!. Spontaneous rupture of the esophagus. Br J Surg 1972; 59:649-52 2 Postlethwith RW. Perforation and rupture. In: Surgery of the esophagus . New York: Appleton-Century-Crofts, 1979; 152-76 Clinical Investigations

3 Kotsis L, Condos T, Penzes I, et al. Modern treatment of the spontaneous rupture of the esophagus. Orv Hetil 1983; 123:1755-59 4 Kotsis L, Szabadi G, Kostic SZ. Successful treatment of a 9-day-old iatrogenic esophageal perforation by suture and Urschel type exclusion. Magy Seb 1983; 36:358-63 5 Ktisar Z, Kotsis L, Dobjanchy S. Twenty Hve perforations of corrosive esophageal stricture. Orv Hetil 1969; 10:178-80 6 Urschel HC, Razzuk MA, Wood RE, et al. Improved management of esophageal perforations: exclusion and diversion in continuity. Ann Surg 1974; 179:634-40 7 Gayet B, Ancona E. Esophageal perforation: II. High risk group patient and treatment: a GEEMO questionnaire. In: Siewert R, Holcsher A, eds. Diseases of the esophagus. Springer-Verlag, 1988; 1331-36 8 Jones WG II, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992; 53:534-43 9 Berger RL, Donato AT. Treatment of esophageal disruption by intubation. Ann Thorac Surg 1972; 13:27-35 10 Imre J. Plastic tube prosthesis for the surgical treatment of perforations in esophageal strictures. Ann Thorac Surg 1973; 15:275-78 11 Skinner DB, Little AG, DeMeester TR. Management of esophageal perforation. Am J Surg 1980; 139:760-64 12 Cameron JL, Kieffer RF, Hendrix TR, et al. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 1979; 27:404-08 13 Abbott OA, Masaour KA, Logan WD, et al. Atraumatic so-called 'spontaneous' rupture of the esophagus. Thorac Cardiovasc Surg 1970; 59:67-83 14 Symbas PN, Hatcher ChR, I-Iaralfist N. Spontaneous rupture of the esophagus. Ann Surg 1978; 187:634-40 15 Westaby S, Shepard MP, Nohl-Oiser HC. The use of diaphragmatic pedicle grafts for reconstructive procedures in the

16 17 18 19 20 21 22 23 24

25 26

esophagus and tracheobronchial tree. Ann Thorac Surg 1982; 33:486-90 Finley RJ, Pearson G, Weisel RD, et al. The management of nonmalignant intrathoracic esophageal perforation. Ann Thorae Surg 1980; 30:575-81 Jara FM. Diaphragmatic pedicle flap for the treatment of Boerhave's syndrome. J Thorac Cardiovasc Surg 1979; 78: 931-34 Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus. Ann Surg 1989; 109:612-17 Orriginer MB, Strirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990; 49:35-43 Chang ChH, Lin PJ, Chang JP, et al. One-stage operation for treatment of delayed diagnosis of thoracic esophageal perforation. Ann Thorac Surg 1992; 53:617-20 Pate JW, Walker WA, Cole FH, et al. Spontaneous rupture of the esophagus: 30-year experience. Ann Thorac Surg 1989; 47:682-92 Lucas AE, Snow N, Tobin GR, et al. Use of the rhomboid major muscle flap for esophageal repair. Ann Thorac Surg 1982; 33:619-23 Richardson JD, Martin LF, Borzotta AP, et al. Unif)ing concepts in the treatment of esophageal leaks. Am J Surg 1985; 149:157-62 Kotsis L. Multimodal strategy for the management of the esophageal perforations and ruptures. In: Nabeya K, Hanaoka T, Nogami H , eds. Tokyo: Springer-Verlag, recent advances in diseases of the esophagus. 1993:289-95 Attar SF, Hankins JR, Suter ChM , et al. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990; 50:45-51 Akiyama H, Tsurumaru M, Ono Y, et al. Mucosal stripping of the esophagus. Dis Esoph 1993; 6:27-30

CHEST I 112 I 5 I NOVEMBER, 1997

1309